Joan B. Gornals

Background Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) and related EUS-guided anastomoses are increasingly used for gastric outlet obstruction (GOO) and other complex gastrointestinal scenarios, but the indications, technical standards, and periprocedural care remain heterogeneous. Methods An international panel of 66 experts (i-EUS) developed statements using a structured modified Delphi process. Literature searches were performed up to 30 April 2025. Comparative PICO-framed questions with extractable evidence underwent structured evidence synthesis and GRADE assessment, whereas procedural, technical, and organizational statements were classified as consensus based. Consensus was predefined as ≥ 85 % agreement. Results Of 25 draft statements, 20 reached consensus and five did not. Six endorsed statements were GRADE based and 14 were consensus based. For malignant GOO, EUS-GE was recommended over duodenal stenting because of greater durability and fewer reinterventions, and suggested over surgical bypass because of comparable efficacy and fewer overall adverse events. Consensus-based statements addressed expert-center requirements, supervised training, catheter-based target-loop distension, freehand lumen-apposing metal stent (LAMS) deployment, fluoroscopy availability, antithrombotic management, refeeding, postprocedural imaging, recurrent obstruction, and misdeployment. Conditional recommendations addressed LAMS-diameter selection, selected benign GOO, EUS-directed transgastric endoscopic retrograde cholangiopancreatography (EDGE)/EUS-directed transgastric interventions (EDGI) in Roux-en-Y gastric bypass (RYGB), and malignant afferent limb syndrome. No formal recommendation was issued for peritoneal carcinomatosis, routine tracheal intubation, antibiotic prophylaxis, EUS-directed entero-enterostomy (EDEE) in non-RYGB anatomy, or EUS-guided coloenterostomy. Conclusions These i-EUS recommendations provide a practical framework for EUS-GE and related anastomoses in expert settings. The evidence base remains limited, and prospective comparative studies are needed to refine patient selection, training requirements, and long-term outcomes.

Background and objectives: Biliary drainage(BD)in distal malignant biliary obstruction(DMBO)is often hampered by difficult biliary cannulation(DBC)during endoscopic retrograde cholangiopancreatography(ERCP). Advanced cannulation techniques(aERCP)may overcome DBC but still fail in up to 15% of cases, increasing the risk of adverse events(AEs). Early endoscopic ultrasound-guided BD(eEUS-BD)is a potential alternative. The aim of this study is to directly compare safety and efficacy of EUS-BD and aERCP. Methods: This is a retrospective, multicentric study(29 centres in United States, Canada, Europe), including patients with DMBO and common bile duct(CBD)diameter >12 mm, treated up to 2024. DBC cases managed with either eEUS-BD or aERCP were analysed. A 1:2 propensity score-matched cohort was generated to ensure comparability, with regression modeling and inverse probability of treatment weighting(IPTW)performed as sensitivity analyses. AEs rate was the primary outcome; secondary outcomes included BD failure and clinical success. Results: Standard cannulation failed in 2066/10,738(19.2%)ERCPs. aERCP and eEUS-BD were attempted in 1733 and 333 cases, respectively. After matching, 313 patients per EUS-BD group and 626 patients per aERCP group were analyzed. AEs occurred in 18.2% of aERCPs and 9.3% of eEUS-BD(p<0.01), with post-procedural pancreatitis the most frequent AE after aERCP(55 cases, 12.0%). Both regression and IPTW confirmed the robustness of these findings on the entire cohort. Technical success was significantly lower with aERCP(82.0% vs. 95.9%, p<0.01), clinical success was comparable(94.5% vs. 96.4%, p=0.89). Conclusions: In patients with DMBO and dilated CBD, eEUS-BD is associated with fewer AEs and higher technical success than aERCP, supporting its role as a safer, more effective option in DBC.

Objectives: Endoscopic ultrasound‐guided gallbladder drainage is increasingly used for malignant distal biliary obstruction, yet predictors of drainage dysfunction remain unknown. This study aimed to identify clinical and procedural factors associated with dysfunction, clinical success, and morbidity. Methods: This retrospective, international, multicenter cohort study included consecutive patients who underwent endoscopic ultrasound‐guided gallbladder drainage with electrocautery‐enhanced lumen‐apposing metal stents for malignant distal biliary obstruction across 17 centers (March 2017–September 2024). The primary endpoint was biliary drainage dysfunction analyzed using Kaplan–Meier estimation and Cox regression. Secondary endpoints included predictors of clinical success and high‐grade adverse events. Results: A total of 166 patients were included. Technical and clinical success rates were 98.8% (164/166) and 82.9% (136/164), respectively. Among 146 patients in the survival analysis, 12‐month biliary patency was 70.4%. Neither the access route (transgastric 68.5% vs. transduodenal 73.5%, p = 0.50) nor stent diameter (8, 10, or 15 mm; p = 0.82) influenced patency. Ascites was the only independent predictor of dysfunction ( HR 2.45 [95% CI 1.17–5.13], p = 0.018). Endoscopic ultrasound‐confirmed cystic duct patency was independently associated with clinical success (86.7% vs. 69.4%, OR 2.88 [95% CI 1.19–6.96], p = 0.019). The 15‐mm stent was associated with fewer high‐grade adverse events (14.3% vs. 32.9%, OR 0.31 [95% CI 0.14–0.69], p = 0.004) without affecting patency. Conclusions: In this large multicenter series, neither access route nor stent diameter influenced biliary patency. Ascites was the sole independent predictor of dysfunction. A protective signal of 15 mm stents against high‐grade morbidity warrants prospective confirmation.

Unresectable malignant distal biliary obstruction (MDBO) may be treated with endoscopic ultrasound-guided (EUS-BD) or percutaneous transhepatic (PTBD) biliary drainage if endoscopic retrograde cholangiopancreatography fails or is not feasible. This study compared EUS-BD and PTBD using an improved ultrasound-guided method with primary metal stenting. A prospective, longitudinal (follow-up 6 months), nonrandomized, noninferiority (10% margin) trial was conducted. Patients were assigned to centers with high competence in one of the two techniques. The primary end point was technical success, with propensity score matching employed to balance differences. Differences in secondary end points were evaluated with two-sided superiority analyses. 209 patients (mean age 73 years) were enrolled between December 2018 and August 2024 from 14 European centers and were subsequently matched 1:1. Noninferiority of PTBD vs. EUS-BD could not be demonstrated with regard to technical success (91.2% vs. 97.1%; P = 0.17; 95%CI –2.3% to 15.1%). Clinical success (intention-to-treat: 73.5% vs. 55.9%; P = 0.05), procedure time, length of hospital stay, and rate of biliary reintervention within 30 days (0.03 vs. 0.31; P < 0.001) were significantly better in the EUS-BD cohort, driven mainly by EUS-guided choledochoduodenostomy (EUS-CDS). No significant differences were observed in adverse events (grades 1–4) (16.7% vs. 14.5%; P = 0.82), pain score, clinical success (per-protocol), rate of biliary reinterventions within 6 months, or overall survival. EUS-BD, particularly EU-CDS, might be preferred over PTBD in unresectable MDBO owing to better clinical success and a lower biliary reintervention rate.

Background Endoscopic ultrasound (EUS)-guided gallbladder drainage (EUS-GBD) is emerging as an alternative to choledochoduodenostomy (EUS-CDS) for malignant distal biliary obstruction (MDBO) after failed endoscopic retrograde cholangiopancreatography (ERCP). Comparative data on long-term patency are limited. Methods This retrospective international study analyzed two historical cohorts of patients who underwent EUS-GBD or EUS-CDS for MDBO after failed ERCP between March 2017 and May 2024. Eligible patients were aged ≥ 18 years with at least 6 months’ follow-up or confirmed death. The primary outcome, after 1 : 1 propensity score matching, was 12-month biliary patency. Secondary outcomes included technical and clinical success, adverse events (AEs), reintervention rates, and overall survival. Results Before matching, 294 patients were included (142 EUS-GBD; 152 EUS-CDS). After matching, 200 patients were analyzed (100 per group). Technical success was 100 % for EUS-GBD and 97 % for EUS-CDS (P = 0.25). Clinical success was 80.5 % for EUS-GBD and 90.6 % for EUS-CDS (P = 0.08). At 12 months, the probability of biliary patency was significantly higher with EUS-GBD than EUS-CDS (86.2 % [95 %CI 74.2 %–92.9 %] vs. 63.8 % [95 %CI 49.5–75.0]; P = 0.01). Biliary reintervention-free survival was significantly longer with EUS-GBD (log-rank, P < 0.001). Periprocedural AEs occurred in 7.0 % vs. 10.0 % (P = 0.61), delayed AEs in 27.0 % vs. 30.0 % (P = 0.75), and reintervention rates were comparable (23.0 % vs. 26.0 %; P = 0.74). Overall survival did not differ significantly (log-rank, P = 0.59). Conclusion In patients with MDBO after failed ERCP, EUS-GBD achieved higher 12-month biliary patency than EUS-CDS, with comparable rates of technical and clinical success, morbidity, reintervention, and overall survival.