Standardizing EUS-guided Gastroenterostomy: a Delphi consensus on technical steps and adverse events management

Aims EUS-guided gastroenterostomy (EUS-GE) is increasingly used in the management of Gastric Outlet Obstruction. However, significant variability exists in technical choices which might account for heterogeneous clinical outcomes. The aim of this Delphi methodology was to address open questions and to gather expert consensus on key aspects of EUS-GE.

Methods A panel of 25 international leading experts in EUS-GE was invited to revise literature around the technique. A Delphi process was conducted over three rounds, with each round involving anonymous voting on 29 predefined statements, using a 5-point Likert scale (1: strongly disagree – 5: totally agree). Responses were analysed through Medians [Interquartile Ranges], with pre-defined thresholds for approval, revision or discard of the statement. Statements reaching final consensus were graded based on the strength of agreement, defined as the proportion of responses rated 4 or 5.

Results Response rate was 88% in Round 1 and 100% in Round 2 and 3. Among 29 statements, eight were approved at Round 1, eighteen at Round 2 and four at Round 3, while two were ultimately rejected. There was early and excellent agreement (> 95%) on the need of fluoroscopy for EUS-GE, the need for electrocautery-enhanced Lumen Apposing Metal Stent (LAMS), and the preference for free-hand LAMS release. All panellists agreed that endoscopists performing EUS-GE should be familiar with management of Adverse Events (AEs) such as bleedings or perforations. After discussion, excellent agreement was obtained for the management of AEs (misdeployments and bleedings) and LAMS dysfunctions. Final Strong agreement (> 90%) was reached for preferred patient positioning, the required sedation and the preference for saline solution for jejunal distention. Extensive discussion with final Moderate agreement (> 80%) was reached on the use of dye, the preference for catheter-assisted EUS-GE instead of endoscope- or needle-directed instillation, the typical location for EUS-GE and the operative space required for LAMS release. Statements on the use of contrast and the choice between WEST and EPASS techniques were removed due to lack of agreement.

Conclusions Despite technical differences (such as the preference of a jejunal catheter or a double-balloon catheter) most EUS-GE experts agree on key technical principles, providing valuable guidance on the standardization of EUS-GE in clinical practice. Conversely, certain topics show limited agreement, identifying future research priorities in the field of EUS-GE.

Publication History

Article published online:
27 March 2025