EUS-guided gastroenterostomy using a parallel enteric tube for luminal distension: Prospective multicenter procedural standardization (with video).

Background and Objectives: The EUS-guided gastroenterostomy (EUS-GE) technique remains nonstandardized. We primarily aimed at standardizing parallel enteric tube (PET)-assisted EUS-GE, secondarily assessing reproducibility and outcomes. Methods: This prospective multicenter study included consecutive adult patients with unresectable malignant gastric outlet obstruction undergoing primary EUS-GE between August 2019 and April 2021. Hierarchical task analysis predefined procedural steps into tasks and subtasks. Subtasks were further categorized into essential (performed in all centers and in more than 85% of the procedures) or optional. Subtask methodology was considered established if performed similarly in all centers or variable if not. Procedure times, injected fluid volume, accessories, adverse events (AEs), and outcomes were recorded. Results: Seven endoscopists performed EUS-GE in 65 patients (50.8% male, median [interquartile range] age 77.5 [65.7-86.5] years). EUS-GE was categorized into 4 tasks (enteric tube placement, endoscope exchange, small bowel distention plus targeting, lumen-apposing metal stent placement) and 10 subtasks (7 essential, 3 optional). Five essential subtasks involved an established methodology (guidewire and PET placement, endoscope exchange, delivery system insertion, and lumen-apposing metal stent deployment).Technical and clinical success rates were 98.5% and 83.3%, respectively. AEs occurred in 10 (15.4%) patients. Success and AE rates were not different between expert and nonexperts. Procedure time was longer (35 [30.6-43.7] vs. 21.8 [16.4-29.5] minutes, P < 0.001) and injected fluid volume higher (510 [439-870] vs. 415 [255-480] mL, P = 0.01) in nonexperts. Conclusions: PET-assisted EUS-GE was standardized, identifying its key steps and technique variants. PET-assisted EUS-GE appears to be a reproducible procedure among advanced endoscopists with different levels of experience.(ClinicalTrials identification no. NCT04660695).