Endoscopic ultrasound (EUS)-guided interventions have revolutionized the management of malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO), providing minimally invasive alternatives with improved outcomes. These procedures have significantly reduced the need for high-risk surgical interventions or percutaneous alternatives and have provided effective palliative care for patients with advanced gastrointestinal and bilio-pancreatic malignancies. EUS-guided biliary drainage (EUS-BD) techniques, including hepaticogastrostomy (EUS-HGS), choledochoduodenostomy (EUS-CDS), and antegrade stenting (EUS-AS), offer high technical and clinical success rates, with a good safety profile particularly when Endoscopic Retrograde Cholangiopancreatography (ERCP) is not feasible. EUS-HGS, which allows biliary drainage by trans-gastric route, is primarily used for proximal stenosis or in case of surgically altered anatomy; EUS-CDS with Lumen-Apposing Metal Stent (LAMS) for distal MBO (dMBO), EUS-AS as an alternative of EUS-HGS in the bridge-to-surgery scenario or when retrograde access is not possible and EUS-guided gallbladder drainage (EUS-GBD) with LAMS in case of dMBO with cystic duct patent without dilation of common bile duct (CDB). EUS-guided gastroenterostomy (EUS-GE) has already established its role as an effective alternative to surgical GE and enteral self-expandable metal stent, providing relief from GOO with fewer complications and faster recovery times. However, we do not yet have strong evidence on how to combine the different EUS-guided drainage techniques with EUS-GE in the setting of double obstruction. This comprehensive review aims to synthesize growing evidence on this topic by randomized controlled trials, cohort studies, and case series not only to summarize the efficacy, safety, and technical aspects of these procedures but also to propose a treatment algorithm based essentially on the anatomy and stage of the neoplasm to guide clinical decision-making, incorporating the principles of personalized medicine. This review also highlights the transformative impact of EUS-guided interventions on the treatment landscape for MBO and GOO. These techniques offer safer and more effective options than traditional approaches, with the potential for widespread clinical adoption. Further research is needed to refine these procedures, expand their applications, and improve patient care and quality of life.

Introduction: Learning curve of EUS‐guided Gastroenterostomy (EUS‐GE) has been explored through retrospective studies involving few elite senior endoscopists (SE), with procedural time as the main surrogate outcome. This study aims to evaluate the training of junior endoscopists (JE) approaching the technique and cover clinically relevant patient outcomes. Methods: From a prospective single‐center registry (PROTECT, ClinicalTrials.gov NCT04813055) of EUS‐GE for malignant Gastric Outlet Obstruction using the Wireless Simplified [WEST] technique, the learning curve of 3 JE experienced in pancreatobiliary endoscopy was analyzed to identify changing points (“knots”) applying linear and spline regression and cumulative sum control chart (CUSUM) on several continuous and dichotomic variables. EUS‐GE performed by a SE and different indications were excluded. Results: From a database of 165 EUS‐GEs, 100 were performed by one novice endoscopist with prior EUS‐GE exposure (JE1) and 35 by two naïve endoscopists (JE2/JE3). On the largest curve (JE1), procedural time and fluoroscopy time did not show any improvement. The use of fluoroscopy (median Air Kerma: 267 Gy [172–506]) showed a significant improvement after 57 interventions (spline regression) and 72 interventions (CUSUM), after which the curve stabilized. The need for supervision/backup of a SE showed a knot after 32 interventions. Technical success (99%), Clinical success (96%), Misdeployments (2%) and AEs (6%) were stable along the learning curve. Conversion from EUS‐GE to enteral stenting (11%) tended to decrease over time. Despite naïve endoscopists required significantly higher fluoroscopy time (234 vs. 187 s, p = 0.009) and procedural time (55 vs. 43 min, p = 0.002) than JE1, efficacy and safety outcomes were not different from the general cohort. Conclusions: From a prospective registry, ≈30 EUS‐GE seems required for independent practice, and ≈55–70 to minimize and stabilize the use of fluoroscopy. Endoscopists learning EUS‐GE in high‐volume institutions using a standardized technique do not compromise high clinical and safety standards.

Aims Gastroesophageal reflux disease (GERD) is one of the most common gastrointestinal disorders, with a global prevalence of approximately 20% of adults in Western countries. Treatment options for patients with chronic GERD include long term therapy with Proton Pump Inhibitors (PPIs), laparoscopic fundoplication or endoscopic anti-reflux procedures. Endoscopic full-thickness plication with GERDx (G-SURG, Germany) device has been proven to be safe and effective in improving quality of life in PPI-dependent patients who refuse surgery or long-term medications are not an option. We showed a case of adverse event(SAE) and management related to the device after GERDx. Methods We performed a GERDx on 64-years-old male patient affected by GERD on PPI-dependent patients who refuse surgery. The patient has a history of reflux esophagitis (Los Angeles grade C) with classic GERD symptoms (heartburn and regurgitation) on long-terms PPI Results We performed GERDx in endoscopic room and lasted 30 minutes under anesthesiological assistance without intraoperative complications. The patient complained of intractable postoperative pain at 48 hours. The chest and abdomen CT is performed and showed pleural empyema at 72 hours. A diagnostic laparoscopy were performed and revealed suture passing through the left crus of diaphragm. The suture had to be removed and a Dor fundoplication was performed followed by video-assisted thoracoscopic surgery (VATS). The patient is discharged after 30 days in good general condition [1] [2]. Conclusions GERDx is an effective and low invasive technique to treat GERD. Serious adverse events require the availability of surgeons with experience in thoracoscopic and abdominal surgery. Article published online: 14 April 2023 © 2023. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany