The i-EUS consensus on EUS-guided gallbladder drainage: A 3-step modified Delphi approach.

Background and Objective: EUS-guided gallbladder drainage (EUS-GBD) has emerged as a viable alternative for patients with acute cholecystitis who are unfit for surgery. However, standardized guidelines for its indications, techniques, and management remain limited. The objective of this study is to develop evidence-based consensus recommendations for EUS-GBD in benign and malignant conditions, aimed at guiding clinical decision-making and improving patient outcomes. Methods: A 3-step modified Delphi process was used by the Interventional Endoscopy and Ultrasound Group, involving multidisciplinary experts in gastroenterology, surgery, and radiology. Four task forces conducted systematic literature reviews and generated PICO (Patients, Interventions, Comparator, and Outcomes)-formatted clinical questions. Evidence was graded using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) system, and consensus was defined as ≥80% agreement among panelists. Results: Twenty-two clinical questions were addressed, covering indications, timing, techniques, device selection, procedural aspects, and postprocedural care for EUS-GBD. Recommendations include the preferential use of EUS-GBD over percutaneous and transpapillary approaches in high-risk patients, early intervention in select cases, the use of lumen-apposing metal stents, and tailored postprocedural strategies. All recommendations were conditional, except for one strong recommendation in favor of EUS-GBD over other modalities, supported by moderate-quality evidence. Conclusions: This consensus offers a comprehensive, multidisciplinary guideline for the safe and effective use of EUS-GBD in clinical practice. These recommendations aim to standardize care and support future research in this rapidly evolving field.