Don’t repeat the cardiovascular and thoracic surgery – Cardiology shift: Surgeons should lead endoscopic ultrasonography-guided gastroenterostomy

Dear Editor in Chief, The ENDURO and similar randomised trials have shown that, in experienced centres, endoscopic ultrasonography-guided gastroenterostomy (EUS-GE) achieves faster return to solid intake and shorter length of stay than laparoscopic gastrojejunostomy, with non-inferior re-intervention rates – clinically meaningful gains for palliative malignant gastric outlet obstruction.[1,2] At the same time, ENDURO’s guardrails, such as operator experience, proctoring and centre expertise, underline that EUS-GE is a complex system intervention, where complications (e.g. Lumen-Apposing Metal Stents maldeployment, bleeding and perforation) can be catastrophic without immediate rescue. For India, the imperative is clear: Surgeons must own the pathway for EUS-GE, from indication to execution to rescue, because we are uniquely positioned to deliver speed, safety and accountability at scale. Rescue-first capability – When adverse events escalate, surgeons can convert and definitively repair, compressing the decisive interval from complication to control (including emergency laparotomy when required). This is not ancillary; it is central to patient safety Service accountability – Surgical services already run morbidity and mortality frameworks, interface control unit interfaces and escalation protocols, ensuring a single point of responsibility for outcomes across heterogeneous Indian settings Scalable training and governance – Surgical training programmes can standardise device-specific credentialing, simulation and supervised case thresholds that mirror ENDURO’s expertise requirements and create durable national capacity. If surgeons remain peripheral, we risk ‘losing the pathway’, echoing how cardiothoracic and vascular surgery ceded interventional territory to cardiology. Because less-invasive therapies consolidate around reliable providers, EUS-GE will be no different. These interventional domains should not default to non-surgical services; surgical ownership best ensures outcomes, accountability and immediate rescue capacity. Education and workforce reform (owning the skillset): Integrate diagnostic endoscopy and colonoscopy into post-graduate general surgery curricula such as competency-based modules with logbooks, simulation and supervised lists Teach complex therapeutic endoscopy through surgical fellowships like IAGES fellowships or in concerned super-specialities to name a few, with formal proctorship, milestone-based credentialing and periodic re-credentialing for EUS-GE, endoscopic retrograde cholangiopancreatography (advanced) and third-space endoscopy Surgical leadership of the EUS-GE service line – Surgeons set indications, run lists and lead complication governance; interventional endoscopy expertise is integrated within a surgical-led pathway, not adjacent to it. Implementation for Indian centres (owning the outcomes): Surgical-led lists with mandatory on-site operative backup for every EUS-GE session Transparent registry: Time-to-oral intake, length of stay, 30-day serious adverse events, maldeployment rate and 6-month re-intervention – benchmarked to ENDURO before expansion beyond hubs Cost-conscious scaling: Surgical leadership in pathway design and Indian cost-effectiveness to extend access beyond metro quaternary centres. EUS-GE is a welcome advance. With surgical ownership across training, execution and rescue, Indian surgeons can scale EUS-GE and related minimally invasive technologies safely and equitably – without ceding another interventional domain. By asserting surgical ownership, we will not only safeguard patient outcomes but also signal to trainees that surgery remains the natural home for advanced interventional care, thereby attracting talent to the speciality. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.