Endoscopic ultrasonography-guided gastroenterostomy versus conventional approaches for cancer-related malignant gastrointestinal outlet obstruction: a meta-analysis with trial sequential analysis

BACKGROUND: Malignant gastric outlet obstruction (MGOO) is a disabling complication of advanced gastrointestinal cancers, accounting for 50-80% of gastric outlet obstruction cases. As patients have unresectable disease, management is palliative and traditionally relies on surgical gastrojejunostomy (SGJ) or enteral stenting, both with limitations. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently emerged, but its role remains uncertain. We conducted a systematic review and meta-analysis comparing EUS-GE with SGJ and enteral stenting. METHODS: statistics and trial sequential analysis evaluated the cumulative evidence. Prespecified subgroup analyses were conducted for randomized controlled trials and propensity score-matched studies. Statistical analyses were performed using RStudio. RESULTS: Twenty-two studies were included, comprising 22,211 and 1,479 patients in the EUS-GE vs SGJ and EUS-GE vs enteral stenting analysis, respectively. EUS-GE was associated with fewer infections (RR 0.46; p = 0.0137), overall postoperative complications (RR 0.38; p < 0.0001), including both major (RR 0.43; p = 0.0109) and minor complications (RR 0.35; p < 0.0001), and a reduced need for reintervention (RR 0.15; p < 0.0001) than SGJ, as well as higher clinical success (RR 1.11; p = 0.0003) compared with enteral stenting. SGJ showed higher technical success (RR 0.98; p = 0.0003). CONCLUSION: EUS-GE offers a safe and effective minimally invasive alternative for MGOO. Its growing evidence base supports its consideration as a preferred option in centers with appropriate expertise.