Endoscopic versus surgical gastroenterostomy in malignant gastric outlet obstruction

Evidence before this study

Endoscopic gastroenterostomy is not currently considered the standard treatment for malignant gastric outlet obstruction. The European Society of Gastrointestinal Endoscopy states that endoscopic gastroenterostomy can be considered an alternative to duodenal stent placement or surgical gastroenterostomy in an expert setting. The American Society for Gastrointestinal Endoscopy does recognise the increasing use of this treatment but does not provide specific recommendations regarding the indications for, or the use of, endoscopic gastroenterostomy. We searched MEDLINE, Embase, and the Cochrane Library for publications on endoscopic and surgical gastroenterostomy as treatment of malignant gastric outlet obstruction. Non-conference articles were considered that were published before initiation of our study (which was approved by the institutional review board on Nov 18, 2021), and the search was updated on April 8, 2025. The search terms used were “gastroenterostomy”, “endoscopic ultrasonography”, and “gastric outlet obstruction”. We restricted the search to articles published in English. We found no randomised controlled trials that compared endoscopic gastroenterostomy with surgical gastroenterostomy. We found one randomised controlled trial (DRA-GOO) that compared endoscopic gastroenterostomy with duodenal stent placement. This study reported a lower 6-month re-intervention rate and shorter length of hospital stay with endoscopic gastroenterostomy compared with duodenal stent placement. The authors concluded that endoscopic gastroenterostomy should be preferred over duodenal stent placement. A recently published network meta-analysis recommended the use of endoscopic gastroenterostomy over surgical gastroenterostomy in terms of effectiveness and safety.

Added value of this study

To our knowledge, this is the first randomised controlled trial comparing endoscopic gastroenterostomy with surgical gastroenterostomy. We found that the anastomosis created with endoscopic gastroenterostomy is more rapidly functional than with surgical gastroenterostomy, without an increased need for re-interventions due to persistent or recurrent obstructive symptoms within 6 months.

Implications of all the available evidence

Taken together, the results of our study and the DRA-GOO trial suggest that endoscopic gastroenterostomy should be the palliative treatment of choice in patients with malignant gastric outlet obstruction in an expert setting. Remaining research objectives include evaluation of the cost-effectiveness of endoscopic gastroenterostomy and assessing the safety and feasibility of implementing the endoscopic approach in non-expert settings.

Source: The Lancet Gastroenterology & Hepatology