A network meta-analysis on the optimal treatment of malignant gastric outlet obstruction

Abstract

Background:

Gastric outlet obstruction (GOO) caused by malignancy significantly impairs patient quality of life. Surgical gastrojejunostomy (SGJ), endoscopic stenting (ES), and endoscopic ultrasound-guided gastroenterostomy (EUS-GE) are the three main palliative treatments. However, the optimal approach remains unclear because of variations in study results and limited studies comparing treatment types.

Objectives:

To evaluate and compare the effectiveness and safety of EUS-GE, ES, and SGJ in the management of GOO.

Design:

Network meta-analysis.

Data sources and methods:

The PubMed, Cochrane Library, and Web of Science databases were systematically searched for full-length articles of randomized controlled trials and cohort studies in English comparing SGJ, ES, and EUS-GE in adult patients with malignant GOO. Studies with unbalanced baseline characteristics or technical variations within a single modality were excluded. The primary outcome was the reintervention rate for recurrent GOO. Secondary outcomes included clinical success and adverse event rates.

Results:

Fifty-four studies involving 6110 patients were analyzed (SGJ, n = 1974, ES, n = 3226, EUS-GE, n = 910). Compared with ES, both SGJ (odds ratio (OR): 0.32, 95% confidence interval (CI): 0.22–0.46) and EUS-GE (OR: 0.29, 95% CI: 0.17–0.51) significantly reduced the risk of reintervention. EUS-GE achieved a higher clinical success rate than ES (OR: 2.46, 95% CI: 1.50–4.04) and also lower adverse event rate than both SGJ (OR: 0.33, 95% CI: 0.19–0.56) and ES (OR: 0.61, 95% CI: 0.37–0.99). Heterogeneity was moderate across outcomes, with no major inconsistency or publication biases detected.

Conclusion:

Of the three treatments for GOO, EUS-GE demonstrated the most favorable profile in terms of efficacy, safety, and durability. SGJ remains a viable alternative, particularly in centers lacking expertise in advanced endoscopy. These findings may inform future clinical guidelines and support the broader adoption of EUS-GE in appropriate settings.

Keywords

endoscopic stenting endoscopic ultrasound-guided gastroenterostomy gastric outlet obstruction percutaneous drainage surgical gastrojejunostomy

Introduction

Gastric outlet obstruction (GOO) is a clinical condition characterized by mechanical blockage at the level of the gastric antrum, pylorus, or duodenum.¹ GOO is frequently associated with symptoms such as nausea, vomiting, dehydration, and an inability to tolerate oral intake, all of which contribute to a marked decline in quality of life.² GOO is most frequently attributable to malignant neoplasms originating from the distal stomach, duodenum, or pancreas,³ although benign etiologies can cause it as well such as peptic ulcer disease, chronic pancreatitis, postoperative anastomotic strictures, Crohn’s disease, and corrosive injury can also lead to the obstruction. The primary therapeutic objectives are to alleviate obstructive symptoms and to provide suitable palliative care.

Surgical gastrojejunostomy (SGJ) has traditionally been the standard intervention to circumvent the site of obstruction. This method is generally effective, but is invasive and may be associated with a relatively high risk of adverse events.⁴ Endoscopic stenting (ES) offers a minimally invasive alternative to treat GOO, with lower rates of adverse events and more favorable short-term outcomes, such as reduced length of hospitalization.⁵ Compared with SGJ, however, ES is associated with a higher likelihood of reintervention due to the potential for stent occlusion. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has recently emerged as an innovative technique that enabling endoscopic bypass of GOO result from both malignant and benign conditions^5,6; in this method, a lumen-apposing metal stent (LAMS) is used to create a direct connection between the stomach and the small intestine distal to the obstructive lesion. This approach can minimize the risk of adverse events associated with surgical interventions while offering the sustained patency characteristic of a complete enteral bypass.^1,7 While EUS-GE has increasingly been adopted worldwide in recent years, with accumulating evidence supporting its safety and efficacy; however, its implementation requires expertise and a learning curve, as highlighted in recent reports.⁸

Although several studies have compared the efficacy and safety of SGJ, ES, and EUS-GE for GOO, few have included large numbers of patients. The present network meta-analysis (NMA) therefore evaluated and compared the effectiveness and safety of EUS-GE, ES, and SGJ in the management of GOO.

Methods

This NMA was conducted and reported in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) statement.⁹ Studies were eligible for inclusion in this NMA if they were randomized controlled trials (RCTs) or prospective/retrospective cohort studies that compared at least two of the three treatment modalities, SGJ, ES, and EUS-GE, in patients with malignant GOO, and reported at least one of the following outcomes: technical success, clinical success, adverse event rate, reintervention rate, or survival time.

Studies that focused solely on benign GOO and those that did not provide extractable data specific to malignant GOO were excluded. Studies were also excluded if they lacked balanced baseline characteristics or appropriate statistical adjustments. Specifically, studies with significantly unbalanced baseline characteristics between groups (e.g., age, performance status, disease stage, comorbidities) without appropriate statistical adjustments such as propensity score matching, were excluded to minimize confounding. In addition, studies were excluded if they did not compare different palliative treatment modalities, if they compared technical variations (e.g., surgical techniques, anastomosis methods, or stent types) within a single treatment modality, if full texts were unavailable or if results were published only as conference abstracts.

Search strategy

Two investigators (T.T. and Y.Y.) independently and comprehensively searched the PubMed, Cochrane Library, and Web of Science databases using the search terms (“gastric outlet obstruction” OR “pyloric stenosis” OR “duodenal obstruction” OR “duodenal obstructions”) AND (“gastroenterostomy” OR “gastroenterostomies” OR “gastric bypass” OR “surgical gastrojejunostomy” OR “endoscopic ultrasound guided gastroenterostomy” OR “endoscopic duodenal stent placement” OR “duodenal stent placement” OR “duodenal stent” OR “endoscopic ultrasound” OR “endoscopic ultrasonography”). The search was limited to full-length articles in English describing studies of adult human subjects. The systematically search of the PubMed, Cochrane Library, and Web of Science databases was with the final search completed in April, 2025. References cited in the original articles and prior systematic reviews were also screened to identify additional relevant studies.

Outcome variables and data extraction

The primary outcome of this NMA was the reintervention rate due to recurrent GOO after treatment for GOO. The secondary outcomes included clinical success rate and early adverse event rate after GOO treatment. Discrepancies or uncertainties between the two investigators (T.T. and Y.Y.) were resolved by consensus decision after group discussions. Study characteristics and statistical data related to the outcomes of interest were recorded.

Statistical analysis and network outcomes

Effect sizes were measured using odds ratios (ORs) with 95% confidence intervals (CIs) for dichotomous outcomes, and mean differences with 95% CIs for continuous outcome. The NMA was conducted to integrate the direct and indirect comparison. Heterogeneity among studies was assessed using I², with values greater than 50% indicating substantial heterogeneity. A random-effect model was employed to obtain conservative estimates, allowing for any heterogeneity among studies. The NMA was employed in frequentist framework and conducted using the netmeta package (version 2.1–0) in R software (version 4.2.0; R Foundation for Statistical Computing, Vienna, Austria). Results showing value of p < 0.05 were considered statistically significant.¹⁰

The results of the NMA are presented in forest plots and league tables. Treatment effectiveness was ranked using the p score (ranging from 0 to 1), which quantifies the mean extent of certainty that a treatment is better than other treatments; higher p scores correspond to more favorable treatments. For outcomes such as complication rate and reintervention rate, effect sizes were defined in the negative direction, indicating that lower values correspond to better treatment efficacy. Publication bias was assessed using funnel plot. The statistical methods have been double-checked T.T. and K.W. and remain appropriate.

Results

Figure 1 outlines the selection process. The initial database search identified 2419 records; of these, 54 studies met the inclusion criteria, comprising of 4 RCT^11–14 and 50 non-RCTs published between 2002 and 2024,^{2,4,7,15–60} met the inclusion criteria. The characteristics of these studies are presented in Table 1 and Supplemental Table 1. The analyzed studies included a total of 6110 patients, of whom 1974 underwent SGJ, 3226 underwent ES, and 910 underwent EUS-GE.

Figure 1.

PRISMA flow diagram showing the study selection process. A total of 2419 records were identified through database searching. After removing 834 duplicates, 1585 studies were screened by title and abstract, and 96 full-text articles were assessed for eligibility. Of these, 42 were excluded because they were review articles or they evaluated only one treatment modality. Ultimately, 54 studies (4 RCTs and 50 non-RCTs) were included in the network meta-analysis.

Table 1.

Summary of 52 studies included in the network meta-analysis.

Study, years	Design	Intervention		Etiology of GOO		Technical success		Overall survival
GJJ vs ES
		GJJ	ES	GJJ	ES	GJJ	ES	GJJ	ES
1. Maetani et al., 2005²⁰	Retrospective	22	22	GC 22	GC 22	100%	100%	Median 90 days	Median 65 days
2. Maetani et al., 2004¹⁷	Retrospective	19	20	PC 14BC 5	PC 12BC 8	100%	100%	Median 75 days	Median 54.5 days
3. Mittal et al., 2004¹⁸	Retrospective	30	16	GC 5BC 2DC 5PC 8	GC 5BC 1DC 1PC 5	–	–	Median 119 days	Median 56 days
4. Wong et al., 2002¹⁵	Retrospective	17	8	PC 17	PC 8	–	–	Median 64 days	Median 110.5 days
5. Johnsson et al., 2004¹⁶	Retrospective	15	21	GC 7PC 4BC 1Others 3	GC 11PC 3BC 2Others 4	100%	100%	Median 77 days	Median 56 days
6. Del Piano et al., 2005¹⁹	Retrospective	23	24	PC 15GC 4BC 3Others 1	PC 18GC 3BC 2Others 1	100%	95.8%	Mean 70.2 days	Mean 90.2 days
7. Sunpaweravong et al., 2005⁵⁶	Retrospective	51	65	PC 67 BC 49		–		Mean 182.5 days	Mean 191.9 days
8. Espinel et al., 2006²¹	Retrospective	17	24	PC 10GC 5BC 1Others 1	PC 13GC 4BC5Others 2	100%	100%	Median 140 days	Median 151.2 days
9. Mehta et al., 2006¹⁴	RCT	13	12	PC 15GC 4BC 3Others 5		100%	100%	–	–
10. Jeurnink et al., 2007^57,73	Retrospective	42	53	PC 40BC 1Others 1	PC 31BC 1GC 5BC 1Others 3	100%	92.5%	Median 88 days	Median 70 days
Study, years	Design	Intervention		Etiology of GOO		Technical success		Overall survival
GJJ vs ES
		GJJ	ES	GJJ	ES	GJJ	ES	GJJ	ES
11. Schmidt et al., 2009⁵⁸	Prospective	16	24	PC 9BC 6GDC 2Others 2	PC 12BC 6GDC 2Others 4	100%	100%	–	–
12. Jeurnink et al., 2010¹²	RCT	18	21	PC13BC 2GC 1Others 2	PC 15GC 2Others 4	88.9%	76.2%	Median 78 days	Median 56 days
13. Rudolph et al., 2011	Retrospective	43	44	PC 19GC 6BC 9Others 9	PC 15GC 7BC 4Others 18	–	–	Mean 224.5 days	Mean 64.7 days
14. Roy et al., 2012²³	Retrospective	75	29	–	–	100%	100%	Median 132 days	Median 118 days
15. Chandrasegaram et al., 2012²²	Retrospective	19	26	PC 8GDC 9Others 2	PC 12GDC 10Others 4	–	–	Median 134 days	Median 70 days
16. Singh et al., 2013²⁶	Retrospective	93	241	PC 45DC 11BC 9GC 4Others 24	PC 133DC 8BC 20GC 30Others 50	–	–	Median 317 days	Median 72 days
17. Fiori et al., 2013⁶⁷	RCT	9	9	GC 9	GC 9	–	–	Mean 283 days	Mean 258 days
18. Keränen et al., 2013²⁴	Retrospective	21	50	GC 21	GC 50	–	–	Median 121 days	Median 43 days
19. Khashab et al., 2013²	Retrospective	227	120	PC 169BC 50Others 41	PC 64BC 5Others 46	99%	96%	–	–
20. No et al., 2013²⁵	Retrospective	41	72	GC 41	GC 72	97.5%	95.8%	Median 293 days	Median 189 days
21. Park et al., 2015²⁷	Retrospective	39	217	GC 39	GC 217	100%	100%	–	–
22. Fiori et al., 2016⁵⁹	Prospective	30	70	GC 30	GC 70	–	–	Median 351 days	Median 327 days
23. Jang et al., 2016	Retrospective	93	371	–	–	–	–	–	–
Study, years	Design	Intervention		Etiology of GOO		Technical success		Overall survival
GJJ vs ES
		GJJ	ES	GJJ	ES	GJJ	ES	GJJ	ES
24. Tsauo et al., 2016²⁹	Retrospective	32	75	PC 32	PC 75	100%	100%	Median 104 days	Median 140 days
25. Jang et al., 2017³⁰	Retrospective	45	99	GC 45	GC 99	–	–	Median 393 days	Median 129 days
26. Yoshida et al., 2017³²	Retrospective	30	23	PC 30	PC 23	100%	95.7%	Median 89 days	Median 95 days
27. Min et al., 2017³¹	Retrospective	43	58	GC 43	GC 58	–	–	Median 114 days	Median 220 days
28. Yukimoto et al., 2018³⁵	Retrospective	28	38	PC 6GDC 21	PC 19GDC 19	–	–	Median 129 days	Median 79 days
29. Leiyuan et al., 2018³³	Retrospective	34	29	GC 29Others 5	GC 25Others 4	100%	100%	Median 122.7 days	Median 141.4 days
30. Uemura et al., 2018³⁴	Retrospective	35	64	PC 35	PC 64	100%	98.4%	Median 133 days	Median 89.5 days
31. Lopez-Sanchez et al., 2019³⁷	Prospective	30	28	GC 20PC 4DC 5Others 1	GC 15PC 6DC 2BC 3Others 2	–	–	Median 288 days	Median 134 days
32. Jang et al., 2019³⁶	Retrospective	127	183	PC 56GDC 42Others 29	PC 93GDC 43Others 47	98.4%	96.2%	Median 193.4 days	Median 119.9 days
33. Fisher et al., 2020³⁸	Retrospective	193	134	PC 113DC 39GC 41	PC 75DC 29GC 30	–	–	Median 105 days	Median 234 days
34. Hang et al., 2020	Retrospective	94	85	GC 94	GC 85	–	–	Median 234 days	Median 120 days
35. Wang et al., 2021⁴⁰	Retrospective	48	46	GC 48	GC 46	–	–	Median 204 days	Median 396 days
36. Azemoto et al., 2022⁴¹	Retrospective	43	57	PC 43	PC 57	–	–	Median 180 days	Median 177 days
37. Tamura et al., 2023⁴	Retrospective	54	73	PC 54	PC 73	100%	98.6%	Median 113 days	Median 63 days
38. Moscovici et al., 2024⁵⁵	Retrospective	19	19	–	–	–	–	–	–
ES vs EUS-GE
		ES	EUS-GE	ES	EUS-GE	ES	EUS-GE	ES	EUS-GE
1. Chen et al., 2017⁷	Retrospective	52	30	PC 28DC 7GC 3BC 4Others 28	PC 17GC 5DC 2BC 2Others 18	94.2%	86.6%	Median 80 days	Median 103 days
2. Ge et al., 2019⁴²	Retrospective	24	78	PC 40GC 8DC 1BC 10Others 19	PC 7GC 1DC 1BC 4Others 9	100%	100%	–	–
3. Sanchez-Aldehuelo et al., 2022⁴³	Retrospective	97	79	PC 45GC 27DC 6BC 8Others 11	PC 49GC 15DC 5BC 5Others 5	92.8%	93.7%	–	–
4. Jaruvongvanich et al., 2022	Retrospective	131	232	–	–	91.6%	98.3%	–	–
5. Van Wanrooij et al., 2022⁴⁴	Retrospective	107	107	PC 70BC 7GC 8DC 10Others 12	PC 50BC 15GC 8DC 10Others 20	98%	94%	Median 57 days	Median 85 days
6. Conti Bellocchi et al., 2024⁴⁵	Retrospective	66	132	PC 101Others 31	PC 38Others 28	98.4%	98.5%	Median 92 days	Median 91.5 days
7. Seitz et al., 2024⁴⁶	Retrospective	60	82	PC 27GC 6BC 5Others 18	PC 25GC 8BC 3Others 13	97.7%	93.2%	–	–
8. Teoh et al., 2025	RCT	49	48	PC 23GC 14DC 6BC 6	PC 21GC 14DC 5BC 8	100%	95.8%	–	–
9. Conti Bellocchi et al., 2024⁴⁵	Retrospective	45	45	×	×	100%	100%	Median 82 days	Median 69 days
10. Vanella et al., 2024	Retrospective	28	28	×	×	96.4%	100%	Median 212 days	Median 121 days
GJJ vs EUS-GE
		GJJ	EUS-GE	GJJ	EUS-GE	GJJ	EUS-GE	GJJ	EUS-GE
1. Khashab et al., 2017	Retrospective	63	30	PC 53BC 9DC 1	PC 17BC 4GC 5	100%	86.7%	Median 148 days	Median 103 days
2. Perez-Miranda et al., 2017⁴⁹	Retrospective	25	29	–	–	100%	88.0%	–	–
3. Bronswijk et al., 2021⁵⁰	Retrospective	77	48	PC 14BC 2GC 5DC 10Others 12	PC 37BC 9GC 7DC 11Others 11	100%	94.8%	Median 152 days	Median 96 days
4. Kouanda et al., 2021⁵¹	Retrospective	14	36	GC 8PC 3BC 1Others 1	PC 26BC 4DC 1Others 5	100%	91.4%	–	–
5. Abbas et al., 2022⁵²	Retrospective	27	25	PC 9BC 1GC 6Others 8	PC 10BC 5GC 1Others 9	100%	100%	–	–
6. Pawa et al., 2024⁵³	Retrospective	15	29	PC 10DC 2BC 0GC 2Others 1	PC 15DC 3BC 2GC 2Others 7	100%	100%	Median 277 days	Median 72 days

BC, biliary tract cancer; DC, duodenal cancer; ES, endoscopic stenting; EUS-GE, endoscopic ultrasound-guided gastrojejunostomy; GC, gastric cancer; GDC, gastroduodenal cancer; GJJ, gastrojejunostomy; GOO, gastric obstruction outlet; PC, pancreatic cancer; RCT, randomized controlled trial.

Primary outcomes

The risk of reintervention for recurrent GOO was significantly lower in patients who underwent SGJ (OR: 0.32; 95% CI: 0.22–0.46) and EUS-GE (OR: 0.29; 95% CI: 0.17–0.51) than those who underwent ES, although the certainty of evidence was low to very low (Figure 2(b) and (c)). Based on reintervention rates, EUS-GE (p = 0.80) and EUS-GE (p = 0.69) had higher probabilities of being the optimal treatment, with ES having the lowest probability of preventing reintervention (p = 0.00; Figure 2(d)). Heterogeneity within this network was moderate (τ² = 0.428; I² = 52.4%; Figure 2(b)). No inconsistency was observed between direct and indirect comparisons, and no publication bias was detected in the network for this outcome (Figure 2(e)). The results of standard pairwise meta-analyses were consistent with those of the NMA.

Figure 2.

Network meta-analysis of reintervention rates for recurrent GOO. (a) Network plot of comparisons between treatment modalities. (b) Forest plot showing ORs and 95% CIs for each comparison. (c) League table with pairwise comparisons of reintervention rates. (d) p-Score ranking of the treatment modalities for preventing reintervention. (e) Funnel plot assessing publication bias. EUS-GE and SGJ were associated with significantly lower reintervention rates than ES.

Secondary outcomes

The clinical success rate was significantly higher in patients who underwent EUS-GE than in those who underwent ES (OR: 2.46; 95% CI: 1.50–4.04) and SGJ (OR: 1.96; 95% CI: 1.16–3.31; Figure 3(b) and (c)). EUS-GE had the highest probability of achieving clinical success (p = 0.99), followed by SGJ (p = 0.45), with ES having the lowest probability (p = 0.05; Figure 3(d)). The heterogeneity in this network was moderate (τ² = 0.305; I² = 44.1%; Figure 3(b)). No significant inconsistency or publication bias was detected. The findings of standard pairwise meta-analyses were consistent with those of the NMA (Figure 3(e)).

Figure 3.

Network meta-analysis of clinical success rates. (a) Network plot of included studies. (b) Forest plot comparing clinical success rates across treatments. (c) League table of clinical success. (d) p-Score ranking based on clinical success. (e) Funnel plot for publication bias. EUS-GE showed the highest probability of achieving clinical success.

The risk of adverse events was significantly lower in patients who underwent EUS-GE than in those who underwent SGJ (OR: 0.33; 95% CI: 0.19–0.56) and ES (OR: 0.61; 95% CI: 0.37–0.99; Figure 4(b) and (c)), and was lower in patients who underwent ES than SGJ (OR: 0.54; 95% CI: 0.37–0.79). EUS-GE had the highest probability of minimizing adverse events (p = 0.98), followed by ES (p = 0.51), with SGJ having the lowest probability (p = 0.00; Figure 4(d)). The heterogeneity in this network was moderate (τ² = 0.465; I² = 50.6%; Figure 4(b)). No significant inconsistency or publication bias was detected (Figure 4(e)). The findings of standard pairwise meta-analyses were consistent with those of the NMA.

Figure 4.

Network meta-analysis of adverse event rates. (a) Network plot of study comparisons. (b) Forest plot showing ORs and 95% CIs for adverse events. (c) League table showing pairwise comparisons. (d) p-Score ranking of safety profiles. (e) Funnel plot assessing publication bias. EUS-GE was associated with the lowest risk of adverse events, followed by ES and SGJ.

The present NMA attempted to compare the technical success rates between EUS-GE, ES, and SGJ. All three procedures, however, demonstrated uniformly high success rates, resulting in insufficient variability to allow for a meaningful network comparison. Although attempts were made to compare post-procedural overall survival between the three groups, the substantial heterogeneity in patient populations, study designs, and subsequent treatments precluded meaningful comparisons.

Discussion

This systematic review and NMA provided a comprehensive comparison of three current treatment strategies for GOO; SGJ, ES, and EUS-GE. Parameters compared included rates of reintervention rates for recurrence of GOO, along with rates of adverse events and clinical success. EUS-GE demonstrated the most favorable outcomes across all three endpoints, with a significantly higher probability of achieving clinical success (p = 0.99) than either SGJ (p = 0.45) or ES (p = 0.06). EUS-GE was associated with lower adverse event rates than either ES or SGJ. The reintervention rate for recurrence of GOO was comparable between patients who underwent EUS-GE and SGJ, but lower than in those who underwent ES. These findings suggest that EUS-GE represents the most balanced and effective treatment option for GOO. Contrasting with previous meta-analyses, which were limited to pairwise comparisons, this NMA approach enabled a comprehensive evaluation across all three treatment modalities.^1,5,61–80

The major limitations of EUS-GE are its technical complexity and limited availability.⁸¹ EUS-GE is performed in a stepwise manner by advancing a nasobiliary or feeding tube beyond the gastric or duodenal stenosis to infuse saline, thereby enabling EUS visualization of the distended proximal jejunal loop. A cautery-enhanced LAMS is subsequently deployed, with the distal flange first inserted into the jejunum, and the proximal flange into the stomach, to create a gastroenteric anastomosis.⁴⁴ Leakage or perforation may occur, however, due to the mobility of the jejunal loop. Performing EUS-GE requires not only expertise in interventional EUS techniques but also specialized equipment, restricting its use to high-volume centers with experienced endoscopists. Therefore, the favorable outcomes associated with EUS-GE in the present meta-analysis may thus reflect results from expert centers, limiting the generalizability of these findings. The EUS-guided double-balloon occluded gastrojejunostomy bypass (EPASS) technique, which involves occlusion of the proximal small bowel loop with a double-balloon catheter, has enabled the safe and consistent performance of this procedure. A recent global multicenter RCT demonstrated that EUS-GE using EPASS technique offers the advantage of stabilizing the jejunal loop, thereby reducing the risk of stent misdeployment, fistula, or perforation.¹³

Of the three treatments evaluated in the present study, ES showed the lowest clinical success rate for GOO and the highest rate of reintervention rate for recurrent GOO. ES is a generally accepted, minimally invasive, and technically simple procedure with advantages that include early resumption of oral intake and shorter duration of hospitalization.⁴ The long-term utility of ES, however, is limited by the high risk of stent obstruction due to tumor ingrowth or migration, resulting in frequent reinterventions for GOO.

SGJ, a conventional surgical approach, demonstrated a moderate clinical success rate and the highest incidence of adverse events among the three treatments. Despite its invasive nature of the treatment and the association with longer recovery times, SGJ is a well-established procedure that offering long-term patency with a relatively low risk of reintervention. SGJ, therefore, remains a viable treatment option, particularly for patients with good performance status and a high expected long-term survival rate. Compared with traditional open surgery, the use of laparoscopic techniques has reduced the invasiveness of SGJ, improving postoperative recovery while maintaining durability.

Current treatment recommendations for malignant GOO vary internationally. The National Comprehensive Cancer Network and the National Institute for Health and Care Excellence guidelines recommend SGJ for patients with an expected survival exceeding 3 months. Similarly, Japanese clinical practice guidelines for pancreatic cancer recommend surgical SGJ in patients with duodenal obstruction who are expected to show relatively good long-term prognosis.^4,5,82 On the other hand, the European Society for Medical Oncology and Korean guidelines emphasize the short-term benefits of ES. Recently updated guidelines from the European Society for Gastrointestinal Endoscopy recommended EUS-GE as an alternative to ES or surgical SGJ in expert settings.¹¹ Similarly, the present study provides strong evidence supporting the clinical utility of EUS-GE. A recent decision tree analysis of procedure selection demonstrated that SGJ resulted in worse oral intake at 1 month than ES and EUS-GE, mainly due to postoperative gastroparesis after SGJ. However, oral intake after ES declined over time because of stent dysfunction, becoming inferior to EUS-GE and SGJ from 3 months onward. By 5–6 months, SGJ and EUS-GE achieved better sustained oral intake than ES, with EUS-GE showing similar mid-term efficacy to SGJ and better early tolerance.⁶⁴

None of the prospective RCTs in the present NMA compared EUS-GE and SGJ. Prospective studies directly comparing these two treatment modalities thus appear warranted. Studies are also needed to evaluate long-term outcomes, including patient quality of life, nutritional status, and feasibility of chemotherapy. The broader adoption of EUS-GE will require the establishment of structured training programs and institutional support for equipment.

This study showed several inherent limitations. The study was not registered in PROSPERO or any other protocol registry before implementation, which may have affected the transparency and reproducibility. First, while the inclusion of non-RCTs expanded the number of patients included, their inclusion may have introduced potential bias due to residual confounding, despite the exclusion of studies with significantly unbalanced baseline characteristics. Second, the evidence base for EUS-GE remains limited, as only one RCT was available at the time of analysis, and most included data were derived from retrospective cohorts. Third, technological advances and procedural refinements over time likely influenced outcomes; and fully adjusting for the impact of evolving techniques was impossible. In addition, the secondary outcomes showed moderate to substantial heterogeneity despite stratification. The effects of anastomosis configuration, stent type, and procedural approach (e.g., laparoscopic vs open SGJ or different EUS-GE techniques) could not be evaluated because of insufficient information in previous reports. Cost-effectiveness and patency duration, as clinically meaningful endpoints, also could not be assessed. Lastly, definitions and grading systems for complications differ in the surgical and endoscopic literature, making direct comparisons challenging. However, data were synthesized across both modalities to ensure a comprehensive assessment. In addition, operator experience and center volume may affect EUS-GE outcomes. As the procedure is technically demanding, greater expertise and higher institutional volume are likely associated with improved success and safety. Future studies should evaluate learning curves to optimize outcomes. The search strategy was restricted to full-length articles published in English, which may have introduced language bias and excluded potentially relevant studies from non-English-speaking regions.

Conclusion

In summary, this NMA provides the most comprehensive comparison to date of the three primary palliative interventions for malignant GOO: ES, SGJ, and EUS-GE. EUS-GE demonstrated superior clinical success and safety profiles, along with a low reintervention rate, suggesting its potential role as a preferred approach. SGJ remains a valid option, particularly in institutions lacking advanced endoscopic capabilities. As EUS-GE continues to evolve, well-designed prospective studies comparing this method with surgical approaches in various clinical settings will be critical to inform future guidelines and improve patient outcomes.

Supplemental Material

sj-docx-1-tag-10.1177_17562848251410800 – Supplemental material for A network meta-analysis on the optimal treatment of malignant gastric outlet obstruction

Supplemental material, sj-docx-1-tag-10.1177_17562848251410800 for A network meta-analysis on the optimal treatment of malignant gastric outlet obstruction by Takashi Tamura, Ke Wan, Reiko Ashida, Yasunobu Yamashita, Yuki Kawaji, Masahiro Itonaga and Masayuki Kitano in Therapeutic Advances in Gastroenterology

Supplemental Material

sj-docx-2-tag-10.1177_17562848251410800 – Supplemental material for A network meta-analysis on the optimal treatment of malignant gastric outlet obstruction

Supplemental material, sj-docx-2-tag-10.1177_17562848251410800 for A network meta-analysis on the optimal treatment of malignant gastric outlet obstruction by Takashi Tamura, Ke Wan, Reiko Ashida, Yasunobu Yamashita, Yuki Kawaji, Masahiro Itonaga and Masayuki Kitano in Therapeutic Advances in Gastroenterology

Footnotes

Appendix

Acknowledgements

The authors thank all the members of the Second Department of Internal Medicine and the Clinical Study Support Center at Wakayama Medical University.

Declarations

ORCID iDs

Takashi Tamura

Yasunobu Yamashita

Masahiro Itonaga

Masayuki Kitano

Supplemental material

Supplemental material for this article is available online.

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