Gastric outlet obstruction (GOO) is a late complication of several malignancies, markedly impairing quality of life. Surgical gastroenterostomy (S-GE) has long been the palliative standard, but outcomes are variable and morbidity remains considerable. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) has emerged as a minimally invasive alternative. We conducted a systematic review and meta-analysis comparing EUS-GE and S-GE, with a specific focus on malignant GOO.

MEDLINE, Embase, Scopus, and the Cochrane Library were searched through September 2025. Eligible studies directly compared EUS-GE and S-GE and reported clinical success (CS), adverse events (AEs), severe AEs, and recurrence/reintervention. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using random-effects models.

Thirteen studies (2 RCTs, 11 retrospective; 1,611 patients) were analyzed. Overall, EUS-GE achieved higher CS (OR 2.69; p=0.007), fewer AEs (OR 0.21; p<0.001) and severe AEs (OR 0.54; p=0.05) compared to S-GE, with no significant difference in recurrence/reintervention rate (OR 0.54; p=0.22). In malignant GOO, CS (OR 1.90; p=0.12) and recurrence/reintervention rate (OR 0.68; p=0.50) were comparable, while overall AEs remained lower with EUS-GE (OR 0.26; p<0.01).

In malignant GOO, EUS-GE provides comparable clinical efficacy to S-GE with fewer overall AEs. These data support EUS-GE as a preferred minimally invasive option in selected patients.