Background:Gastric outlet obstruction (GOO) in oncologic patients is usually attributed to malignant duodenal infiltration or peritoneal carcinomatosis. However, careful imaging review in mandatory in the context of profound cachexia because rarely benign extrinsic compression of the third portion of the duodenum may closely resemble malignant obstruction. International guidelines increasingly recognize EUS-guided gastroenterostomy (EUS-GE) with lumen-apposing metal stents (LAMS) as a minimally invasive alternative to surgical bypass in both malignant and selected benign GOO, particularly when performed in high-expertise centers.

Case:We report a 72-year-old woman with metastatic ductal breast carcinoma and severe cachexia presenting with non-traversable duodenal stenosis in a context of normal duodenal mucosa. Endoscopy and computed tomography showed obstruction of the third duodenal portion without clear malignant infiltration. Despite initial PEG–PEJ placement for decompression and nutrition, symptoms persisted. Following multidisciplinary evaluation, an EUS-guided gastroenterostomy using a 15 × 10 mm LAMS was performed, resulting in rapid symptom resolution, restored enteral continuity, and nutritional improvement.

Conclusion:EUS-GE is a valuable minimally invasive therapeutic option for benign or indeterminate GOO in oncologic patients, particularly when the distinction between malignant and benign etiologies is challenging. Current ESGE and ASGE guidelines, supported by recent meta-analyses, endorse its use in expert centers.

Keywords: EUS-guided gastroenterostomy, lumen-apposing metal stent, gastric outlet obstruction, SMA syndrome–like compression, metastatic breast cancer