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

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.

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

Network meta-analysis.

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.

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.

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.