Malignant Double Obstruction: How Can Advanced Endoscopy Help?

Background and Objectives: Malignant double obstruction, defined as the coexistence of malignant biliary obstructio (MBO) and malignant gastric outlet obstruction (mGOO), frequently complicates advanced pancreatic and periampullary malignancies. Because biliary and duodenal obstructions are anatomically and functionally interconnected, treatment of one may influence the outcome of the other. This review aims to summarize current evidence on endoscopic management strategies and to propose an anatomy-driven approach integrating conventional and endoscopic ultrasound (EUS)-guided techniques. Materials and Methods: A narrative review of the current literature was performed, focusing on endoscopic approaches for malignant biliary and gastric outlet obstruction. Available evidence regarding endoscopic retrograde cholangiopancreatography (ERCP), EUS-guided biliary drainage (EUS-BD), enteral self-expandable metal stenting, and EUS-guided gastroenterostomy (EUS-GE) was critically analyzed, focusing on technical feasibility, clinical outcomes, adverse events, and therapeutic sequencing. Results: ERCP remains an effective option when papillary access is preserved; however, duodenal obstruction, especially when involving the papilla, represents a major limitation. EUS-BD has emerged as a reliable alternative after failed ERCP and may provide a primary drainage strategy in selected patients. In the setting of concomitant gastric outlet obstruction, EUS-guided hepaticogastrostomy may offer advantages over choledochoduodenostomy by avoiding the obstructed duodenal pathway. For malignant gastric outlet obstruction, enteral stenting provides rapid symptom relief, but is associated with limited long-term durability. EUS-GE has demonstrated high technical and clinical success rates, lower rates of recurrent obstruction compared with enteral stenting, and outcomes comparable to surgical gastrojejunostomy with reduced invasiveness. These findings support an integrated EUS-based approach for selected patients. Conclusions: Malignant double obstruction should be considered a single anatomofunctional entity rather than two independent conditions. An individualized, anatomy-driven strategy combining EUS-guided biliary drainage and EUS-GE may represent the future direction of endoscopic palliation, allowing durable internal bypass and facilitating oncological management. Further prospective studies are required to define optimal treatment sequencing and patient selection.