Optimal endoscopic drainage strategy for concomitant biliary and gastric outlet obstruction: a multicenter retrospective study (ENDO-GOBO)

Background: Concomitant malignant gastric outlet obstruction (MGOO) and malignant biliary obstruction (MBO) represent a challenging clinical scenario in which the optimal endoscopic strategy remains unclear. Objectives: This study aimed to compare real-life combinations of endoscopic ultrasound-guided biliary drainage—hepatogastrostomy (EUS-HGS) or choledochoduodenostomy (EUS-CDS)—with gastric outlet obstruction management—EUS-guided gastroenterostomy (EUS-GE) or enteral stenting (ES). Design: This was an international multicenter retrospective cohort study involving 11 tertiary centers (2017–2023). Methods: Consecutive patients with MBO and MGOO were included. All patients underwent both biliary and gastric outlet drainage using one of four combinations: EUS-HGS/EUS-GE, EUS-HGS/ES, EUS-CDS/EUS-GE, or EUS-CDS/ES. The primary outcome was stent dysfunction (biliary or digestive). Secondary outcomes included clinical success and adverse events. Results: A total of 159 patients were included (median age 70 years; pancreatic cancer 64.8%). Stent dysfunction occurred in 12.0% of patients treated with EUS-HGS/EUS-GE versus 26.6% with EUS-CDS/ES, 36.7% with EUS-HGS/ES, and 50.0% with EUS-CDS/EUS-GE ( p = 0.059). At 12 months, stent obstruction-free survival was significantly higher with EUS-HGS/EUS-GE (84.0%) compared with EUS-CDS/ES (51.2%, p = 0.0466), EUS-CDS/EUS-GE (42.0%, p = 0.0377), and EUS-HGS/ES (52.3%, p = 0.0512). Severe adverse events were more frequent with EUS-HGS (15.0% in HGS/ES; 8.0% in HGS/EUS-GE) compared with EUS-CDS (1.6% in CDS/ES; 0% in CDS/EUS-GE; p = 0.014). Conclusion: In malignant obstruction, the choice of gastric outlet strategy appears to markedly influence biliary stent patency. When EUS-GE is performed, EUS-HGS may provide superior durability but at the cost of higher morbidity. Conversely, when ES is selected, EUS-CDS appears safer. These findings support a tailored approach integrating anatomical considerations and center expertise when selecting the optimal endoscopic double-drainage strategy.