EUS-Guided Choledochoduodenostomy Versus Hepaticogastrostomy in Case of Concomitant Gastric Outlet Obstruction Treated by EUS-Guided Gastroenterostomy: A Systematic Review and Meta-Analysis.

Biliary (BO) and gastric outlet obstruction (GOO) frequently complicate pancreatic cancer, often delaying treatment. While EUS-guided gastroenterostomy (EUS-GE) is preferred over duodenal stenting for GOO, the optimal approach for biliary drainage (BD) between EUS-guided choledochoduodenostomy (EUS-CDS) and hepaticogastrostomy (EUS-HGS) remains undefined. This systematic review and meta-analysis aimed to identify the preferred BD strategy in patients undergoing EUS-GE for concurrent GOO and BO. We searched Medline, Scopus, and EMBASE up to February 2026. Studies were eligible if they reported outcomes of EUS-CDS or EUS-HGS in patients with malignant BO and concomitant GOO treated by EUS-GE. Outcomes included technical and clinical success, stent dysfunction, and adverse events (AEs) analyzed using a random-effects model. Results were reported as relative risks (RRs) with 95% confidence intervals (CIs). Five studies were included (128 patients; 45.5% female; mean age range 63.0-73.0 years), with 61 undergoing EUS-CDS and 67 undergoing EUS-HGS. Four studies were European, one American, and one prospective. Technical and clinical success rates were similar between groups (RR 0.96, 95% CI 0.83-1.11; I2 = 0%; EUS-CDS 94.5% vs. EUS-HGS 96.4%), (RR 1.04, 95% CI 0.92-1.19; I2 = 0%; EUS-CDS 96.5% vs. EUS-HGS 89.1%). Stent dysfunction was significantly higher in EUS-CDS (RR 4.42, 95% CI 1.71-11.43; I2 = 0%; EUS-CDS 45.1% vs. EUS-HGS 10.9%), while AEs were comparable (RR 1.14, 95% CI 0.24-5.50; I2 = 40.8%; EUS-CDS 10.7% vs. EUS-HGS 16.0%). EUS-CDS and EUS-HGS appear similarly safe and effective for managing malignant BO with concomitant GOO. However, EUS-CDS carries a significantly higher risk of stent dysfunction, potentially delaying critical cancer treatment.