Double EUS‐Bypass Versus Conventional Endoscopic Strategies for Concurrent Malignant Gastric Outlet and Biliary Obstruction

OBJECTIVES: Advanced malignancies frequently cause concurrent malignant biliary obstruction (MBO) and gastric outlet obstruction (GOO). Conventional endoscopic approaches would be duodenal stenting combined with endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous transhepatic biliary drainage (PTBD), with limited long-term efficacy. Novel therapeutic endoscopic ultrasound (EUS), known as double EUS-bypass, may offer improved outcomes. This study aimed to compare the efficacy and safety of two approaches for managing concurrent MBO and GOO. METHODS: In this retrospective cohort study, 106 patients with concurrent MBO and GOO were included between 2011 and 2025. Among them, 44 underwent double EUS-bypass, while 62 received conventional endoscopic approaches. Clinical success rate, technical success, adverse events, re-intervention rate, and long-term patency were compared. RESULTS: Technical success was achieved in 93.2% of the EUS group and 100% of the traditional group (p = 0.136). The clinical success rate was significantly higher in the EUS group (59.1% vs. 37.1%, p = 0.041), particularly in postoperative improvement on GOO (p = 0.007). Recurrence rates of MBO and GOO were significantly lower in the EUS group (p = 0.078 and p = 0.010, respectively). Notably, the re-intervention rate was markedly reduced in the EUS group (9.1% vs. 46.8%, p < 0.001). Adverse event rates, procedure duration, and hospitalization length were comparable between groups. CONCLUSIONS: Double EUS-bypass offers superior clinical outcomes and reduces the need for re-intervention in patients with concurrent malignant GOO and MBO compared to conventional endoscopic approaches.