Background and study aims: Gastric outlet obstruction (GOO) is traditionally managed by surgical gastroenterostomy (surgical-GE) and enteral stenting (ES). EUS-guided gastroenterostomy (EUS-GE) is now a third option. Large studies assessing their relative risks and benefits with adequate follow-up are lacking. We conducted a comparative analysis of patients who underwent EUS-GE, ES, or surgical-GE for GOO. Patients and methods: In this retrospective comparative cohort study, consecutive patients presenting with GOO who underwent EUS-GE, ES, or surgical-GE at two academic institutions were reviewed and independently cross-edited to ensure accurate reporting. The primary outcome was need for re-intervention. Secondary outcomes were technical and clinical success, length of hospital stay (LOS), and adverse events (AE). Results: A total of 436 patients (232 EUS-GE, 131 ES, 73 surgical-GE) were included. The median duration of follow-up of the entire cohort was 185.5 days (IQR 55.25-454.25 days). The rate of re-intervention of the EUS-GE group was lower than the ES and surgical-GE groups (0.9%, 12.2%, and 13.7%, P<0.0001). Technical success was achieved in 98.3%, 99.2%, and 100% (P=0.58), and clinical success was achieved in 98.3%, 91.6%, and 90.4% (P<0.0001) in the EUS-GE, ES, and surgical-GE groups, respectively. The EUS-GE group had a shorter LOS (2 days vs. 3 days vs. 5 days, P<0.0001) and a lower AE rate than the ES and surgical-GE groups (8.6% vs. 38.9% vs. 27.4%, P<0.0001). Conclusion: This large cohort study demonstrates the safety and palliation durability of EUS-GE as an alternative strategy for GOO palliation in select patients.

Metabolic and bariatric surgery is the most effective therapy for weight loss and improving obesity-related comorbidities, comprising the Roux-en-Y gastric bypass (RYGB), gastric banding, sleeve gastrectomy (SG), and biliopancreatic diversion with duodenal switch. While the effectiveness of weight loss surgery is well-rooted in existing literature, weight recurrence (WR) following bariatric surgery is a concern. Endoscopic bariatric therapy presents an anatomy-preserving and minimally invasive option for managing WR in select cases. In this review article, we will highlight the endoscopic management techniques for WR for the most commonly performed bariatric surgeries in the United States –RYGB and SG. For each endoscopic technique, we will review weight loss outcomes in the short and mid-terms and discuss safety and known adverse events. While there are multiple endoscopic options to help address anatomical issues, patients should be managed in a multidisciplinary approach to address anatomical, nutritional, psychological, and social factors contributing to WR.

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