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Background and study aims  Gastric outlet obstruction (GOO) is traditionally managed with surgical gastroenterostomy (surgical-GE) and enteral stenting (ES). Endoscopic ultrasound-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 reintervention. Secondary outcomes were technical and clinical success, length of hospital stay (LOS), and adverse events (AEs). 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 (interquartile range 55.25-454.25 days). The rate of reintervention in the EUS-GE group was lower than in 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., Competing Interests: Competing interests Dr. Abu Dayyeh is a consultant for Endogenex, Endo-TAGSS, Metamodix, and BFKW; is a consultant for and receives grant/research support from USGI, Boston Scientific; receives grant/research support from Cairn Diagnostics, Aspire Bariatrics; has speaker roles with Olympus, Johnson and Johnson; has speaker and grant/research support from Medtronic, Endogastric solutions; and has research support from Apollo Endosurgery, and Spatz Medical. Dr. Law is a consultant for ConMed and Medtronic. Dr. Chandrasekhara is a consultant for Boston Scientific, Covidien, and LP; a shareholder at Nevakar Corporation; and on the medical advisory board for Interpace Diagnostics. Dr. Storm is a consultant for Apollo Endosurgery, ERBE, GI Dynamics, and Olympus and received research grant support from Apollo Endosurgery, Boston Scientific, Endo-TAGSS, Endogenex, and Enterasense. Dr. Marya is a consultant for AnX Robotica. Dr. Kunda is a consultant of Boston Scientific, Omega Medical Imaging, Apollo Endosurgery, and Olympus, Ambu, M.I.Tech, Medconsgroup, EndiaTx, Q3 Medical – AMG International and Tigen Pharma., (The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)