BACKGROUND AND STUDY AIMS: Enteral stenting has been traditionally employed for managing malignant gastric outlet obstruction (GOO). However, concerns regarding high reintervention rates have brought into question its cost-effectiveness. Endoscopic ultrasound-guided gastroenterostomy (EUS-GE) with a lumen-apposing metal stent (LAMS) provides an alternative to luminal stenting. The goal of this study was to assess the cost-effectiveness of EUS-GE relative to duodenal stenting. PATIENTS AND METHODS: A decision analysis was performed to analyze costs and survival in patients with unresectable or metastatic GOO. The model was designed with two treatment arms: self-expanding metal stent (SEMS) placement and EUS-GE with LAMS. Costs were derived from Medicare reimbursement rates (US while effectiveness was measured by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). Probabilistic sensitivity analyses were performed. RESULTS: Endoscopic stenting resulted in an average cost of 2,748 and 0.31 QALYs whereas EUS-GE cost 2,254 and yielded 0.53 QALYs, which yielded a difference of ,507 in cost and 0.23 in QALY. EUS-GE was found to be a cost-effective strategy over duodenal stenting (ICER, 1994/QALY) at a willingness-to-pay of 00,000/QALY. In 10,000 Monte-Carlo simulations, EUS-GE was favored 62% of the time. Using a tornado diagram, the model was most sensitive to the probability of mortality in patients with duodenal stents compared with EUS-GE. CONCLUSIONS: In patients with malignant GOO, EUS-GE is a cost-effective palliative intervention compared with duodenal stenting.