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Background Although surgical gastrojejunostomy (SGJ) is the standard method for palliation of gastric outlet obstruction (GOO), an endoscopic method—endoscopic ultrasound-guided gastroenterostomy (EUS-GE)—has been proposed as a novel, less invasive approach.Objective We compared both methods to determine whether clinical outcomes for EUS-GE are superior to surgery.Design We conducted a multicentre, randomised superiority trial of patients with malignant GOO to receive either EUS-GE or SGJ. Primary endpoint was composite measure, consisting of Gastric Outlet Obstruction Scoring System (GOOSS) score of 0 or 1 at hospital discharge, need for reinterventions or supplemental nutrition, or procedure-related adverse events during 6-month follow-up or until death. Secondary endpoints were time to solid diet, length of hospitalisation, health-related quality of life (HRQoL) and treatment costs.Results 74 patients were randomly assigned to EUS-GE (38 patients) or SGJ (36 patients). Primary endpoint occurred in 7.9% of patients who received EUS-GE and 38.9% in SGJ (risk difference −31.0%, 95% CI −47.6% to −11.4%, p=0.002). EUS-GE was associated with more rapid advancement to solid diet (median 2 days (P25–P75, 2–3) vs 5 days (P25–P75, 3.5–9)), shorter hospitalisation (median 3 days (P25–P75, 3–6) vs 9 days (P25–P75, 6–12.5)), better HRQoL for physical (p=0.0016) and social functioning (p=0.011) and lower treatment costs (US$33 934 vs US$51 437, difference −US$17 503 (95% CI −US$27 807 to −US$7920)).Conclusion In this randomised trial, EUS-GE was superior to SGJ with regards to oral intake, need for reinterventions or supplemental nutrition, length of hospitalisation, quality of life and treatment costs.Trial registration number NCT05548114.