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Background: Combining antegrade stenting (AGS) and hepaticogastrostomy (HGS) is an increasingly used endoscopic ultrasound-guided intervention when stenting by endoscopic retrograde cholangiopancreatography is impossible. Objectives: We comprehensively assessed the benefits and downsides of combined AGS and HGS (HGS procedure with AGS, HGAS). Data sources and methods: From 788 HGS and 295 HGAS cases, a random-effects meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Five electronic databases were searched for studies on HGS with or without AGS from inception until May 2024. The odds ratio (OR) and pooled rates were used for single and two-arm comparisons with 95% confidence intervals (CI). Results: From 26 eligible studies. The pooled technical and clinical success was 94% (CI: 92%–96%) and 88% (CI: 84%–91%) for HGS and 89% (CI: 83%–93%) and 94% (CI: 89%–97%) for HGAS, respectively. Pooled OR of HGAS and HGS showed an OR = 0.38 (CI: 0.07–2.00) for technical success and an OR = 1.02 (CI: 0.50–2.06) for clinical success. The pooled adverse event rates were 20% (CI: 16%–25%) for HGS and 14% (CI: 9%–20%) for HGAS, whereas pooled OR showed an OR = 1.09 (CI: 0.30–3.94). For re-intervention, an OR = 0.37 (CI: 0.27–0.52) was found. Time to stent dysfunction increased, HGAS 333 (CI: 280–Not reached) and HGS 209 (CI: 120–325) with no change in overall survival HGS 117 (CI: 94–147) and 140 (CI: 105–170). Conclusion: The use of HGAS appears to increase clinical success and reduce the need for re-intervention. Overall adverse event rates were similar but bile leakage prevalence was decreased. Time to stent dysfunction seems to increase with no change in overall survival. Trial registration: Our protocol was prospectively registered with PROSPERO (CRD42024509412).