EUS-guided choledochoduodenostomy (EUS-CDS) with lumen-apposing metal stents (LAMS): a comprehensive technical review

Introduction: Endoscopic ultrasound-guided choledochoduodenostomy using lumen-apposing metal stents (EUS-CDS-L) has evolved as a main therapeutic option for distal malignant biliary obstruction after failed endoscopic retrograde cholangiopancreatography (ERCP). This review aimed to provide a comprehensive overview of the technical aspects for performing EUS-CDS-L. Areas covered: This review summarized the current evidence on all apsects of the EUS-CDS-L procedure, focusing on pre-procedural, procedural, and post-procedural management. We conducted a structured, detailed search of multiple databases (PubMed, Web of Science, Embase, and the Cochrane Library) from January 2010 to March 2026. Expert opinion: EUS-CDS-L should be considered the preferred rescue strategy after failed ERCP in patients with distal malignant biliary obstruction (DMBO), given its consistently high technical and clinical success rates and acceptable safety profile. Beyond salvage therapy, accumulating high-quality evidence suggests EUS-CDS-L’s potential role as a primary drainage modality in selected patients, particularly in specializing centers. However, variability in technique, stent selection, and peri-procedural management continues to limit standardization. Future efforts should focus on protocol and peri-procedural harmonization.