EUS-CDS With LAMS Gets Its First Detailed International Procedural Consensus: UEG Journal | September 2026

Introduction:

EUS-guided choledochoduodenostomy using lumen-apposing metal stents (EUS-CDS-L) is increasingly used for distal biliary obstruction, particularly after failed ERCP. As the technique moves from rescue therapy toward possible first-line use, standardized patient selection and procedural practice are needed.

Why was this consensus needed?

EUS-guided biliary drainage is expanding rapidly.

Technical approaches and patient selection vary between centres.

LAMS-specific procedural guidance has been limited.

Wider adoption requires clear competency and safety standards.

Key Takeaways:

32 international experts reached consensus on 24 of 26 statements.

After failed ERCP for distal malignant biliary obstruction, EUS-CDS-L is preferred over percutaneous drainage when appropriate expertise is available.

Without gastric-outlet obstruction, EUS-CDS-L is generally favored over EUS-hepaticogastrostomy.

A CBD diameter ≥15 mm was considered a safer threshold for LAMS deployment.

Experts generally favored smaller-diameter LAMS.

Operators should be proficient in both ERCP and therapeutic EUS.

Primary EUS-CDS-L may be considered in selected distal malignant obstruction.

Use for benign obstruction remains cautious and should involve multidisciplinary discussion.

Most statements rely on low or very-low quality evidence.

What’s New?

The consensus provides the first detailed procedural framework for EUS-CDS-L as it evolves from rescue drainage toward selected primary biliary drainage.

Bottom Line:

EUS-CDS-L is becoming an established alternative after failed ERCP and may eventually move earlier in selected malignant obstruction. Standardized technique, expert operators, and stronger comparative evidence remain essential.