Endoscopic ultrasound–guided choledochoduodenostomy (EUS-CDS) with lumen-apposing metal stents (LAMS) is an established technique for biliary drainage in malignant distal obstruction [1,2]. Nevertheless, recurrent biliary obstruction (RBO) due to stent occlusion or migration remains a concern and the placement of a coaxial double-pigtail stent (DPS) has been proposed to improve long-term stent patency [3]. This multicenter Italian study compared RBO rates between EUS-CDS performed with LAMS alone and LAMS combined with a coaxial DPS.

We conducted a retrospective analysis of consecutive patients who underwent EUS-CDS across eleven Italian tertiary centers between October 2023 and October 2025. Patients were stratified into two groups: LAMS-alone and LAMS-plus-DPS. The primary endpoint was the incidence of RBO after achieving clinical success. Secondary outcomes included technical and clinical success, adverse events (AEs), and reintervention rates.

A total of 192 patients were included (142 treated with LAMS alone and 50 with LAMS-plus-DPS). RBO occurred in 23/142 (16.2%) patients in the LAMS-alone group compared with 4/50 (8.0%) in the LAMS-plus-DPS group (risk ratio 2.02, 95% CI 0.74–5.57; p=0.23). Technical and clinical success rates exceeded 95% in both groups, and no significant differences were observed in adverse events or in the need for reintervention.

In this Italian multicenter experience, EUS-CDS using LAMS with a coaxial DPS was associated with a lower rate of RBO compared with LAMS alone. Although the difference was not statistically significant, the data support further investigation in larger, prospective trials to better define the role of DPS in optimizing long-term stent patency.