Endoscopic ultrasound–guided choledochoduodenostomy (EUS-CDS) is a minimally invasive procedure for the management of malignant biliary obstruction (MBO), achieved through transduodenal placement of a lumen-apposing metal stent (LAMS) into the extrahepatic bile duct. Despite the recent widespread adoption of the technique, the existing literature encompasses a heterogeneous case mix in terms of procedural and clinical settings, along with variable study quality, which limits the generalizability of previous meta-analyses. To more reliably identify factors associated with safe and effective EUS-CDS using LAMS, we pooled data exclusively from high-quality prospective studies.

The methodology of our analysis was based on PRISMA recommendations. Electronic databases (Medline, Scopus, EMBASE) were searched up to September 2025 for prospective study including patients with distal malignant biliary obstruction who underwent EUS-CDS using LAMS. Meta-analysis was performed reporting pooled rates of technical success, clinical success, stent dysfunction, and adverse events (AEs) by means of a random model. Univariate meta-regression was performed to assess possible cause-effect associations between outcomes and both baseline, and procedural variables.

Thirteen studies comprising 662 patients were included in the meta-analysis. The pooled technical and clinical success rates were 95.0% (I² = 33.6%) and 89.7% (I² = 48.7%), respectively. Stent dysfunction occurred in 16.5% (I² = 73.3%) of cases over a mean follow-up period ranging from 30 to 360 days. Duodenal involvement and the use of a small-caliber LAMS (6 mm) were associated with an increased risk of stent dysfunction. Coaxial stent placement had no impact on the risk of stent dysfunction. The pooled adverse event rate was 19.2% (I² = 82.2%). Stent maldeployment was reported in 4.0% (I² = 0%) of cases, with smaller CBD diameter trending as a potential risk factor for this event (p: 0.056).

EUS-CDS with LAMS is a safe and effective option for relief of MBO. Avoiding patients with duodenal involvement and selecting an appropriate stent size is crucial for minimizing stent dysfunction.