Endoscopic ultrasound–guided choledochoduodenostomy (EUS-CDS) using a lumen-apposing metal stent (LAMS) has emerged as an alternative method for biliary drainage when endoscopic retrograde cholangiopancreatography (ERCP) fails, particularly in the management of malignant obstructive jaundice. Given the growing applicability of this procedure, especially in palliative settings, recognizing factors that influence procedural success is crucial. The aim of our study is to identify predictors of failure in EUS-CDS with LAMS in malignant biliary obstruction.

We conducted a retrospective single-center cohort study including patients with malignant obstructive jaundice who underwent EUS-CDS with LAMS, between 2018 and 2025. The following data were collected: patient and procedure details, adverse events, technical (correct placement of the LAMS) and clinical success (≥50% reduction in baseline bilirubin levels within four weeks). Univariable analysis was performed to identify predictors associated with technical failure. Statistical analysis included both parametric and non-parametric tests, chi-square and binomial logistic regression. A p-value < 0.05 was considered statistically significant.

A total of 31 patients were included (median age 71 [36–91] years, 48.5% female). Pancreatic cancer was the most common etiology of malignant biliary obstruction (MBO) (n=24, 77.4%). Technical success was 87.1%, with a clinical success rate of 96.3% among these patients. In our analysis, extrahepatic bile duct diameter of ≤15mm was not associated with increase odds of technical failure, although lower diameters were more common in this group (16 [9–24] vs 14 [12–17] mm, p=0.49). Non-pancreatic MBO (cholangiocarcinoma, ampullary cancer and metastasis) exhibited higher rates of technical failure (p=0.03). Technical failure was significantly associated with elevated C-reactive protein (CRP) levels (3.9 [1.1–10.3] vs 12.2 [1.1–15.0] mg/dL; p=0.02; OR = 1.49 [1.10–2.09]) and with severe hypoalbuminemia (<2.5 mg/dL) (7 (25.9%) vs 4 (100%); p=0.01; OR = 1.57 [1.11–2.46]). Median survival was 118 [7–1432] days.

The etiology of MBO and the interaction between pro-inflammatory evolving tumor microenvironment and nutritional deterioration, reflected by elevated CRP and severe hypoalbuminemia, may contribute to technical failure of EUS-CDS. These findings highlight the need for careful pre-procedural assessment.