EUS-Guided Choledochoduodenostomy With Lumen-Apposing Metal Stents: A Recommendation From an Expert Delphi Consensus

Background and Aims Endoscopic ultrasound-guided choledochoduodenostomy with a lumen apposing metal stent (EUS-CDS-L) is an increasingly utilized therapeutic option for biliary drainage. However, numerous procedural and periprocedural factors may influence technical and clinical outcomes. The aim of this study was to develop an expert consensus on key recommendations for EUS-CDS-L.Methods Thirty-two international experts in EUS-CDS-L contributed to this Delphi process over two rounds by voting anonymously on 28 statements using a five-point Likert scale. Statements were accepted in the first round or revised in the second round based on an agreement level of >= 80%, with a median >= 4, and an interquartile range (IQR) <= 1.Results 28 statements were initially circulated, 2 were removed, and 26 were considered for final consensus. A consensus was achieved for 24 of 26 (92.3%) statements after two voting rounds across the three domains, with the first focusing on indications: (1) the preference for EUS-CDS-L in distal malignant biliary obstruction (DMBO) without gastric outlet obstruction (GOO); (2) the inclusion of EUS-CDS-L as a therapeutic option in benign biliary obstruction, and (3) the performance of EUS-CDS-L in patients scheduled for upfront surgery. A second domain focused on procedural considerations: (1) the preferred cutoff of common bile duct (CBD) diameter for safe EUS-CDS-L, and (2) the lack of evidence for antibiotic prophylaxis, and several technical steps in the recommended deployment process.Conclusion This modified Delphi consensus provides international expert panel agreement on several key aspects of EUS-CDS-L, while also highlighting areas that require further research.