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Traditional alternative methods, such as enteroscopy\u2010 or laparoscopy\u2010assisted ERCP, are associated with technical and logistical limitations. Endoscopic ultrasound (EUS)\u2010directed ERCP uses lumen\u2010apposing metal stents (LAMS) to create temporary anastomoses between adjacent lumens, thus restoring access for standard ERCP. These procedures include EUS\u2010directed transgastric (EDGE), transenteric (EDEE), transduodenal (EDDE), and transcholedochal\/transcystic (EDCE) ERCP. This review provides an evidence\u2010based analysis of the available techniques and comparative outcomes, with a particular focus on technical and strategic aspects including: (1) how to create an EUS\u2010guided anastomosis across different surgical scenarios; (2) how to perform a through\u2010the\u2010LAMS ERCP, including endoscope and accessory selection, ERCP timing and LAMS fixation; and (3) how to manage the fistula after completion of therapy, including timing of LAMS removal and fistula closure. An algorithm is proposed to guide the endoscopist through the complex decision\u2010making inherent to pancreatobiliary interventions in SAA.<\/jats:p>","DOI":"10.1111\/den.70098","type":"journal-article","created":{"date-parts":[[2026,2,3]],"date-time":"2026-02-03T07:21:32Z","timestamp":1770103292000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":5,"title":["Accessing the Pancreatobiliary System via Lumen\u2010Apposing Metal Stents: A State\u2010of\u2010the\u2010Art Review of Endoscopic Ultrasound\u2010Directed Interventions"],"prefix":"10.1111","volume":"38","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7280-1761","authenticated-orcid":false,"given":"Giuseppe","family":"Vanella","sequence":"first","affiliation":[{"name":"IRCCS San Raffaele Scientific Institute and Vita\u2010Salute University  Milan Italy"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-2039-5022","authenticated-orcid":false,"given":"Michiel","family":"Bronswijk","sequence":"additional","affiliation":[{"name":"University Hospitals Gasthuisberg, University of Leuven  Leuven Belgium"},{"name":"Imelda General Hospital  Bonheiden Belgium"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0001-8254-7453","authenticated-orcid":false,"given":"Enrique","family":"P\u00e9rez\u2010Cuadrado\u2010Robles","sequence":"additional","affiliation":[{"name":"Georges\u2010Pompidou European Hospital  Paris France"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roy L. 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