Standardising minimally invasive management in surgically unfit patients requiring cholecystectomy: Overview of current recommendations and future directions

Abstract

Percutaneous cholecystostomy (PC) is a minimally invasive radiological intervention that can rapidly decompress the gallbladder, provide symptomatic relief, and decrease systemic inflammation in surgically unfit patients with acute cholecystitis. It has its own risks and complications, including catheter dependence, migration, blockage, and leakage. Several recent studies and trials have reported that laparoscopic cholecystectomy (LC) yields better long-term outcomes than PC or PC with delayed LC. We read with interest the study published in the World Journal of Gastrointestinal Surgery by Hassanesfahani et al, who highlighted the importance of early PC, standardized catheter management protocols, and definitive interval LC for selected patients in improving the long-term outcomes of PC. We agree that evidence-based protocols for patient selection, timing of PC, interval to LC, catheter checks, and catheter removal should be incorporated into routine practice. In addition, endoscopic techniques, such as trans papillary gallbladder drainage and endoscopic ultrasound-guided stenting, are emerging as alternatives to PC, with lower readmission and complication rates. Depending on the availability of specialised personnel, endoscopic procedures should be preferred over PC for managing patients with acute cholecystitis who are unfit for surgery. This editorial reviews current recommendations and provides a framework for nonsurgical gallbladder drainage based on the available evidence.

Key Words: Cholecystectomy; Cholecystostomy; High-risk patients; Endoscopic ultrasound-guided gallbladder drainage; Endoscopic retrograde transpapillary gallbladder drainage

Core Tip: Percutaneous cholecystostomy (PC) has traditionally been the primary treatment for surgically unfit patients with acute cholecystitis; however, endoscopic gallbladder drainage techniques, such as endoscopic transpapillary drainage and endoscopic ultrasound-guided drainage, are emerging as effective alternatives with fewer reinterventions and enhanced patient comfort. While endoscopic procedures are preferred over PC whenever possible, PC with standardized protocols is still beneficial, especially due to wider availability, bedside feasibility and as it can be performed under local anaesthesia without the requirement of sedation or general anaesthesia. A multidisciplinary and standardized approach is crucial for optimizing the outcomes.

This editorial refers to “Defining endpoints in percutaneous cholecystostomy: Catheter management, patient survival, and long-term outcomes from a twelve-year retrospective study” by Hassanesfahani et al, 2026; https://dx.doi.org/10.4240/wjgs.v18.i2.115744.

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INTRODUCTION

In a recently published article in the World Journal of Gastrointestinal Surgery, Hassanesfahani et al[1] reported less favourable long-term outcomes of percutaneous cholecystostomy (PC) compared with laparoscopic cholecystectomy (LC). They emphasised the importance of patient selection, early PC, interval to LC, catheter checks, and appropriate catheter management at standardised intervals to improve quality of life and reduce morbidity. Currently, three modalities of gallbladder drainage (GBD) are in practice: PC, endoscopic trans papillary GBD (ET-GBD), and endoscopic ultrasound-guided GBD (EUS-GBD) (Figure 1). While the creation and adherence to standardised protocols will improve outcomes for patients undergoing PC, we also highlight emerging endoscopic alternatives that are increasingly replacing PC in patients unfit for surgery.

Figure 1 Routes of nonsurgical drainage of the gallbladder. 1: Transhepatic percutaneous cholecystostomy; 2: Transperitoneal percutaneous cholecystostomy; 3: Endoscopic ultrasound guided placement of lumen opposed metal stent; 4: Endoscopic trans papillary stenting.

LC was previously considered a contraindication for acute cholecystitis because of the difficulty of dissection due to inflammation and complications. With time and experience, LC has emerged as the procedure of choice for cholelithiasis and acute and chronic cholecystitis. Early surgery for acute cholecystitis, through the laparoscopic route, has been shown to reduce post-operative morbidity, pneumonia, wound infection rates, mortality and hospital stay[2]. Acute cholecystitis can be categorised into grade I or mild (healthy patient, mild inflammation, no organ dysfunction), grade II or moderate (any one: Leukocyte count > 18000/mm³, palpable tender mass in the right upper abdomen, duration of symptoms > 72 hours or marked local inflammation), and grade III or severe (organ dysfunction)[3]. According to the 2018 Tokyo guidelines, early LC is indicated in grade I cholecystitis if the patient can withstand surgery based on the Charlson comorbidity index and the American Society of Anaesthesiologists physical status classification scores. Otherwise, conservative treatment, including antibiotics and supportive care, is administered first, followed by delayed surgery. For grade II cholecystitis, LC can be performed at an advanced surgical centre if the patient is fit for surgery. Care must be taken to avoid injury, and a switch to open or subtotal cholecystectomy is considered based on the intraoperative findings. Unfit patients may require conservative management and/or biliary drainage. In patients with grade III cholecystitis, organ support and antimicrobials are provided. Based on recovery from organ dysfunction and Charlson comorbidity index and American Society of Anaesthesiologists physical status classification scores, early LC can be performed by a specialist in a tertiary care setting with intensive care unit facilities. If surgery is not possible, conservative management and early biliary drainage are done if the inflammation cannot be controlled[4].

In this editorial, we review the current role and recommendations for percutaneous and endoscopic cholecystostomy in the management of surgically unfit patients with grade II and III cholecystitis. The indications and follow-up of GBD using all three modalities are shown in Figure 2.

Figure 2 Algorithmic approach to non-surgical management of acute cholecystitis. GB: Gallbladder; EUS: Endoscopic ultrasound; GBD: Gallbladder drainage; LAMS: Lumen-apposing metal stents; DPT: Double pigtail stent; GI: Gastrointestinal.

LITERATURE SEARCH

We conducted keyword searches in PubMed and Google Scholar for articles on PC, ET-GBD, EUS-GBD, and LC. The most relevant and recent articles and guidelines, including retrospective studies, randomised controlled trials, systematic reviews and meta-analyses on procedural steps and modifications in PC, procedure, efficacy and safety of ET-GBD and EUS-GBD, and on the comparison between different techniques, were reviewed for best practices and current recommendations. In this article, we discuss the conventional procedural steps, modifications, follow-up recommendations, the safety and efficacy of various techniques, and comparisons between different techniques.

PC

PC, which began in the 1980s, is an image-guided (usually ultrasound-guided) procedure in which a pigtail catheter is placed into the gallbladder lumen. It can be useful in patients with calculous or acalculous cholecystitis, cholangitis, or biliary obstruction. Moreover, it can serve as a pathway for stone dissolution and extraction[5]. In intensive care unit patients, acute cholecystitis can be a cause of unexplained sepsis, as the diagnosis can be difficult to make, often confounded by ascites and difficulty in manoeuvring the patient for assessment of the gallbladder wall in the bedside setting. PC has been proven to be useful in such patients as well as in pregnant women with acute cholecystitis (as a minimally invasive bridge to post parturition surgery), and those with gallbladder perforation[5].

Pre-procedural work-up

Currently, there are no absolute contraindications for this procedure. Relative contraindications are coagulopathy, perihepatic ascites, persistently contracted or decompressed gallbladder, gallbladder packed with calculi, and malignancy of the gallbladder[6,7]. Because this procedure carries a moderate bleeding risk, the international normalized ratio should be less than 1.5, and the platelet count should be greater than 50000/μL; deranged parameters should be corrected with platelets and fresh frozen plasma. If uncorrectable, the procedure is still performed if absolutely indicated and lifesaving. Preoperative cross-sectional imaging is preferable, although not mandatory, to provide a baseline for post-procedural monitoring and to identify potential procedure-related complications[7]. Broad-spectrum antibiotics with adequate coverage of gram-negative bacteria, such as Escherichia coli, should be administered prior to the procedure. If the patient is not already on antibiotics and immediate parenteral therapy is required, a bolus dose of antibiotic (intravenous ceftriaxone or ampicillin/sulbactam; or, in case of penicillin allergy, vancomycin or clindamycin) is administered[7,8].

Procedure

The patient is positioned in a supine or semi-lateral position. The procedure can be performed under local anaesthesia (2% lignocaine), preferably with conscious intravenous sedation. Ultrasound guidance is preferred because it is faster, more readily available, allows real-time visualisation, and permits bedside catheter placement. In obese patients, emphysematous cholecystitis (non-visualisation beyond the air), bowel interposition between the gallbladder and the skin, and computed tomography (CT) guidance are required[7].

A transhepatic or transperitoneal approach can be used to access the gallbladder (Figure 1). Although the transhepatic route carries a risk of haemorrhage, it is a safe and stable route to the gallbladder. The subcostal transhepatic approach is preferable to the intercostal approach because it carries a lower risk of diaphragm, lung, or intercostal nerve bundle injury, resulting in less pain, fewer pneumothoraxes, fewer pleurobiliary fistulas, and less blood loss. The transperitoneal approach carries the risks of bile leakage, catheter slippage, and bowel injury. However, this route is preferred in cases of widespread hepatic masses or cysts that prevent a safe penetration of the liver[7,9].

An 8- or 10-F pigtail catheter is placed in the gallbladder using the trocar or Seldinger technique. In the trocar technique, a trocar system (catheter containing a stylet and needle) is advanced into the gallbladder. Once inside the lumen, the needle is removed, and the catheter is advanced further using the stylet. Real-time ultrasound visualisation is essential for the trocar technique; therefore, it is not performed under CT guidance[7]. The Seldinger technique can be performed under ultrasound or CT guidance. This involves puncturing the gallbladder with an 18-gauge needle and advancing a 0.035-inch stiff guidewire through the needle tract after confirming needle position in the lumen by bile aspiration. Serial dilatations are performed over the guidewire, followed by the advancement of the catheter, which coils into a pigtail once the guidewire is removed. Dilatation and catheter advancement may be performed under fluoroscopic visualisation to avoid guidewire dislodgement. The trocar technique is faster and easier to perform, results in less post-procedural pain, and is as effective as the Seldinger technique; however, the latter is usually considered safer, as the initial entry is through a smaller needle, thereby reducing the risk of erroneous punctures and complications[10,11]. The choice of entry approach depends on the operator’s expertise, the availability of fluoroscopy, the environment (bedside vs Cath lab), and the patient’s anatomical factors and body habitus. Smaller central venous catheters have also been used for bedside PC, as they are more readily available; however, there is a risk of catheter dislodgement due to a lack of pigtail formation and difficulty draining viscous contents with smaller-calibre catheters[7,12].

Post-procedural considerations

PC has a technical success rate of 95%-100% and complication rates of 2.4%-16%[13,14]. Daily catheter flushing with 10 mL of normal saline is recommended to prevent blockage. Complications include haemorrhage, haemobilia, bile leaks, and pneumothorax. Patients and caregivers must be trained in daily catheter flushing, dressing changes, and skin hygiene at the entry site. Caution must be exercised to avoid accidental catheter dislodgement in such cases. Catheter blockage and leaks caused by viscous contents can be addressed by upgrading the catheter size. If dislodgement is the cause, mature tracts (2-3 weeks) can be probed with a hydrophilic guidewire to regain access and place the catheter[7,15].

The timing of PC removal is variable; in one systematic review, it ranged from 2 days to 193 days, with a clinical success rate of 97.1%, a procedure-related morbidity rate of 34.3%, and a 30-day mortality rate of 11.4%[16]. If a cholecystectomy is planned, the catheter can be removed during surgery. If cholecystectomy is not planned, the catheter can still be removed if the cystic duct becomes patent and there is adequate tract maturity. Tract maturity and cystic duct patency can be assessed by fistulography, which involves exchanging the catheter for a sheath over a guidewire. Contrast is injected through the sheath while the sheath is gradually withdrawn to detect any abdominal leak and the passage of contrast into the duodenum, thereby ascertaining cystic duct patency. If a leak or no contrast passage beyond the gallbladder is noted, the catheter is reinserted into the gallbladder[7,9]. Alternatively, catheter clamping can be performed 1 month after insertion, and if the patient remains asymptomatic, the catheter can be removed without fistulography[17,18]. For long-term catheter placements in patients in whom cholecystectomy cannot be performed and the cystic duct is persistently not patent, scheduled catheter exchanges must be performed every three months. Internalisation via the cystic duct or cystic duct stenting can also be considered[19,20]. The recommendations and factors influencing the success of cholecystostomy are summarised in Table 1[4,15,20-25].

Table 1 Selected literature on evidence-based practices of percutaneous cholecystostomy and factors influencing its success.

Ref.	Type	Results/recommendation
Okamoto et al[4], 2018	Tokyo guidelines	Conservative treatment and biliary drainage to be considered in grade II and grade III acute cholecystitis if the patient cannot withstand surgery
Park et al[25], 2019	Retrospective study	PC to be kept for more than 6 weeks and to be clamped 1 weeks to 2 weeks before removal. For those with the presence of common bile duct stones, calculous cholecystitis, and underlying malignancy, PC must be left for a longer duration and observed for recurrent cholecystitis
Karakas et al[21], 2021	Review	Patients are clinically and radiologically (by ultrasound) assessed 3 days, 1 week, 4 weeks, and 6 weeks after PC. Clinical efficacy of the procedure is assessed on the 3rd day
Devane et al[15], 2020	Society of Interventional Radiology Quality Improvement Standards (guideline)	The majority of PC (> 95%) are indicated for acalculous or calculus cholecystitis in surgically unfit patients, or to provide a route for stone dissolution and extraction. Less than 5% PC are done for decompression of the biliary tree, diversion from bile leak, therapeutic access for bile duct procedures (dilatation, stenting or stone removal). Preprocedural antibiotics are to be given. Transhepatic route is preferred. Flushing of catheters to be done at least once per day to avoid tube occlusion
Abdelhalim et al[22], 2023	Meta analysis of 4 studies, 684 patients	Both transhepatic and transperitoneal approaches are safe. In this meta-analysis, although the overall rate of bleeding was significantly higher with the transhepatic approach, there were confounding factors due to technical differences between the studies
Koushesh et al[20], 2024	Review	Cholecystogram 4 weeks to 6 weeks following placement to evaluate catheter position, tract formation, and cystic duct patency
Lin et al[23], 2025	Retrospective cohort study	Urgent drainage is unnecessary for patients with grade I or II AC. Reductions in hospital stay were observed for patients with grade III AC who underwent PC within 6 hours, and for those with grade II AC who underwent PC within 24 hours of admission
Reinsoo et al[24], 2025	Retrospective cohort study	PC removal within 1 week from placement was non-inferior to delayed removal in terms of AC recurrence or readmission rates. The cumulative risk of recurrent cholecystitis plateaus within the first year after PC tube removal, with rare recurrences beyond this period

AC: Acute cholecystitis; PC: Percutaneous cholecystostomy.

Changing trends with endoscopic gallbladder drainage

The morbidity, contraindications, and recurrence of cholecystitis associated with PC led to the development of endoscopic GBD. Endoscopic GBD can be performed via trans papillary or transmural access. Endoscopic drainage omits external drainage and its associated adverse events. Although advancements in EUS-GBD have largely superseded ET-GBD, the latter remains a viable option in specific clinical scenarios.

ET-GBD

ET-GBD is performed during endoscopic retrograde cholangiopancreatography (ERCP) by cannulating the cystic duct and placing a plastic stent in the gallbladder. ET-GBD is preferred in patients with severe ascites, severe coagulopathy, portal hypertension with significant collaterals around the gallbladder, or when the gallbladder is far from the gastroduodenal wall in the case of EUS-GBD access[26]. ET-GBD allows natural drainage of the gallbladder and may be advantageous if the patient becomes a surgical candidate in the future.

Technical details of ET-GBD

After biliary cannulation, a standard cholangiogram is performed to identify the orientation and location of the cystic duct. The biliary catheter is then advanced near the cystic duct opening, and cystic duct cannulation is attempted using a 0.035-inch angled guide wire. The wire is carefully navigated through the tortuous cystic duct, across the valves of Heister, and coiled in the gallbladder. If the initial cannulation techniques fail, further assessment of the cystic duct with contrast, use of a small guidewire (0.018 inch), utilisation of multiple guidewires with a Haber ramp catheter, or balloon occlusion of the common bile duct can be performed to facilitate cystic duct cannulation. Cholangioscopy can also facilitate cystic duct cannulation. Once cannulation is achieved, if severe cystic duct narrowing is noted, the cystic duct is dilated with a 3-4 mm coronary balloon, and the gallbladder is stented. Typically, 5 Fr or 7 Fr double-pigtail plastic stents of variable length are used. If gallbladder stenting is effective, plastic stents can be left in place indefinitely to manage acute cholecystitis. Routine exchange is generally not performed, except in cases of recurrent cholecystitis[27].

Efficacy and safety of ET-GBD

Evidence on the efficacy and safety of trans papillary GB drainage is predominantly from observational studies and a few randomized controlled trials. The randomized controlled trials published on ET-GBD are summarised in Table 2[28-34]. Jandura and Puli[30] conducted a meta-analysis of 21 studies involving 1307 patients, showing that the pooled technical success rate was approximately 82.6%, the clinical success rate was approximately 94.9%, the overall complication rate was approximately 8.8%, and the recurrence rate was 1.5% (Table 2). This meta-analysis included three studies with follow-up periods of up to 3 years and reported a rate of recurrent biliary complications, including cholangitis, distal stent migration, and biliary pain, ranging from 9% to 20%[30]. Mohan et al[35] conducted a meta-analysis comparing the three modalities of GBD (percutaneous, transpapillary, and transmural) and found that technical success (83% vs 95.3%) and clinical success (88.1% vs 96.7%) were lower with ET-GBD than with EUS-GBD. Overall, the complications were comparable across all three groups. However, stent migration was more frequent in the PC group. As with PC, ET-GBD provides only a temporary measure for acute cholecystitis, with recurrent biliary colic and cholecystitis occurring in 10% of patients after a median follow-up of 17 months[36,37]. This recurrent cholecystitis can be prevented by placing a dual double pigtail stent, which may provide effective drainage of pus and debris and reduce the risk of obstruction. Haddad et al[32] showed that unplanned reintervention was significantly lower in the double-stenting group (0% vs 25.4%; P = 0.02).

Table 2 Efficacy and safety of endoscopic gallbladder drainage.

Ref.	Study population	Results/recommendation
Itoi et al[28], 2015	RCT; ENGBD (n = 37) by 5F or 7F tube; ET-GBD (n = 36) by 7F stent	Similar technical and clinical success, adverse event is higher in ENGBD group than ET-GBD (2 vs 1)
Sobani et al[29], 2021	Retrospective study; (n = 21); dual stenting	Second stent placed simultaneously or after an interval. The median interval between the placement of the first and the second stents was 37 days. Technical and clinical success rates were 100% with adverse events in 9.2%
Jandura and Puli[30], 2021	Meta analysis. 21 studies, 1307 patients	The pooled technical success rate was (82.62%), and the clinical success rate (94.87%). The pooled overall complication rate was 8.83% (bleeding 1.03%, perforation 0.78%, peritonitis/bile leak 0.45% and pancreatitis 1.98%). The pooled rates of stent occlusion and migration were 0.39% and 1.3%, respectively. The pooled recurrence rate of cholecystitis following ET-GBD was 1.48%
Ridtitid et al[31], 2024	RCT. ET-GBD (n = 60); only antibiotic (n = 60)	ET-GBD has a significantly lower rate of recurrent cholecystitis compared to the no ET-GBD group; most recurrences occurred within 3 months of acute cholecystitis
Haddad et al[32], 2025	Multicentre retrospective study. Single vs double stent (59 vs 16)	Overall technical and clinical success 88.2% and 81.3%, respectively. Unplanned reintervention was lower in the double-stenting group (0.5% vs 25.4%)
Nakahara et al[33], 2025	Retrospective study ET-GBD for gangrenous acute cholecystitis. GC (n = 29) and non-GC (n = 62)	The technical success rate, clinical success rate for acute cholecystitis, and rate of early adverse events are similar in both GC and non-GC groups [86.2% vs 91.9% (P = 0.63), 79.3% vs 91.9% (P = 0.17), and 27.6% vs 16.1% (P = 0.32)]
Amin et al[34], 2025	Multicenter retrospective. ET-GBD (n = 73); dual 7 Fr DPT used EUS-GBD (n = 56)	No significant difference in technical or clinical success. Similar rate of repeat procedure, recurrent cholecystitis in the ET-GBD compared to the EUS-GBD group

RCT: Randomized controlled trial; ENGBD: Endoscopic naso-gallbladder drainage; ET-GBD: Endoscopic trans papillary gallbladder drainage; GC: Gangrenous cholecystitis; DPT: Double pigtail stent; EUS-GBD: Endoscopic ultrasound-guided gallbladder drainage; GBD: Gallbladder drainage.

Limitations of ET-GBD

ET-GBD requires skill in guiding the wire through the cystic duct, and guidelines emphasise that it should be performed in high-volume centres by experienced endoscopists. It is associated with all ERCP complications. The rate of acute pancreatitis in ET-GTB is 2.5%-15%, which is particularly concerning in high-risk, fragile patients undergoing ET-GBD[30,38]. Obstructive pathologies of the cystic duct (such as stones, strictures, or masses) associated with acute cholecystitis may result in lower technical and clinical success rates than those of other modalities[39].

Current status of ET-GBD

Multiple studies have demonstrated higher technical and clinical success rates and lower reintervention rates with EUS-GBD than with ET-GBD[34,40,41]. However, ET-GBD remains the preferred option for certain patients and is more cost-effective than EUS-GBD. Its ability to preserve the patient’s anatomy and the integrity of the gallbladder wall, thereby reducing procedure-related fibrosis and adhesions, could benefit patients who may later become surgical candidates for cholecystectomy. For patients requiring ERCP for other indications, such as choledocholithiasis, both ET-GBD and ERCP can be performed during the same procedure, thereby reducing the number of interventions required. It is considered the preferred option over EUS-GBD and PC in patients with severe coagulopathy, thrombocytopenia, or large-volume abdominal ascites.

EUS-GBD

EUS-GBD, first documented in 2007, has expanded its therapeutic indications in the past decade[42]. With the advent of cautery-enabled lumen-apposing metal stents (LAMS), the procedure has become simpler and safer, further reinforcing the role of EUS-GBD in GBD. EUS-GBD is a valuable alternative for palliation in patients in whom ERCP has failed or who are unsuitable for traditional techniques. The indications for EUS-GBD include high-risk surgical patients with acute cholecystitis, bridge therapy until cholecystectomy, gateway for cholecystolithotomy, internalisation of PC, and rescue therapy in failed ERCP for distal biliary obstruction[43]. The American Gastroenterological Association recommends EUS-GBD over PC in patients who can undergo safe sedation without the risk of gallbladder perforation[26]. However, recent Italian guidelines do not recommend EUS-GBD as the first-line treatment for patients who may be fit for surgery in the future[44].

Technical aspects

EUS-GBD is generally performed under monitored anaesthesia with or without endotracheal intubation. A curved linear array oblique-viewing therapeutic echoendoscope is recommended for EUS-GBD. Adequate pre- and post-antibiotic prophylaxis, as described previously, should be administered. The gallbladder neck is accessible via the first part of the duodenum, whereas the body or fundus is accessible via the stomach. The duodenum, being closer and less mobile, poses a lower risk of stent migration than the trans gastric route. Additionally, the transduodenal route reduces the risk of food reflux[45]. However, transgastric puncture is easier owing to the echoendoscope’s position, and cholecystectomy is simpler in patients who have undergone EUS-GBD via the transgastric route than in those who have undergone the transduodenal route[46]. A recent study comparing the transgastric and transduodenal approaches to EUS-GBD found no significant differences in technical or clinical success; however, the transduodenal route had more misdeployments[47].

EUS-GBD involves placing a covered self-expandable metal stent or LAMS between the gallbladder and duodenum (cholecystoduodenostomy) or stomach (cholecystogastrostomy). With the advent of hot LAMS, the use of tubular self-expanding metallic self-expandable metal stent through traditional puncture, dilation, and placement of tubular stents in the gallbladder has been significantly reduced. Because of the risk of migration associated with plastic or tubular stents (as they lack an opposing force), these stents are not preferred for transmural drainage. Using a linear echoendoscope, the avascular plane between the duodenum or stomach and gallbladder is identified, and a LAMS is deployed using a single-step EUS-guided delivery system. The gallbladder is punctured using a cautery-enhanced device, and a LAMS catheter is advanced into the lumen. The distal flange is deployed under EUS guidance, with the flanges opposed to the gallbladder wall by a slight retraction[44]. The proximal flange is then released under endoscopic guidance. A 7-Fr or 10-Fr double-plume drainage tube (DPT) can be placed for LAMS stabilisation to prevent stent-induced abrasion of the gallbladder wall. As with other interventional EUS procedures, post-procedural follow-up is required. In patients with a shorter life expectancy, LAMS can be placed in situ. In patients with expected normal life expectancy but who are not surgical candidates, replacing the LAMS with a DPT alone after 4-6 weeks has been shown to reduce complications. The DPT can be left in place indefinitely and exchanged if symptoms recur[43].

Efficacy and safety of EUS-GBD

EUS-GBD is associated with higher technical and clinical success rates than percutaneous transhepatic-GBD and ET-GBD. The technical and clinical success rates of EUS-GBD range from 93% to 98.4%[35,41]. In addition, it has been shown to have lower rates of reintervention than other GBD routes. A recent meta-analysis by Hu et al[41] compared three gallbladder drainage modalities. This study included 2251 patients from 17 trials and showed that both PC and EUS-GBD had superior technical success, with comparable clinical success and procedure-related adverse events. In the ranking analysis, EUS-GBD had the highest clinical success rate, whereas PC had the highest technical success rate.

Earlier studies have warned that interval cholecystectomy can be difficult for patients with EUS-GBD, often resulting in a high rate of conversion from laparoscopic to open cholecystectomy. A multicentre study by Tyberg et al[48] compared surgical technical success between patients who underwent PC and EUS-GBD. They also showed that patients who underwent EUS-GBD underwent an earlier cholecystectomy than those who underwent PC-GBD (38 days vs 70 days). However, surgical success was lower (93.5% vs 98%) and surgical time was shorter (84.2 minutes vs 168 minutes, P < 0.00001) in the EUS-GBD group. The incidence of intraoperative surgical complications was similar between the groups, and the rate of laparoscopic-to-open cholecystectomy conversion was comparable (11% vs 19%; P = 0.234). A meta-analysis also examined the outcomes of interval cholecystectomy in patients who underwent EUS-GBD, revealing that approximately 32.9% of patients across the trials underwent surgery[49]. Most patients underwent LC (76.2%), and only 14% required conversion from laparoscopy to an open cholecystectomy procedure. The removal of LAMS and endoscopic fistula closure are recommended before performing cholecystectomy.

The EUS-GBD fistula tract can be used for future cholecystolithotomy, and several observational studies have shown high technical success rates, with stone clearance rates ranging from 88% to 97%[50,51]. However, a meta-analysis indicated that EUS-guided cholecystolithotomy is associated with high adverse event rates, such as fever, peritonitis, and bleeding[51]. Cholecystoscopy should be performed 4 weeks after EUS-GBD to achieve definitive endotherapy before replacing the LAMS with a DPT[43]. A meta-analysis by Canakis et al[52] investigated the long-term (> 1 year) clinical outcomes of EUS-GBD. In this study, the recurrence rate of cholecystitis was 4.2%, the readmission rate was 19%, and the reintervention rate was 6% 1 year after the intervention. The need for repeat endoscopy due to stent obstruction or occlusion was 2.9%, with a median stent patency of 418.8 days[52]. Another indication for EUS-GBD is the need for rescue biliary drainage after failed ERCP. The published literature has shown high technical and clinical success rates in this subgroup[53]. EUS-GBD for malignant biliary obstruction requires a patent cystic duct for biliary drainage. A summary of studies comparing the utility of LC, PC, and endoscopic GBD is presented in Table 3[40,41,48,54-62].

Table 3 Comparison of percutaneous cholecystostomy and laparoscopic cholecystectomy, endoscopic trans papillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage.

Ref.	Sample	Results/recommendation
Zehetner et al[54], 2014	Retrospective matched pair analysis, PC = 23, LC = 23	PC failed to show a significant reduction in morbidity compared with LC and was associated with a significantly longer hospital stay
Loftus et al[55], 2017	Retrospective cohort analysis, PC = 114, cholecystectomy = 234	Persistent systemic inflammation and higher long-term mortality with PC than with cholecystectomy
Loozen et al[56], 2018	Multicentre RCT, PC = 68, LC = 66	Laparoscopic cholecystectomy is superior to percutaneous catheter drainage for acute calculous cholecystitis. Cholecystectomy not only reduced the rate of major complications, but also reduced utilisation of healthcare resources and costs by more than 30%
Siddiqui et al[40], 2019	Multicentre retrospective study, PC (n = 146), ET-GBD (n = 124), EUS-GBD (n = 102)	Technical and clinical success were higher in both PC and EUS-GBD compared to the ET-GBD group. Hospital stay was lower with the EUS-GBD group. Complications and higher surgical interventions in the PC group
Mu et al[62], 2021	RCT, PC (n = 11), EN-GBD (n = 11)	The EN-GBD group presented less pain and less surgical difficulties (less haemorrhage, abdominal drain placement) during cholecystectomy procedures. Similar adverse events
Nassar et al[57], 2022	Meta analysis. 14 studies, PC = 11565, early cholecystectomy = 205361	Early cholecystectomy is preferred over PC. However, patient and disease-specific factors should be considered to avoid unfavourable outcomes with early LC
Kaneta et al[58], 2022	Retrospective study, PC = 26, ET-GBD = 7	No significant difference was observed between the ET-GBD and PC groups in terms of surgery duration or bleeding amount when surgery was performed after gallbladder drainage for acute cholecystitis. Therefore, ET-GBD was considered a useful preoperative drainage method that did not require a drainage bag
Tyberg et al[48], 2023	Retrospective cohort study, PC = 93, EUS-GBD = 46	EUS-GBD had a significantly shorter interval between gallbladder drainage and cholecystectomy, shorter surgical procedure times, and shorter length of stay for the cholecystectomy compared with PC
Boregowda et al[59], 2023	Meta analysis, 11 studies, PC = 698, EUS-GBD = 477	EUS-GBD is a safe and effective alternative to PC for treating acute cholecystitis in non-surgical patients with fewer adverse events and a lower reintervention rate than PC
Fanciulli et al[60], 2025	Meta analysis, 27 studies, 16 comparing PC and cholecystectomy, 11 comparing PC and PC with delayed cholecystectomy	Cholecystectomy is associated with better outcomes, including lower mortality and readmission rates, compared to both PC alone and PC followed by CC. The combined approach did not show a significant advantage over immediate CC
Pawa et al[61], 2025	Retrospective study, PC = 57, EUS-GBD = 57	EUS-GBD is superior to PC, requiring fewer gallbladder-related procedures and lower rates of adverse events. It has emerged as the preferred non-surgical alternative in the management of patients with AC who are poor surgical candidates
Hu et al[41], 2025	Meta-analysis of 17 trials and 2254 patients, PT-GBD vs ET-GBD vs EUS-GBD	Technical and clinical success lower in ET-GBD compared to other groups. Procedure related adverse events are similar across the groups

PC: Percutaneous cholecystostomy; LC: Laparoscopic cholecystectomy; RCT: Randomized controlled trial; ET-GBD: Endoscopic trans papillary gallbladder drainage; EUS-GBD: Endoscopic ultrasound-guided gallbladder drainage; EN-GBD: Endoscopic naso-gallbladder drainage; PT-GBD: Percutaneous transhepatic gallbladder drainage; CC: Cholecystectomy; AC: Acute cholecystitis.

Limitations of EUS-GBD

In surgically unfit patients, EUS-GBD is a technically challenging, operator-dependent procedure that should only be performed by experienced interventional endoscopists at specialised centres with surgical and radiological backup. These high-risk patients often have significant comorbidities, coagulopathy, ascites, or advanced malignancy, which increase the risk of procedure-related adverse events. The overall adverse events associated with EUS-GBD range from 7% to 32%, with recurrent cholecystitis, bleeding, bile leak, perforation, stent blockage or migration, and peritonitis being commonly reported[43,63,64].

Current role of EUS-GBD

With the advent of cautery-enabled LAMS, EUS-GBD has rapidly evolved into a reliable, minimally invasive option for managing acute cholecystitis in patients with high surgical risk or surgical unfitness. It is increasingly favoured over PC due to fewer procedures and improved patient comfort. Emerging data suggest that the applications of this technique should be expanded beyond acute cholecystitis to include malignant biliary obstruction and interval approaches prior to delayed cholecystectomy. However, adverse events associated with it can have devastating effects on high-risk patients. Nevertheless, optimal indications, long-term management, and consensus guidelines continue to evolve, underscoring the need for high-quality evidence and expert collaboration in this field.

FUTURE DIRECTIONS

With the increasing number of elderly patients and those with multiple comorbidities, the population considered unfit for cholecystectomy continues to expand, making nonsurgical GBD an increasingly vital treatment option. In this high-risk subgroup of patients with acute cholecystitis, non-surgical GBD has shifted from a temporary measure to a definitive therapeutic strategy. Although PC remains widely available, its limitations with respect to patient comfort, reintervention rates, and long-term outcomes are increasingly apparent. As highlighted by Hassanesfahani et al[1], there is a need for consensus guidelines on pre-procedural patient selection, procedural techniques, and post-procedural follow-up for PC, including catheter care and conversion to LC, to enhance long-term outcomes in surgically unfit patients requiring GBD. As an alternative, endoscopic methods, especially EUS-GBD, provide superior clinical success with fewer adverse events and improved quality of life when performed at expert centres. However, the main limitations of endoscopic techniques are that they are more invasive than PC, require sedation or general anaesthesia and experienced personnel to perform them. PC, on the other hand, is more widely available and can even be performed at the bedside under local anaesthesia. As evidence continues to accumulate, standardised, patient-centred algorithms incorporating standardised protocols on PC and, wherever possible, endoscopic techniques should become a core aspect of modern gallbladder disease management.

CONCLUSION

Early PC in grade II-III acute cholecystitis, standardized catheter management protocols including daily catheter flushing, follow up ultrasound, clamping before removal at 6 weeks and interval LC can improve the long-term outcomes of PC. With increasing experience and availability of endoscopic procedures, ET-GBD and EUS-GBD should be incorporated into the management algorithm and preferred over PC for GBD whenever feasible.