EUS-Guided Gallbladder Drainage for Acute Cholecystitis in the Western World: Heterogeneity in Current Practice and...

Laparoscopic cholecystectomy is the standard treatment for acute cholecystitis (AC), but some patients are unfit for (immediate) surgery. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) is increasingly used in this population.

This multicenter cohort study aimed to evaluate practice patterns in EUS-GBD across Western centers and to identify factors that influence outcomes.

We retrospectively analyzed data from patients undergoing EUS-GBD for AC across 18 centers. Patient-related, procedural and outcome data were collected. The primary outcomes of interest were LAMS-related adverse events (AEs), recurrent biliary disease, recurrent acute cholecystitis, and all-cause mortality. Time-to-event analyses were performed using center-stratified Cox proportional hazards and Fine-Gray competing-risk models to identify LAMS procedural factors associated with clinical outcomes.

We included 496 patients with a median follow-up of 176 days (IQR 44-569). Technical and clinical success rates of EUS-GBD were 98.2% and 93.5%, respectively. LAMS-related AEs and recurrent biliary disease occurred in 11.1% and 18.8% of patients, respectively. Transduodenal access was associated with a lower cumulative incidence of LAMS-related AEs compared with transgastric access (SHR 0.42, 95% CI 0.23-0.76, p = 0.004) and lower rates of recurrent biliary disease and recurrent acute cholecystitis during follow-up. Larger LAMS diameters (> 10 mm) were associated with a lower risk of recurrent acute cholecystitis and all-cause mortality. No association between coaxial DPPS placement and improved long-term outcomes could be demonstrated after competing-risk adjustment. Among patients undergoing interval cholecystectomy (N = 46), LAMS-related conversion from laparoscopy to laparotomy occurred in 3 cases (6.5%).

In this large cohort study, transduodenal access route and choice of a large (> 10 mm) LAMS diameter were associated with improved outcomes of EUS-GBD. EUS-GBD may be a feasible option as a bridge to laparoscopic cholecystectomy, with limited risk of conversion to laparotomy. The findings of our study require prospective validation.