Outcomes of EUS-guided Gallbladder Drainage in Acute Cholecystitis with Contained Perforation: a prospective cohort

Aims EUS-guided Gallbladder Drainage (EUS-GBD) using a Lumen Apposing Metal Stent (LAMS) is an established treatment option for acute cholecystitis (AC) in unfit-for-surgery patients. However, gallbladder perforation is traditionally considered an absolute contraindication for EUS-GBD. This study reports the outcomes of EUS-GBD in patients with AC and contained perforation (cp-AC).

Methods All consecutive patients undergoing EUS-GBD at a single institution between 2020 and 2024 were enrolled in a prospective registry (PROTECT, ClinicalTrials.gov NCT04813055). Patients were considered to have cp-AC when imaging revealed a gallbladder wall rupture with adjacent encapsulated fluid collections. Baseline demographics and technical details were registered along with Technical success, Clinical success, Adverse Events (AEs), Recurrence and Survival prospectively evaluated every 60 days.

Results Of 48 patients who underwent EUS-GBD during study period, 19 presented with cp-AC (median age 71 [62-78], male 42.1%, Charlson Comorbidity Index 8 [7-10]). AC was iatrogenic in 79% of these cases (14 following ERCP with metal stenting, 1 after TACE). Cholecystectomy was avoided due to advanced underlying malignancy in 89.5% and comorbidities in 15.8%. Ascites was present in 26.3% of cases. 94.7% of procedures were performed transduodenally, with a median operative luminal space of 31 [25 – 36] mm and a median interluminal distance of 6 [5-8] mm. A 10x10 mm Hot Axios LAMS was used in 94.7% of cases, deployed either free-hand (89%) or over-the-wire (11%) after saline injection. Antibiotic prophylaxis and coaxial double-pigtail plastic stents were adopted in 94.7% of cases. Technical success was 100%. Clinical success was 94.7%, with a significant 7-days reduction of white blood cells and CRP. AEs rate was 21%, with severe/fatal events in 11%. Notably, 2 AEs (1 fatal) were related to attempted drainage of the liver abscesses adjacent to the GBD. Four patients (21%) underwent separate-session peroral cholecystoscopy for GBD clearance followed by LAMS removal without complications, while two (11%) patients experienced uneventful LAMS migration. Median hospital stay was 8 [6-13] days. Among patients eligible for oncological treatment (n=10), the median time to start/restart chemotherapy was 26 [19-56] days. Over a median follow-up of 254 [56-454] days, no AC recurrence was observed.

Conclusions In the setting of AC, contained perforation with adjacent collections doesn’t appear to contraindicate EUS-GBD with LAMS, despite the added complexity related to patient characteristics and gallbladder morphology (such as thicker interluminal distance). Additional attention should be paid to large adjacent abscesses, which require multidisciplinary management potentially including temporary percutaneous drainage.

Publication History

Article published online:
27 March 2025