Practical Approaches for High-Risk Surgical Patients with Acute Cholecystitis: The Percutaneous Approach versus Endoscopic Alternatives

In high-risk surgical patients with acute cholecystitis who are not candidates for early laparoscopic cholecystectomy, gallbladder (GB) drainage is an alternative treatment option. Percutaneous transhepatic gallbladder drainage (PTGBD) is a recommended first line intervention because of its high efficacy and feasibility in most centers. However, with the advent of endoscopic accessories and technology, endoscopic GB drainage has been chosen as a more favorable choice by endoscopists. Endoscopic transpapillary gallbladder drainage (ETGBD) can be performed under either fluoroscopic or peroral cholangioscopic guidance via endoscopic retrograde cholangiopancreatography by the transpapillary placement of a long double-pigtail stent. In a patient with common bile duct stones, this procedure is accompanied with stone removal. ETGBD is especially useful for acute cholecystitis patients who are contraindicated for PTGBD or those with severe coagulopathy, thrombocytopenia, and abnormal anatomy. Moreover, the advantage of ETGBD is its preservation of the external GB structure. Thereby it would not disturb the future cholecystectomy. Recently, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using plastic, fully covered metallic, or lumen-apposing metal stents transmurally has emerged as a modality for GB drainage with higher technical and clinical success rates. EUS-GBD can provide a more permanent GB drainage than PTGBD and ETGBD.