{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T08:07:04Z","timestamp":1784102824406,"version":"3.55.0"},"reference-count":51,"publisher":"MDPI AG","issue":"14","license":[{"start":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T00:00:00Z","timestamp":1784073600000},"content-version":"vor","delay-in-days":0,"URL":"https:\/\/creativecommons.org\/licenses\/by\/4.0\/"}],"content-domain":{"domain":[],"crossmark-restriction":false},"short-container-title":["JCM"],"abstract":"<jats:p>Acute cholecystitis (AC) is one of the most prevalent gastrointestinal emergencies, with laparoscopic cholecystectomy representing the definitive treatment per current guidelines. However, a substantial proportion of patients\u2014particularly elderly individuals with major comorbidities, multiorgan dysfunction, or advanced malignancy\u2014are considered poor surgical candidates in whom operative intervention carries prohibitive risk. Although percutaneous transhepatic gallbladder drainage (PT-GBD) has traditionally served as the first-line non-surgical alternative, its significant morbidity and technical limitations in patients with coagulopathy, massive ascites, or an unsafe percutaneous window have driven the development of endoscopic drainage modalities. This review critically appraises the comparative evidence for two endoscopic gallbladder drainage strategies: endoscopic transpapillary gallbladder drainage (ET-GBD), performed via endoscopic retrograde cholangiopancreatography, and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), most commonly using lumen-apposing metal stents (LAMS). In appropriately selected high-risk surgical candidates, EUS-GBD with LAMS has emerged as a preferred endoscopic option, supported by high technical success rates, low recurrent AC rates, AGA expert guidance, and FDA regulatory reclassification of the AXIOS stent for gallbladder drainage. Nevertheless, ET-GBD retains distinct clinical indications, including concurrent biliary intervention, large-volume ascites, high bleeding risk, anticipated surgical candidacy, and resource-limited settings. Optimal management requires a systematic, algorithm-driven multidisciplinary approach integrating comorbidity profile, biliary anatomy, cystic duct patency, and institutional expertise.<\/jats:p>","DOI":"10.3390\/jcm15145536","type":"journal-article","created":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T07:29:39Z","timestamp":1784100579000},"page":"5536","update-policy":"https:\/\/doi.org\/10.3390\/mdpi_crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Clinical Challenges in Acute Cholecystitis: Endoscopic Drainage Strategies (EUS-GBD vs. ET-GBD) in Patients with Surgical Contraindications"],"prefix":"10.3390","volume":"15","author":[{"given":"Dong Wook","family":"Lee","sequence":"first","affiliation":[{"name":"Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-9903-1282","authenticated-orcid":false,"given":"Chang Min","family":"Cho","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine, School of Medicine, Kyungpook National University, Daegu 41944, Republic of Korea"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"1968","published-online":{"date-parts":[[2026,7,15]]},"reference":[{"key":"ref_1","doi-asserted-by":"crossref","first-page":"41","DOI":"10.1002\/jhbp.515","article-title":"Tokyo Guidelines 2018: Diagnostic criteria and severity grading of acute cholecystitis (with videos)","volume":"25","author":"Yokoe","year":"2018","journal-title":"J. Hepato-Biliary-Pancreat. Sci."},{"key":"ref_2","doi-asserted-by":"crossref","first-page":"183","DOI":"10.1111\/j.1477-2574.2009.00052.x","article-title":"Systematic review of cholecystostomy as a treatment option in acute cholecystitis","volume":"11","author":"Winbladh","year":"2009","journal-title":"HPB"},{"key":"ref_3","doi-asserted-by":"crossref","first-page":"1343","DOI":"10.1007\/s00464-011-2035-0","article-title":"Short- and long-term outcomes following percutaneous cholecystostomy for acute cholecystitis in high-risk patients","volume":"26","author":"McKay","year":"2012","journal-title":"Surg. Endosc."},{"key":"ref_4","doi-asserted-by":"crossref","unstructured":"Troncone, E., Amendola, R., Moscardelli, A., De Cristofaro, E., De Vico, P., Paoluzi, O.A., Monteleone, G., Perez-Miranda, M., and Del Vecchio Blanco, G. (2024). Endoscopic Gallbladder Drainage: A Comprehensive Review on Indications, Techniques, and Future Perspectives. Medicina, 60.","DOI":"10.3390\/medicina60040633"},{"key":"ref_5","doi-asserted-by":"crossref","first-page":"96","DOI":"10.1055\/a-1020-3932","article-title":"Endoscopic ultrasound-guided gallbladder drainage, transpapillary drainage, or percutaneous drainage in high-risk acute cholecystitis patients: A systematic review and comparative meta-analysis","volume":"52","author":"Mohan","year":"2020","journal-title":"Endoscopy"},{"key":"ref_6","doi-asserted-by":"crossref","first-page":"523","DOI":"10.1016\/S0016-5107(90)71134-0","article-title":"Endoscopic transpapillary drainage of gallbladder empyema","volume":"36","author":"Feretis","year":"1990","journal-title":"Gastrointest. Endosc."},{"key":"ref_7","doi-asserted-by":"crossref","first-page":"81","DOI":"10.1007\/s00534-012-0570-2","article-title":"TG13 indications and techniques for gallbladder drainage in acute cholecystitis (with videos)","volume":"20","author":"Tsuyuguchi","year":"2013","journal-title":"J. Hepato-Biliary-Pancreat. Sci."},{"key":"ref_8","doi-asserted-by":"crossref","first-page":"87","DOI":"10.1002\/jhbp.504","article-title":"Tokyo Guidelines 2018: Management strategies for gallbladder drainage in patients with acute cholecystitis (with videos)","volume":"25","author":"Mori","year":"2018","journal-title":"J. Hepato-Biliary-Pancreat. Sci."},{"key":"ref_9","doi-asserted-by":"crossref","first-page":"1904","DOI":"10.1007\/s00464-020-07409-7","article-title":"EUS-guided versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis: A systematic review and meta-analysis","volume":"34","author":"Krishnamoorthi","year":"2020","journal-title":"Surg. Endosc."},{"key":"ref_10","doi-asserted-by":"crossref","first-page":"483","DOI":"10.1016\/j.gie.2019.04.238","article-title":"EUS-guided gallbladder drainage with a lumen-apposing metal stent versus endoscopic transpapillary gallbladder drainage for the treatment of acute cholecystitis (with videos)","volume":"90","author":"Higa","year":"2019","journal-title":"Gastrointest. Endosc."},{"key":"ref_11","doi-asserted-by":"crossref","first-page":"362","DOI":"10.1016\/j.gie.2023.04.002","article-title":"Comparison of long-term outcomes of EUS-guided gallbladder drainage and endoscopic transpapillary gallbladder drainage for calculous cholecystitis in poor surgical candidates: A multicenter propensity score-matched analysis","volume":"98","author":"Inoue","year":"2023","journal-title":"Gastrointest. Endosc."},{"key":"ref_12","doi-asserted-by":"crossref","first-page":"289","DOI":"10.1016\/j.gie.2018.08.052","article-title":"EUS-guided gallbladder drainage versus endoscopic transpapillary gallbladder drainage in high-risk surgical patients with acute cholecystitis","volume":"89","author":"Oh","year":"2019","journal-title":"Gastrointest. Endosc."},{"key":"ref_13","doi-asserted-by":"crossref","first-page":"735","DOI":"10.1016\/j.gie.2006.07.041","article-title":"Endoscopic transduodenal drainage of the gallbladder: Implications for endoluminal treatment of gallbladder disease","volume":"65","author":"Baron","year":"2007","journal-title":"Gastrointest. Endosc."},{"key":"ref_14","doi-asserted-by":"crossref","first-page":"1008","DOI":"10.1016\/j.gie.2007.03.1080","article-title":"EUS-guided transmural cholecystostomy as rescue management for acute cholecystitis in elderly or high-risk patients: A prospective feasibility study","volume":"66","author":"Lee","year":"2007","journal-title":"Gastrointest. Endosc."},{"key":"ref_15","doi-asserted-by":"crossref","first-page":"582","DOI":"10.1016\/j.gie.2007.02.065","article-title":"EUS-guided cholecystenterostomy: A new technique (with videos)","volume":"66","author":"Kwan","year":"2007","journal-title":"Gastrointest. Endosc."},{"key":"ref_16","doi-asserted-by":"crossref","first-page":"634","DOI":"10.1016\/j.gie.2009.11.024","article-title":"EUS-guided cholecystoenterostomy with single-step placement of a 7F double-pigtail plastic stent in patients who are unsuitable for cholecystectomy: A pilot study (with video)","volume":"71","author":"Song","year":"2010","journal-title":"Gastrointest. Endosc."},{"key":"ref_17","doi-asserted-by":"crossref","first-page":"805","DOI":"10.1053\/j.gastro.2011.12.051","article-title":"Endoscopic ultrasound-guided transmural and percutaneous transhepatic gallbladder drainage are comparable for acute cholecystitis","volume":"142","author":"Jang","year":"2012","journal-title":"Gastroenterology"},{"key":"ref_18","doi-asserted-by":"crossref","first-page":"5200","DOI":"10.1007\/s00464-016-4894-x","article-title":"Endoscopic ultrasound-guided transmural stenting for gallbladder drainage in high-risk patients with acute cholecystitis: A systematic review and pooled analysis","volume":"30","author":"Anderloni","year":"2016","journal-title":"Surg. Endosc."},{"key":"ref_19","doi-asserted-by":"crossref","first-page":"525","DOI":"10.1111\/den.12221","article-title":"Endoscopic ultrasound-guided endoluminal drainage of the gallbladder","volume":"26","author":"Widmer","year":"2014","journal-title":"Dig. Endosc."},{"key":"ref_20","doi-asserted-by":"crossref","first-page":"656","DOI":"10.1055\/s-0034-1365720","article-title":"Long-term outcomes after endoscopic ultrasonography-guided gallbladder drainage for acute cholecystitis","volume":"46","author":"Choi","year":"2014","journal-title":"Endoscopy"},{"key":"ref_21","doi-asserted-by":"crossref","first-page":"1141","DOI":"10.1016\/j.cgh.2022.12.039","article-title":"AGA Clinical Practice Update on Role of EUS-Guided Gallbladder Drainage in Acute Cholecystitis: Commentary","volume":"21","author":"Irani","year":"2023","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_22","unstructured":"U.S. Food and Drug Administration (2023, August 01). De Novo Classification Request for the AXIOS Stent and Electrocautery Enhanced Delivery System (DEN230019), Available online: https:\/\/www.accessdata.fda.gov\/cdrh_docs\/reviews\/DEN230019.pdf."},{"key":"ref_23","doi-asserted-by":"crossref","first-page":"2054","DOI":"10.1136\/gutjnl-2016-312812","article-title":"Lumen-apposing metal stents (LAMS) for drainage of pancreatic fluid collections: May not be business as usual","volume":"66","author":"Bang","year":"2017","journal-title":"Gut"},{"key":"ref_24","doi-asserted-by":"crossref","first-page":"303","DOI":"10.1016\/j.gie.2012.09.021","article-title":"EUS-guided transenteric gallbladder drainage with a new fistula-forming, lumen-apposing metal stent","volume":"77","author":"Alcaide","year":"2013","journal-title":"Gastrointest. Endosc."},{"key":"ref_25","doi-asserted-by":"crossref","first-page":"1110","DOI":"10.1016\/j.gie.2015.05.045","article-title":"EUS-guided gallbladder drainage with a lumen-apposing metal stent (with video)","volume":"82","author":"Irani","year":"2015","journal-title":"Gastrointest. Endosc."},{"key":"ref_26","first-page":"63","article-title":"A novel lumen-apposing metal stent for endoscopic ultrasound-guided drainage of pancreatic fluid collections: A prospective pilot study","volume":"47","author":"Walter","year":"2015","journal-title":"Endoscopy"},{"key":"ref_27","doi-asserted-by":"crossref","first-page":"1225","DOI":"10.1016\/j.gie.2016.10.014","article-title":"Feasibility of per-oral cholecystoscopy and advanced gallbladder interventions after EUS-guided gallbladder stenting (with video)","volume":"85","author":"Chan","year":"2017","journal-title":"Gastrointest. Endosc."},{"key":"ref_28","doi-asserted-by":"crossref","first-page":"636","DOI":"10.1016\/j.gie.2017.02.027","article-title":"EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an electrocautery-enhanced lumen-apposing metal stent device","volume":"86","author":"Dollhopf","year":"2017","journal-title":"Gastrointest. Endosc."},{"key":"ref_29","doi-asserted-by":"crossref","first-page":"E964","DOI":"10.1055\/a-0915-2098","article-title":"Outcomes of an international multicenter registry on EUS-guided gallbladder drainage in patients at high risk for cholecystectomy","volume":"7","author":"Teoh","year":"2019","journal-title":"Endosc. Int. Open"},{"key":"ref_30","doi-asserted-by":"crossref","first-page":"48","DOI":"10.1016\/j.gie.2025.07.025","article-title":"Clinical outcomes of Endoscopic ultrasound-guided gallbladder drainage in patients with acute cholecystitis with \u22651 year of follow-up: A systematic review and meta-analysis","volume":"103","author":"Canakis","year":"2026","journal-title":"Gastrointest. Endosc."},{"key":"ref_31","doi-asserted-by":"crossref","first-page":"797","DOI":"10.1016\/j.gie.2020.09.040","article-title":"Comparison of EUS-guided, endoscopic transpapillary, and percutaneous gallbladder drainage for acute cholecystitis: A systematic review with network meta-analysis","volume":"93","author":"Podboy","year":"2021","journal-title":"Gastrointest. Endosc."},{"key":"ref_32","doi-asserted-by":"crossref","first-page":"E92","DOI":"10.1055\/a-1005-6602","article-title":"EUS-guided gallbladder drainage: A learning curve modified by technical progress","volume":"8","author":"Tyberg","year":"2020","journal-title":"Endosc. Int. Open"},{"key":"ref_33","doi-asserted-by":"crossref","first-page":"231","DOI":"10.1097\/MCG.0000000000001036","article-title":"Successful Cholecystectomy After Endoscopic Ultrasound Gallbladder Drainage Compared with Percutaneous Cholecystostomy, Can it Be Done?","volume":"53","author":"Saumoy","year":"2019","journal-title":"J. Clin. Gastroenterol."},{"key":"ref_34","doi-asserted-by":"crossref","first-page":"E1063","DOI":"10.1055\/a-2180-9817","article-title":"Long-term results after EUS gallbladder drainage in high-surgical-risk patients with acute cholecystitis: A 3-year follow-up registry","volume":"11","author":"Jover","year":"2023","journal-title":"Endosc. Int. Open"},{"key":"ref_35","doi-asserted-by":"crossref","first-page":"360","DOI":"10.1111\/jgh.16392","article-title":"Endoscopic ultrasound-guided gallbladder drainage with long-term lumen-apposing metal stent indwell: 1-year results from a prospective nationwide observational study","volume":"39","author":"Bazaga","year":"2024","journal-title":"J. Gastroenterol. Hepatol."},{"key":"ref_36","first-page":"a24955542","article-title":"US multicenter outcomes of endoscopic ultrasound-guided gallbladder drainage with lumen-apposing metal stents for acute cholecystitis","volume":"13","author":"David","year":"2025","journal-title":"Endosc. Int. Open"},{"key":"ref_37","doi-asserted-by":"crossref","unstructured":"Binda, C., Anderloni, A., Forti, E., Fusaroli, P., Macchiarelli, R., Manno, M., Fugazza, A., Redaelli, A., Aragona, G., and Lovera, M. (2024). EUS-Guided Gallbladder Drainage Using a Lumen-Apposing Metal Stent for Acute Cholecystitis: Results of a Nationwide Study with Long-Term Follow-Up. Diagnostics, 14.","DOI":"10.3390\/diagnostics14040413"},{"key":"ref_38","first-page":"514","article-title":"Safety and clinical outcomes of endoscopic ultrasound-guided gallbladder drainage with lumen-apposing metal stents in patients with dwell time over one year","volume":"32","author":"Cimavilla","year":"2019","journal-title":"Ann. Gastroenterol."},{"key":"ref_39","doi-asserted-by":"crossref","first-page":"476","DOI":"10.1016\/j.cgh.2015.10.026","article-title":"Conversion of percutaneous cholecystostomy to internal transmural gallbladder drainage using an endoscopic ultrasound-guided, lumen-apposing metal stent","volume":"14","author":"Law","year":"2016","journal-title":"Clin. Gastroenterol. Hepatol."},{"key":"ref_40","doi-asserted-by":"crossref","first-page":"1085","DOI":"10.1136\/gutjnl-2019-319996","article-title":"Endosonography-guided gallbladder drainage versus percutaneous cholecystostomy in very high-risk surgical patients with acute cholecystitis: An international randomised multicentre controlled superiority trial (DRAC 1)","volume":"69","author":"Teoh","year":"2020","journal-title":"Gut"},{"key":"ref_41","doi-asserted-by":"crossref","first-page":"1260","DOI":"10.1007\/s00464-018-6406-7","article-title":"Three-way comparative study of EUS-guided transmural gallbladder drainage using lumen-apposing metal stents versus endoscopic transpapillary drainage versus percutaneous cholecystostomy for gallbladder drainage in high-risk surgical patients with acute cholecystitis","volume":"33","author":"Siddiqui","year":"2019","journal-title":"Surg. Endosc."},{"key":"ref_42","doi-asserted-by":"crossref","first-page":"448","DOI":"10.4103\/EUS-D-20-00130","article-title":"Endoscopic gallbladder drainage for acute cholecystitis with high-risk surgical patients between transduodenal and transpapillary stenting","volume":"10","author":"Nishiguchi","year":"2021","journal-title":"Endosc. Ultrasound"},{"key":"ref_43","doi-asserted-by":"crossref","first-page":"AB492","DOI":"10.1016\/j.gie.2022.04.1247","article-title":"Endoscopic transpapillary stenting versus EUS-guided transmural gallbladder drainage in high surgical-risk patients with acute calculous cholecystitis: A randomized trial","volume":"95","author":"Faknak","year":"2022","journal-title":"Gastrointest. Endosc."},{"key":"ref_44","doi-asserted-by":"crossref","first-page":"S88","DOI":"10.1055\/s-0044-1782880","article-title":"Two-year outcomes of endoscopic transpapillary gallbladder stenting versus EUS-guided transmural gallbladder drainage in high-surgical risk patients with acute calculous cholecystitis: A randomized trial","volume":"56","author":"Chaikajornwat","year":"2024","journal-title":"Endoscopy"},{"key":"ref_45","doi-asserted-by":"crossref","first-page":"469","DOI":"10.1055\/a-1962-7305","article-title":"Intermediate- to long-term outcomes of endoscopic transpapillary gallbladder stenting in patients with gallstone-related disease: A 10-year single-center experience","volume":"55","author":"Ridtitid","year":"2023","journal-title":"Endoscopy"},{"key":"ref_46","doi-asserted-by":"crossref","first-page":"79","DOI":"10.1097\/MCG.0000000000000786","article-title":"EUS-guided Versus Percutaneous Gallbladder Drainage: Isn\u2019t It Time to Convert?","volume":"52","author":"Tyberg","year":"2018","journal-title":"J. Clin. Gastroenterol."},{"key":"ref_47","doi-asserted-by":"crossref","unstructured":"Yi, H., Liu, Q., He, S., Zhong, L., Wu, S.H., Guo, X.D., and Ning, B. (2022). Current uses of electro-cautery lumen apposing metal stents in endoscopic ultrasound guided interventions. Front. Med., 9.","DOI":"10.3389\/fmed.2022.1002031"},{"key":"ref_48","doi-asserted-by":"crossref","first-page":"12893","DOI":"10.1038\/s41598-024-63608-5","article-title":"Revolutionizing outcomes: Endoscopic ultrasound-guided gallbladder drainage using innovative electrocautery enhanced-lumen apposing metal stents for high-risk surgical patients","volume":"14","author":"Chon","year":"2024","journal-title":"Sci. Rep."},{"key":"ref_49","doi-asserted-by":"crossref","first-page":"457","DOI":"10.1016\/j.gie.2021.05.020","article-title":"Lumen-apposing metal stents (with videos)","volume":"94","author":"Law","year":"2021","journal-title":"Gastrointest. Endosc."},{"key":"ref_50","first-page":"133","article-title":"Artificial intelligence in gastrointestinal endoscopy: A comprehensive review","volume":"37","author":"Ali","year":"2024","journal-title":"Ann. Gastroenterol."},{"key":"ref_51","first-page":"471","article-title":"Artificial Intelligence in Biliopancreatic Disorders: Applications in Cross-Sectional Imaging and Endoscopy","volume":"196","author":"Verpalen","year":"2025","journal-title":"Gastroenterology"}],"container-title":["Journal of Clinical Medicine"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/14\/5536\/pdf","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,7,15]],"date-time":"2026-07-15T07:40:57Z","timestamp":1784101257000},"score":1,"resource":{"primary":{"URL":"https:\/\/www.mdpi.com\/2077-0383\/15\/14\/5536"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,7,15]]},"references-count":51,"journal-issue":{"issue":"14","published-online":{"date-parts":[[2026,7]]}},"alternative-id":["jcm15145536"],"URL":"https:\/\/doi.org\/10.3390\/jcm15145536","relation":{},"ISSN":["2077-0383"],"issn-type":[{"value":"2077-0383","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,7,15]]}}}