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Review

Endoscopic Ultrasound-Guided Gallbladder Drainage in the Treatment of Acute Cholecystitis and Malignant Biliary Obstruction: A Literature Review

by
Xinyue Zhao
and
Nan Ge
*
Department of Gastroenterology, Shengjing Hospital of China Medical University, Shenyang 110004, China
*
Author to whom correspondence should be addressed.
Gastroenterol. Insights 2026, 17(2), 36; https://doi.org/10.3390/gastroent17020036 (registering DOI)
Submission received: 6 March 2026 / Revised: 24 May 2026 / Accepted: 2 June 2026 / Published: 6 June 2026
(This article belongs to the Topic Advanced Endoscopic Ultrasound (EUS) Techniques: Current and Future Directions)
Versions Notes

Abstract

Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is an emerging intervention that provides a minimally invasive approach to drainage of the gallbladder, showing promising results in treating acute cholecystitis (AC) and malignant biliary obstruction (MBO). This review summarizes the current applications of EUS-GBD and compares its clinical effectiveness with traditional methods such as percutaneous transhepatic gallbladder drainage (PT-GBD) and endoscopic transpapillary gallbladder drainage (ET-GBD). Available evidence suggests that EUS-GBD may offer potential advantages in terms of success rates and complication profiles, particularly in patients who are not candidates for surgery or those at high surgical risk. The method is effective in reducing inflammation, alleviating symptoms from obstruction, and improving patient quality of life. This article also discusses the technical evolution of EUS-GBD, its indications, complications, and its comparative advantages over other drainage techniques. These observations suggest that EUS-GBD may represent a valuable addition to the therapeutic armamentarium for selected high-risk patients.

1. Introduction

EUS-GBD is a form of internal drainage, which connects the gallbladder with the stomach or duodenum through the different stent to release the infected bile, and the long-term drainage effect is obvious. In the Tokyo Guidelines 2018, when laparoscopic cholecystectomy cannot be performed due to, for example, the patient status of acute cholecystitis, EUS-GBD can be performed by skilled endoscopists after a multidisciplinary consultation in a large medical institution [1].
In addition to patients with acute cholecystitis, EUS-GBD can also be used for conversion of long-term external percutaneous transhepatic gallbladder drainage (PT-GBD) to internal EUS-GBD, and to relieve malignant biliary obstruction after failure of EUS-guided biliary drainage (EUS-BD) [2,3,4]. In some medical institutions, EUS-GBD is also used for primary treatment of symptomatic biliary colic and secondary prevention of gallstone pancreatitis and choledocholithiasis.
Additionally, some endoscopists also perform secondary operations on the gallbladder after EUS-GBD, such as gallbladder observation, biopsy or stone extraction [5]. A paper published in 2021 showed that it was possible for an endoscopist to use a multibending endoscope inserted lumen-apposing metal stent (LAMS) for cholecystoscopy and sampling or stone removal. Seventeen peroral cholecystoscoies were performed in samples of 14 patients. The technical success rate was 88.2% and no adverse events occurred [6].

2. Review Methodology

This review was conducted following the principles of a systematic literature review. A comprehensive literature search was performed in PubMed and Web of Science for articles published from January 2006 to March 2026. The search strategy used the following keywords and their combinations: “endoscopic ultrasound-guided gallbladder drainage”, “EUS-GBD”, “acute cholecystitis”, “malignant biliary obstruction”, “lumen-apposing metal stent”, “percutaneous cholecystostomy”, and “endoscopic transpapillary gallbladder drainage”.
Studies were included if they: (1) evaluated EUS-GBD in patients with acute cholecystitis or malignant biliary obstruction; (2) reported at least one outcome of interest (technical success, clinical success, adverse events, or long-term outcomes); and (3) were published in English as full-length original articles, systematic reviews, or meta-analyses. Editorials, and conference abstracts were excluded. Data were extracted on study design, sample size, patient characteristics, intervention details, and outcome measures. A narrative synthesis was conducted due to heterogeneity in study designs and outcome definitions. No formal quality assessment or risk-of-bias analysis was performed, as this is a narrative review.
What this review adds: Several systematic reviews and meta-analyses on EUS-GBD have been published previously, many of which focus on specific comparisons (e.g., EUS-GBD vs. PT-GBD) or specific indications (e.g., acute cholecystitis alone). This review differs from prior work by providing a comprehensive overview that: (1) covers both acute cholecystitis and malignant biliary obstruction indications within a single manuscript; (2) systematically compares EUS-GBD with PT-GBD, ET-GBD, EUS-CDS, and laparoscopic cholecystectomy; (3) includes the most recent evidence published up to 2026; and (4) offers a balanced clinical perspective aligned with current international guidelines.
Throughout this review, we explicitly distinguish between different study designs (retrospective case series, multicenter registries, prospective trials, and meta-analyses) and comment on their relative evidence strength. Meta-analyses and large prospective studies are considered to provide higher-level evidence, whereas small retrospective series (e.g., n < 50) are more susceptible to bias. This grading is reflected in the narrative synthesis and in critical notes provided under Table 1, Table 2 and Table 3.

3. Developing History

In 2006, Baron TH et al. reported the first case of endoscopic ultrasound-guided gallbladder drainage. The patient suffered from unresectable hilar cholangiocarcinoma complicated with acute cholecystitis, and ET-GBD failed because the hydrophilic guide wire could not pass through the inflammatory cystic duct. Endoscopic physicians tried connecting the angle on the duodenum and the gallbladder neck with a 7F 4 cm double pigtail biliary stent, and succeeded. Balloon dilation was performed, and another 7F 4 cm double pigtail stent was placed to prevent blockage during follow-up observation. The patient was asymptomatic for 11 weeks after surgery [7].

3.1. The History of Stents

After that case, EUS-GBD began to be gradually applied in major medical institutions. Meanwhile, the improvement of EUS-GBD is also in progress. On the one hand, there is no stent specially designed for EUS-GBD, so the fully covered self-expandable metal biliary stent (FCSEMS), antimigrating tubular self-expandable metal stent (ATSEMS) and LAMS are usually considered to be utilized. Although one prospective study found that ATSEMS and LAMS had no significant effect on surgical success rate or postoperative complications [8], LAMS is still considered as the first choice of EUS-GBD, whose self-distension can prevent stent displacement and reduce biliary leakage. According to a 2019 systematic review, the early AE rate of LAMS was 6.5% and the delayed AE rate was 8.3%. The incidence of recurrent cholecystitis and/or cholangitis was 4.6% [9]. However, FCSEMS and ATSEMS are considered when the distance between the stomach/duodenum and the gallbladder is too far, beyond the range that LAMS can reach, or patients are located in countries where LAMS is not yet permitted, such as Japan. Also, a plastic stent being added on the metal stent to prevent displacement is also a commonly used method. In addition to the above, a new monolithic double pigtail plastic stent was developed for stent recovery in the event of stent implantation failure [10].

3.2. Electrocautery-Enhanced Delivery System

Balloon dilation has been gradually replaced by the electric cautery system. An animal experiment showed that the operation time of the electrocautery-enhanced delivery system was shorter than that of the traditional dilation method, and the success rate was quite satisfactory [11]. However, in some cases, the use of the LAMS delivery system presents challenges due to the thickness and stiffness of the device, which limits the puncture angle. In 2023, a case utilized a 22-gauge needle with a novel 0.018-inch guidewire for EUS-GBD, overcoming challenges posed by LAMS system. A 7F spiral dilator was used for tract dilation, and a double-pigtail plastic stent was successfully placed. This approach reduces bile leakage risk and resolves recurrent acute cholecystitis [12].
At present, the specific methods used by the major medical institutions are not exactly the same. In general, the electrocautery-enhanced delivery system and LAMS are preferred.

3.3. Transgastric or Transduodenal Implantation

Duodenal implantation is also preferred. This is because endoscopic surgeons believe that the connection between the duodenum and gallbladder neck can reduce food entry into the gallbladder and reduce gallbladder pollution. In addition, duodenal motility is lower, which can better avoid the occurrence of side effects such as stent displacement.
However, in the case of a long distance to the duodenum, it is also a common method to select the connection between the stomach and gallbladder body, because the stomach has a large area and a wide range of choices. The comparison of transgastric and transduodenal samples was mentioned in two studies, with sample sizes of 42 and 59, respectively. However, the conclusions are not consistent; some think that the adverse reactions and success rate are related to the location of the puncture, and others vice versa. Moreover, its long-term effects on food reflux and so on have not been mentioned, indicating that prospective experiments with larger sample sizes are still needed [13,14]. If subsequent cholecystectomy is considered, the transgastric route may be better, as the fistula and anatomical structure may recover better after stent removal.

4. Acute Cholecystitis

Gallbladder drainage for acute cholecystitis is currently a key application of EUS-GBD. Certain patients, due to underlying conditions or the severity of the cholecystitis, may not be suitable candidates for surgery, such as the elderly. Data indicate that the mortality rate following laparoscopic cholecystectomy in patients over 65 is three times higher than that in younger individuals. To minimize the risk of complications, laparoscopic cholecystectomy should be cautiously considered in elderly patients with acute cholecystitis. Additionally, in patients with coagulation disorders due to liver cirrhosis or cardiovascular procedures, laparoscopic cholecystectomy should be approached with care. For patients who refuse cholecystectomy for non-medical reasons, gallbladder drainage remains a necessary intervention.

4.1. EUS-GBD for AC Is Effective

Studies on the use of EUS-GBD combined with LAMS for the treatment of acute cholecystitis in high-risk patients have shown high technical and clinical success rates. Several studies support the effectiveness of this treatment approach. As summarized in Table 1, multiple retrospective and prospective studies, including a large 2025 systematic review (n = 701), consistently report high technical and clinical success rates (90–96% and 86–94%, respectively) with acceptable adverse event rates, especially when LAMSs are used. Long-term stent patency (mean 419 days) and favorable outcomes after stent removal have also been documented [15,16,17,18,19,20].
It should be noted, however, that most of these studies are retrospective and include relatively small sample sizes; the single prospective multicenter trial provides higher-level evidence but still lacks a control group. Meta-analyses and large prospective cohorts carry more weight than small retrospective series. In contrast, the single prospective multicenter trial and the 2025 systematic review provide higher-level evidence, but the former lacks a control group and the latter is limited by the quality of its included studies.
Collectively, these findings suggest that EUS-GBD with LAMS is a safe and effective treatment option for high-risk AC, although late adverse events such as stent migration may occur, and the current evidence is primarily derived from retrospective studies [21,22].

4.2. Conversion from PT-GBD to EUS-GBD, and Subsequent Cholecystectomy After EUS-GBD

The conversion of PT-GBD to internal EUS-GBD was studied in a 2019 multicenter retrospective study, which achieved a technical success rate of 90.5% in 21 patients, with no early adverse events. Only three late complications occurred, including recurrent cholecystitis due to stent migration and obstruction [23]. Separately, regarding the impact of EUS-GBD on subsequent surgery, a 2025 review of 707 patients found a 32.9% success rate for interval cholecystectomy (CCY) after EUS-GBD, with 76.2% of procedures being laparoscopic. The overall adverse event rate was 13.2%, with infections being the most common [5]. These findings suggest that EUS-GBD does not preclude subsequent cholecystectomy and may serve as a bridge to surgery in appropriate candidates [24].

4.3. Comparison of Preoperative Bridging Drainage Methods for Subsequent Cholecystectomy

In patients with acute cholecystitis requiring preoperative drainage as a bridge to elective laparoscopic cholecystectomy, a comparative study evaluated three endoscopic drainage methods: endoscopic transpapillary gallbladder drainage (ETGBD), EUS-guided gallbladder drainage (EUS-GBD), and percutaneous transhepatic gallbladder drainage (PTGBD). The study included 138 patients who underwent ETGBD, 17 who underwent EUS-GBD, and 45 who underwent PTGBD. Technical success rates were 87.0% for ETGBD, 94.1% for EUS-GBD, and 100% for PTGBD. ETGBD was associated with a significantly shorter time to white blood cell normalization (p = 0.02) and oral intake initiation (p < 0.01) compared with PTGBD, and a shorter time to temporary discharge (p < 0.01) compared with both EUS-GBD and PTGBD. Among 114 patients who proceeded to elective laparoscopic cholecystectomy, the waiting period before surgery was significantly shorter in the ETGBD group (p = 0.03) than in the other two groups. Operative time and blood loss did not differ significantly among the three groups; however, open conversion occurred in four cases (11.1%) in the PTGBD group, which was significantly higher than in the ETGBD group (p = 0.02). The adverse event rate was highest in the PTGBD group (nine cases, 25%), and the postoperative hospital stay was shortest in the ETGBD group (4 days). The authors concluded that ETGBD should be the first choice for preoperative bridging drainage, with EUS-GBD as a second-line option when ETGBD fails [25].

5. Malignant Biliary Obstruction

In the past three years, there has been an increasing number of studies on EUS-GBD for the treatment of malignant biliary obstruction, reflecting growing attention to the application of EUS-GBD in this area.

5.1. EUS-GBD as Rescue Biliary Drainage After Failed ERCP/EUS-BD

EUS-GBD has been proven effective and safe as a rescue treatment for patients with benign [12] and MBO after the failure of ERCP and EUS-guided biliary drainage (EUS-BD) in several studies [26]. Studies conducted in 2016 and 2020 reported technical success rates of 100%, with clinical success rates of 91.7% and 93%, and adverse event rates of 16.7% and 17.9% [27,28]. A study involving 25 patients found that both the technical and clinical success rates of EUS-GBD were 100% and 96%, respectively, with a low rate of adverse events [29]. A 2023 multicenter study involving 14 centers in Italy showed that EUS-GBD combined with LAMS achieved a technical success rate of 100%, a clinical success rate of 81.3%, a bilirubin reduction of 66.5%, an average procedure time of 26.4 min, an average hospital stay of 9.2 days, and an adverse event rate of 10.4% in patients with distal malignant biliary obstruction (DMBO) [30]. A 2025 retrospective study across nine centers in Spain reported a technical success rate of 99%, a clinical success rate of 78.1%, and 65.6% of patients achieving bilirubin normalization, with a median normalization time of 15 days. The adverse event rate in this study was 26.3% [26,31] A 2025 meta-analysis showed a technical success rate of 99.2%, and an adverse event rate of 13.7% [32]. The studies cited here range from small retrospective series (n = 12) to large multicenter cohorts and meta-analyses. Meta-analyses and large prospective cohorts provide higher-quality evidence, whereas single-center retrospective series are more prone to bias. Although the high success rates are consistent, the heterogeneous methodologies limit direct comparability. Specifically, the meta-analysis and the large multicenter registry offer stronger support than the small retrospective series.

5.2. The Omission of ERCP Did Not Compromise Technical Success or Safety of EUS-GBD

Typically, ERCP is attempted first in cases of MBO, with alternative methods considered if it fails. However, even without prior ERCP, directly performing EUS-GBD for drainage has been shown to be a safe and effective option. Without prior ERCP, a 2024 prospective study evaluated 37 patients with DMBO who directly underwent EUS-GBD using a novel electrocautery-enhanced LAMS (EC-LAMS). The procedure achieved a 100% clinical success rate, defined as a bilirubin reduction of >15% within 24 h and >50% within 14 days after stent placement. Adverse events occurred in four patients, including one case of bleeding, one of food impaction, and two of bile duct stent obstruction, with no stent-related deaths. The average hospital stay was 7.7 days, and the median survival time was 4 months. The study concluded that EUS-GBD with EC-LAMS—performed without prior ERCP—is a safe and effective palliative option for patients with malignant jaundice who are not surgical candidates. The omission of ERCP did not compromise technical success or safety, highlighting EUS-GBD as a practical alternative for complex biliary obstructions with low complication rates and short hospitalization [33]. This single prospective study provides encouraging data, but it is small (n = 37) and without a control arm. Confirmation in larger randomized trials is required before broad adoption as first-line therapy.

5.3. EUS-GBD as Prophylaxis or Treatment of Cholecystitis in Patients with MBO

In patients with MBO who undergo biliary SEMS placement, acute cholecystitis is a recognized complication, particularly when the cystic duct orifice is involved. EUS-GBD may play a role in both preventing and managing this complication.
Regarding prophylaxis, a 2023 randomized trial evaluated the role of EUS-GBD in preventing acute cholecystitis in patients with distal MBO and cystic duct orifice involvement. The study included 44 patients randomly assigned to an intervention group (routine ERCP biliary drainage and SEMS placement followed by EUS-GBD) and a control group (biliary drainage only). The results showed that no acute cholecystitis occurred in the intervention group, while five patients in the control group developed acute cholecystitis. The intervention group had a significantly shorter median hospital stay compared to the control group, with no significant difference in median survival time between the two groups. This study suggests that prophylactic EUS-GBD may reduce the occurrence of acute cholecystitis in patients with DMBO [34].
Regarding treatment, a 2024 retrospective study further evaluated the effectiveness of EUS-GBD in treating cholecystitis after SEMS placement. The study analyzed data from 1437 patients, with 1084 cases of DMBO and 353 cases of hilar MBO (HMBO), all of whom received SEMS placement. The results showed a cholecystitis incidence rate of 7.5% in the DMBO group and 5.9% in the HMBO group. In DMBO patients, the risk of cholecystitis was closely related to stent or catheter issues, while in HMBO patients, the risk increased with the number of SEMS placements and the presence of gallstones. The study suggested that EUS-GBD may be a valuable option for managing cholecystitis after SEMS placement [35,36].

5.4. EUS-GBD Versus EUS-Guided Choledochoduodenostomy (EUS-CDS) or EUS-Guided Hepaticogastrostomy (EUS-HGS) as Competing EUS-Guided Drainage Strategies

When EUS-guided drainage is indicated for malignant distal biliary obstruction after failed ERCP, both EUS-GBD and EUS-CDS or EUS-HGS are available options. These competing strategies have been compared in several studies, which are discussed in Section 7.3.

6. The Remaining Applications

Indications for non-acute cholecystitis drainage include primary treatment of symptomatic biliary colic and secondary prevention of gallstone pancreatitis and choledocholithiasis. A study reported in 2021 showed that the technical success rate and early adverse events were 100% and 14.6%, respectively, without late complications [37].
In addition, a literature report in 2020 reported that the technical and clinical success rate of a single EUS-GBD combined with ERCP in the treatment of choledocholithiasis was comparable to that of EUS-GBD alone, suggesting that it is possible to perform simultaneous ERCP and EUS-GBD in the future, and it is feasible to use pure endoscopic surgery for comprehensive treatment of choledocholithiasis [14].
EUS-GBD is a safe procedure for patients who have been on antithrombotic medications, as demonstrated by a 2025 retrospective study of 177 patients, including 118 on ATT. The study showed no significant differences in bleeding risk, thrombotic events, hospital stay, or 30-day mortality between the ATT and non-ATT groups. Importantly, there was no increased bleeding risk within 48 h after EUS-GBD in ATT patients [38].

7. Comparison of Different Drainage Techniques

EUS-GBD has emerged as a promising technique for gallbladder drainage. However, according to major international guidelines, including the Tokyo Guidelines 2018, PT-GBD remains the first-line recommendation for gallbladder drainage in high-risk surgical patients with acute cholecystitis. This is primarily due to its long-established safety profile, widespread availability across different healthcare settings, and lower requirements for specialized endoscopic expertise. Nevertheless, in large medical institutions with experienced endoscopists, EUS-GBD can be considered a valuable alternative, especially for patients who may benefit from internal endoscopic drainage or who have failed PT-GBD. The following sections summarize comparative studies.

7.1. Comparison of EUS-GBD, PT-GBD, and ET-GBD

A 2021 systematic review aimed to compare three gallbladder drainage methods for patients with acute cholecystitis who are not suitable for surgery: PT-GBD, E T-GBD, and EUS-GBD. A network meta-analysis of 10 studies involving 1267 patients was conducted. The results showed that EUS-GBD and PT-GBD had the highest technical success rates and clinical success rates. EUS-GBD had the lowest recurrence risk of cholecystitis, while PT-GBD had the highest risk of reintervention and unplanned readmission. ET-GBD was associated with the lowest mortality rate. The choice of the most appropriate treatment method depends on available expertise [39]. The evidence base for pairwise comparisons varies: meta-analyses and large multicenter registries provide moderate-to-high quality evidence, whereas single-center retrospective studies are more limited. For instance, the network meta-analysis provides the highest level of evidence for three-way comparisons, whereas the single-center retrospective study (n = 54) is much more susceptible to bias and should be interpreted with caution.
Several pairwise meta-analyses and retrospective studies have compared EUS-GBD with PT-GBD. A 2023 meta-analysis of 11 studies (1155 patients) found no overall difference in major outcomes, but a subgroup analysis suggested that LAMS use was associated with lower adverse events, recurrence, and readmission rates [40]. A 2024 meta-analysis of six studies reported that EUS-GBD with LAMS led to shorter hospital stays and fewer delayed adverse events [35]. A large retrospective cohort (n = 182) showed lower early adverse events with EUS-GBD and identified in situ PT-GBD as an independent recurrence risk factor [41]. In contrast, a trial sequential analysis suggested that PT-GBD may have a higher technical success rate, although clinical success was comparable and EUS-GBD was associated with fewer overall adverse events and unplanned readmissions [42].
When comparing EUS-GBD and ET-GBD, most studies (including a 2021 retrospective study of 54 patients [43], a 2020 meta-analysis [44], and a 2023 multicenter propensity-matched analysis of 379 patients) consistently indicate that EUS-GBD offers higher technical success rates, shorter operation time, and fewer late adverse events, whereas ET-GBD better preserves native anatomy for subsequent cholecystectomy [45].
Regarding subsequent surgery, EUS-GBD does not preclude later cholecystectomy (see Section 4.2).
Overall, while EUS-GBD (particularly with LAMS) may offer advantages in terms of recurrence, hospital stay, and delayed adverse events, the quality of evidence is moderate at best due to the lack of large prospective randomized controlled trials. Direct comparisons are further limited by variability in patient selection, stent types, and operator experience across studies [46].

7.2. Comparison of EUS-GBD and Laparoscopic Cholecystectomy

An article published in 2021 even compared EUS-GBD to laparoscopic cholecystectomy, with the following results: technical success rate, clinical success rate, length of hospital stay, 30-day adverse events and mortality rate were similar. The rates of recurrent biliary events within 1 year of reintervention, and unplanned rehospitalization were similar [46].

7.3. Comparison of EUS-GBD and EUS-Guided Choledochoduodenostomy (EUS-CDS)

When treating patients with obstructive jaundice caused by DMBO after failed ERCP, the therapeutic options include EUS-GBD and EUS-CDS. Two retrospective studies published in 2025 compared these two procedures, showing similar clinical and technical success rates, efficacy, and safety profiles. The first study included 78 DMBO patients. The results showed that the clinical success rate was 87.8% for EUS-GBD and 89.2% for EUS-CDS, with no significant difference between them. The technical success rate was 100% for EUS-GBD and 94.6% for EUS-CDS, with no significant difference. However, the late adverse event rate was significantly higher in the EUS-CDS group than in the EUS-GBD group. At a median follow-up of 4.7 months, there were no significant differences in overall survival or time to biliary obstruction recurrence between the two groups. Therefore, the study concluded that EUS-GBD and EUS-CDS offer similar therapeutic outcomes, with EUS-GBD possibly having a lower incidence of late adverse events [47]. The second international multicenter retrospective study included 291 patients with DMBO, of whom 82 underwent EUS-GBD and 209 underwent EUS-CDS. After performing a 1:1 propensity score-matched analysis, 154 patients were compared. The results showed that there were no significant differences between EUS-GBD and EUS-CDS in terms of technical success and clinical success. The overall adverse event rate in both groups was 14.2%, with 8% of those being severe adverse events. This study also concluded that EUS-GBD and EUS-CDS had similar efficacy and safety profiles in treating distal MBO, with EUS-GBD possibly being a simpler and safer option for patients with an intact gallbladder and patent gallbladder duct [48]. Both studies emphasize the similar therapeutic outcomes of EUS-GBD and EUS-CDS after ERCP failure, with EUS-GBD potentially offering a lower rate of late adverse events.

7.4. Cost-Effectiveness

With regard to cost-effectiveness, a 2019 article analyzed the cost-effectiveness of three gallbladder drainage modes and concluded that compared with PT-GBD, ET-GBD is more cost saving, while EUS-GBD is more cost-effective. Compared with ET-GBD, EUS-GBD requires an additional cost of $8950 to avoid an additional day of hospitalization. The additional cost of endoscopic intervention is less than the average cost of a hospital bed per day. However, the metal stent required for drainage is expensive, which will greatly affect this model [49].
Although many studies suggest that endoscopic drainage may offer advantages over PT-GBD, PT-GBD remains the first recommendation; ET-GBD and EUS-GBD are only recommended when there are skilled endoscopicians available in large medical institutions. This is because PT-GBD has been developed for many years, and many primary hospitals can also perform this operation, but endoscopic drainage is still limited by institutions and physicians.

8. Technical Aspects and Considerations

Several technical aspects and challenges specifically related to the EUS-GBD procedure warrant discussion beyond the stent-related considerations discussed in Section 3.1.

8.1. Contraindications

Based on current evidence and expert consensus, contraindications and important precautions to EUS-GBD include: (1) massive ascites, which increases the risk of stent migration and peritonitis; (2) interposed vessels along the puncture route, which increases the risk of bleeding; (3) inaccessible gallbladder due to prior surgery or anatomical variants; (4) non-distended gallbladder, which provides an insufficient target for puncture; and (5) when EUS-GBD is intended for jaundice palliation in patients with malignant biliary obstruction, confirmation of cystic duct patency is recommended before the procedure, as bile must be able to flow from the bile duct into the gallbladder for subsequent drainage.

8.2. LAMS Size Selection

The most commonly used LAMS diameters are 10 mm, 15 mm, and 20 mm. The 15 mm LAMS is the most frequently reported size in the literature, offering a balance between adequate luminal patency and an acceptable risk of adverse events. The 10 mm LAMS may be considered when anatomical space is limited, while the 20 mm LAMS may be associated with a higher risk of food impaction and bleeding [50].

8.3. Coaxial Double-Pigtail Plastic Stent

Some experts advocate placing a coaxial double-pigtail plastic stent through the LAMS to reduce the risk of food impaction and to maintain lumen patency even if the LAMS becomes occluded. However, this practice is not universally adopted, and prospective data supporting its routine use are lacking [50].

8.4. Stent Removal Versus Indefinite Indwelling

LAMS can be removed electively once the acute episode resolves and the patient becomes eligible for cholecystectomy. Indefinite indwelling may be considered for patients who remain poor surgical candidates. Long-term adverse events associated with retained LAMS include buried stent syndrome, recurrent cholecystitis, and bleeding [16].

8.5. Management of Adverse Events

Food impaction can often be managed endoscopically using a snare or biliary retrieval basket [51,52]. Bleeding is usually self-limited but may require endoscopic hemostasis or angiographic embolization in severe cases. Perforation is rare (<1%) but may require surgical intervention [9]. Bile leak can be managed with additional stent placement or percutaneous drainage. Stent migration may necessitate endoscopic retrieval or replacement. Buried stent syndrome, characterized by hyperplastic tissue overgrowth at the stent flanges, may require endoscopic resection or stent removal [53]. Recurrent cholecystitis may be treated with antibiotics, stent exchange, or cholecystectomy [35].

8.6. Technical Challenges and Future Directions

The main technical difficulties lie in gallbladder mobilization and unfavorable anatomy. To address gallbladder mobility, the use of retrievable puncture anchors has been proposed. An animal study demonstrated that anchors could be used to fix a mobile gallbladder to the gastric or duodenal wall prior to stent implantation, potentially improving technical success [54]. However, clinical data on this technique remain limited, and further prospective studies are needed before widespread adoption can be recommended. Future research should also focus on large-scale prospective randomized controlled trials, standardization of technical protocols, long-term outcomes beyond one year, and patient-centered outcomes such as quality of life and cost-effectiveness.

9. Conclusions

In conclusion, EUS-GBD, as an emerging gallbladder drainage technique, has shown good efficacy and acceptable complication rates in clinical practice. However, PT-GBD remains the standard in many clinical settings due to its widespread availability, lower cost, and longer track record. The choice of drainage method should be guided by local expertise, institutional resources, and individual patient characteristics rather than a one-size-fits-all approach.
Several limitations should be considered when interpreting the findings of this review. First, the majority of the included studies are retrospective in nature, which may introduce some degree of selection bias and may limit the generalizability of the conclusions. Second, considerable variability exists across studies regarding stent types, puncture routes, operator experience, and follow-up durations, which poses challenges for direct comparisons between studies. Third, the sample sizes in many individual studies are relatively modest, and large-scale prospective randomized controlled trials are currently lacking; therefore, the relevant findings warrant further validation. Fourth, data on long-term outcomes beyond one year remain limited. Fifth, as highlighted in Table 2 and Table 3, the evidence base is heterogeneous; meta-analyses and prospective trials carry more weight than small retrospective case series, and our review has attempted to reflect this gradation in the narrative.
Despite these limitations, this review strives to provide a comprehensive and objective synthesis of the available evidence and to identify directions for future higher-quality research.

Author Contributions

Conceptualization, X.Z. and N.G.; methodology, X.Z.; software, X.Z.; validation, X.Z., N.G.; formal analysis, X.Z.; investigation, X.Z.; resources, X.Z.; data curation, X.Z.; writing—original draft preparation, X.Z.; writing—review and editing, N.G.; visualization, X.Z.; supervision, N.G.; project administration, N.G.; funding acquisition, N.G. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

Not applicable.

Informed Consent Statement

Not applicable.

Data Availability Statement

No new data were created or analyzed in this study. Data sharing is not applicable to this article.

Conflicts of Interest

The authors declare no conflicts of interest.

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Table 1. Clinical outcomes and adverse events of EUS-GBD in the treatment of AC.
Table 1. Clinical outcomes and adverse events of EUS-GBD in the treatment of AC.
Study/YearNumber of PatientsTechnical Success RateClinical Success RateAdverse Event RateMortality RateNotes
A retrospective study/2022 2592%88%16%30-day 12%, 1-year 32%Deaths mainly due to comorbidities
A retrospective study/20236891.7%72%Year 1: 18%, Year 2: 20%, Year 3: 26%0%Gastric stent placement had higher AE rate than duodenal
A prospective multicenter study/20233093.3%86.7%30%3.3%Stent removal success 100%, recurrence 10%
A systematic review/202570195.8%94.3%12.1%2.8%Recurrence 4.2%, 1-year readmission 19%
A multicenter retrospective study/20192190.5%85.7%14.3%0%No early AEs, 3 late complications
A study/201712100%100%0%0%Only 1 recurrence
Note: AEs, adverse events. Studies in this table include retrospective, prospective, and systematic review designs. Evidence strength varies; the prospective multicenter trial provides higher-level evidence than retrospective series.
Table 2. Clinical outcomes and adverse events of EUS-GBD in the treatment of MBO.
Table 2. Clinical outcomes and adverse events of EUS-GBD in the treatment of MBO.
Study/YearNumber of PatientsTechnical Success RateClinical Success RateAdverse Event RateNotes
A study/201612100%91.7%16.7%Rescue after failed ERCP
A multicenter retrospective study/202028100%93%17.9%Multicenter retrospective
A retrospective study/202125100%96%12%-
A multicenter study/2023 48100%81.3%10.4%EUS-GBD with LAMS for distal MBO
A retrospective study/20259699%78.1%26.3%After ERCP/EUS-BD failure
A meta-analysis/202519399.2%88.1%13.7%Meta-analysis
A prospective study/202437100% 100% 10.8%Direct EUS-GBD without prior ERCP
Note: “-” indicates data not reported in the original source. This table includes studies with markedly different designs (small retrospective series, multicenter registries, prospective trials, and meta-analyses). Evidence strength varies considerably: meta-analyses and prospective studies provide higher-quality evidence, whereas single-center retrospective studies (e.g., n = 12) are more prone to bias. Readers should interpret the aggregated data with attention to these methodological differences.
Table 3. Comparison of EUS-GBD, PT-GBD, and ET-GBD.
Table 3. Comparison of EUS-GBD, PT-GBD, and ET-GBD.
Study/YearComparisonTechnical Success RateClinical Success RateRecurrence RiskNotes
A systematic review/2021PT-GBD, ET-GBD, EUS-GBD Higher (EUS-GBD/ PT-GBD)Higher (EUS-GBD/PT-GBD)Lower (EUS-GBD)Network meta-analysis
A multicenter retrospective study/2023EUS-GBD vs. PT-GBDNSDNSDLower (EUS-GBD)EUS-GBD-LAMS shows advantages in safety and recurrence
A retrospective study/2023EUS-GBD vs. PT-GBDNSDNSD-Lower early AE rate with EUS-GBD
A retrospective study/2023EUS-GBD vs. either ectopic/in situ PT-GBDNSD--Advantages in delayed AEs
A trial sequential analysis/2021EUS-GBD vs. PT-GBDHigher (PT-GBD)NSD-EUS-GBD reduced overall AEs and unplanned readmissions
A retrospective study/2021EUS-GBD vs. ET-GBDHigher (EUS-GBD)Higher (EUS-GBD)Lower (EUS-GBD)Overall survival similar
A meta-analysis/2020EUS-GBD vs. ET-GBDHigher (EUS-GBD)Higher (EUS-GBD)Lower (EUS-GBD)Meta-analysis
A study/2023EUS-GBD vs. ET-GBDHigher (EUS-GBD)-NSDPropensity score-matched analysis
Note: NSD, no significant difference; AEs, adverse events; “-” indicates not reported. All comparisons are based on original studies, with evidence predominantly from retrospective designs. The studies summarized in this table include retrospective analyses, a trial sequential analysis, and meta-analyses. The level of evidence differs: network meta-analyses and large multicenter studies provide more robust estimates, whereas single retrospective studies (e.g., the 2021 retrospective study with 54 patients) are more susceptible to bias. The conclusions drawn from this table should therefore consider the underlying study designs.
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Zhao, X.; Ge, N. Endoscopic Ultrasound-Guided Gallbladder Drainage in the Treatment of Acute Cholecystitis and Malignant Biliary Obstruction: A Literature Review. Gastroenterol. Insights 2026, 17, 36. https://doi.org/10.3390/gastroent17020036

AMA Style

Zhao X, Ge N. Endoscopic Ultrasound-Guided Gallbladder Drainage in the Treatment of Acute Cholecystitis and Malignant Biliary Obstruction: A Literature Review. Gastroenterology Insights. 2026; 17(2):36. https://doi.org/10.3390/gastroent17020036

Chicago/Turabian Style

Zhao, Xinyue, and Nan Ge. 2026. "Endoscopic Ultrasound-Guided Gallbladder Drainage in the Treatment of Acute Cholecystitis and Malignant Biliary Obstruction: A Literature Review" Gastroenterology Insights 17, no. 2: 36. https://doi.org/10.3390/gastroent17020036

APA Style

Zhao, X., & Ge, N. (2026). Endoscopic Ultrasound-Guided Gallbladder Drainage in the Treatment of Acute Cholecystitis and Malignant Biliary Obstruction: A Literature Review. Gastroenterology Insights, 17(2), 36. https://doi.org/10.3390/gastroent17020036

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