Improving care of acute cholecystitis in non-surgical or high risk surgical patients with endoscopic drainage

Gallbladder disease is a major and growing burden in Australia, generating >70,000 hospital admissions each year. Acute calculous cholecystitis (gallbladder infection and inflammation) is the commonest gallbladder diagnosis necessitating admission. Laparoscopic cholecystectomy (surgical removal of the gallbladder) is the gold-standard definitive therapy, with 63,388 operations performed nationally in 2022–23, including 20,989 emergencies. Outcomes are excellent in low-risk patients, but rapid population ageing is reshaping case-mix and risk. The proportion aged ≥65 years rose from 12% (1995) to 16% (2020) and is projected to reach 21–23% by 2066; those ≥80 years doubled from 1.1% to 2.1% and are projected to reach 3.6–4.4%. Older adults present later and sicker, accumulate multimorbidity, and have reduced physiological reserve. In this cohort, operative risk—particularly for emergency cholecystectomy—rises sharply. NSQIP data suggest cholecystectomy-related mortality of ~5.5% in nonagenarians, climbing to ~9.5% for emergency cases, with higher cardiopulmonary and infectious complications, more conversions to open or subtotal procedures, and prolonged hospitalisation. Consequently, there is a pressing need for safe, effective alternatives for patients at very high surgical risk or those who cannot have surgery safely. Traditional alternatives—antibiotics, percutaneous transhepatic gallbladder drainage (PT-GBD), and interval surgery—can control sepsis but external drains are uncomfortable, infection-prone, and burdensome. Endoscopic ultrasound–guided gallbladder drainage (EUS-GBD) offers an internal solution: under EUS guidance a drain can be placed between the gallbladder and bowel (cholecystogastrostomy or cholecystoduodenostomy) allowing for infection control. Early reports in 2007 used double-pigtail plastic stents but suffered migration and bile leak. Fully covered lumen-apposing metal stents (LAMS) have flanged ends and wide calibre, minimising migration and enabling endoscopic stone management. Evidence is promising but still maturing. One randomised trial (Teoh, 2021) in very high-risk acute cholecystitis supports EUS-GBD; observational series show high technical/clinical success and faster recovery versus PT-GBD. Key questions remain: optimal timing, access route, device and dwell time, protocols for stone clearance, need for interval cholecystectomy, and long-term outcomes (recurrence, quality of life, costs). Implementation demands multidisciplinary selection, reliable access to advanced endoscopy, standardised peri-procedural care, and equitable regional availability. Defining EUS-GBD’s role in Australia is timely. A pragmatic program addressing safety, effectiveness and implementation can deliver a patient-centred, minimally invasive pathway that achieves rapid source control, preserves independence, and stewards scarce surgical resources.