Endoscopic ultrasound-guided gallbladder drainage in acute cholecystitis with contained perforation: a prospective cohort study

Background: Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) is usually contraindicated in perforated cholecystitis, although initial reports suggest feasibility in contained perforation. Methods: This prospective single-center cohort study aimed to explore EUS-GBD outcomes in patients with acute cholecystitis with contained perforation (cp-AC; Niemeier classification type 2). A secondary exploratory comparison was performed with a contemporaneous cohort of patients with intact gallbladder walls. Results: Between January 2021 and March 2025, 23 patients with cp-AC (39.7% of the overall EUS-GBD cohort) were enrolled. This subgroup showed high prevalence of underlying malignancy (87.0%) and previous endoscopic retrograde cholangiopancreatography with placement of metal stents (65.2%). Median operative space and interluminal distance were 30.5 mm (interquartile range [IQR] 26.0-37.0) and 5 mm (IQR 2-8), respectively. Technical and clinical success of EUS-GBD were 100% (95%CI 85.7-100) and 87.0% (95%CI 67.9-95.5), respectively. The adverse event rate was 21.7% (95%CI 9.7-41.9) and did not differ significantly from that in the cohort with intact gallbladder walls; however, two fatal events occurred in the cp-AC group. Conclusions: EUS-GBD appeared to be technically feasible in patients with contained perforation, despite the additional complexity. However, this represents a particularly high-risk population, and the procedure may be considered only for carefully selected patients in expert centers.