Standardising minimally invasive management in surgically unfit patients requiring cholecystectomy: Overview of current recommendations and future directions

Table 1 Selected literature on evidence-based practices of percutaneous cholecystostomy and factors influencing its success

Ref.	Type	Results/recommendation
Okamoto et al[4], 2018	Tokyo guidelines	Conservative treatment and biliary drainage to be considered in grade II and grade III acute cholecystitis if the patient cannot withstand surgery
Park et al[25], 2019	Retrospective study	PC to be kept for more than 6 weeks and to be clamped 1 weeks to 2 weeks before removal. For those with the presence of common bile duct stones, calculous cholecystitis, and underlying malignancy, PC must be left for a longer duration and observed for recurrent cholecystitis
Karakas et al[21], 2021	Review	Patients are clinically and radiologically (by ultrasound) assessed 3 days, 1 week, 4 weeks, and 6 weeks after PC. Clinical efficacy of the procedure is assessed on the 3rd day
Devane et al[15], 2020	Society of Interventional Radiology Quality Improvement Standards (guideline)	The majority of PC (> 95%) are indicated for acalculous or calculus cholecystitis in surgically unfit patients, or to provide a route for stone dissolution and extraction. Less than 5% PC are done for decompression of the biliary tree, diversion from bile leak, therapeutic access for bile duct procedures (dilatation, stenting or stone removal). Preprocedural antibiotics are to be given. Transhepatic route is preferred. Flushing of catheters to be done at least once per day to avoid tube occlusion
Abdelhalim et al[22], 2023	Meta analysis of 4 studies, 684 patients	Both transhepatic and transperitoneal approaches are safe. In this meta-analysis, although the overall rate of bleeding was significantly higher with the transhepatic approach, there were confounding factors due to technical differences between the studies
Koushesh et al[20], 2024	Review	Cholecystogram 4 weeks to 6 weeks following placement to evaluate catheter position, tract formation, and cystic duct patency
Lin et al[23], 2025	Retrospective cohort study	Urgent drainage is unnecessary for patients with grade I or II AC. Reductions in hospital stay were observed for patients with grade III AC who underwent PC within 6 hours, and for those with grade II AC who underwent PC within 24 hours of admission
Reinsoo et al[24], 2025	Retrospective cohort study	PC removal within 1 week from placement was non-inferior to delayed removal in terms of AC recurrence or readmission rates. The cumulative risk of recurrent cholecystitis plateaus within the first year after PC tube removal, with rare recurrences beyond this period

AC: Acute cholecystitis; PC: Percutaneous cholecystostomy.

Table 2 Efficacy and safety of endoscopic gallbladder drainage

Ref.	Study population	Results/recommendation
Itoi et al[28], 2015	RCT; ENGBD (n = 37) by 5F or 7F tube; ET-GBD (n = 36) by 7F stent	Similar technical and clinical success, adverse event is higher in ENGBD group than ET-GBD (2 vs 1)
Sobani et al[29], 2021	Retrospective study; (n = 21); dual stenting	Second stent placed simultaneously or after an interval. The median interval between the placement of the first and the second stents was 37 days. Technical and clinical success rates were 100% with adverse events in 9.2%
Jandura and Puli[30], 2021	Meta analysis. 21 studies, 1307 patients	The pooled technical success rate was (82.62%), and the clinical success rate (94.87%). The pooled overall complication rate was 8.83% (bleeding 1.03%, perforation 0.78%, peritonitis/bile leak 0.45% and pancreatitis 1.98%). The pooled rates of stent occlusion and migration were 0.39% and 1.3%, respectively. The pooled recurrence rate of cholecystitis following ET-GBD was 1.48%
Ridtitid et al[31], 2024	RCT. ET-GBD (n = 60); only antibiotic (n = 60)	ET-GBD has a significantly lower rate of recurrent cholecystitis compared to the no ET-GBD group; most recurrences occurred within 3 months of acute cholecystitis
Haddad et al[32], 2025	Multicentre retrospective study. Single vs double stent (59 vs 16)	Overall technical and clinical success 88.2% and 81.3%, respectively. Unplanned reintervention was lower in the double-stenting group (0.5% vs 25.4%)
Nakahara et al[33], 2025	Retrospective study ET-GBD for gangrenous acute cholecystitis. GC (n = 29) and non-GC (n = 62)	The technical success rate, clinical success rate for acute cholecystitis, and rate of early adverse events are similar in both GC and non-GC groups [86.2% vs 91.9% (P = 0.63), 79.3% vs 91.9% (P = 0.17), and 27.6% vs 16.1% (P = 0.32)]
Amin et al[34], 2025	Multicenter retrospective. ET-GBD (n = 73); dual 7 Fr DPT used EUS-GBD (n = 56)	No significant difference in technical or clinical success. Similar rate of repeat procedure, recurrent cholecystitis in the ET-GBD compared to the EUS-GBD group

RCT: Randomized controlled trial; ENGBD: Endoscopic naso-gallbladder drainage; ET-GBD: Endoscopic trans papillary gallbladder drainage; GC: Gangrenous cholecystitis; DPT: Double pigtail stent; EUS-GBD: Endoscopic ultrasound-guided gallbladder drainage; GBD: Gallbladder drainage.

Table 3 Comparison of percutaneous cholecystostomy and laparoscopic cholecystectomy, endoscopic trans papillary gallbladder drainage or endoscopic ultrasound-guided gallbladder drainage

Ref.	Sample	Results/recommendation
Zehetner et al[54], 2014	Retrospective matched pair analysis, PC = 23, LC = 23	PC failed to show a significant reduction in morbidity compared with LC and was associated with a significantly longer hospital stay
Loftus et al[55], 2017	Retrospective cohort analysis, PC = 114, cholecystectomy = 234	Persistent systemic inflammation and higher long-term mortality with PC than with cholecystectomy
Loozen et al[56], 2018	Multicentre RCT, PC = 68, LC = 66	Laparoscopic cholecystectomy is superior to percutaneous catheter drainage for acute calculous cholecystitis. Cholecystectomy not only reduced the rate of major complications, but also reduced utilisation of healthcare resources and costs by more than 30%
Siddiqui et al[40], 2019	Multicentre retrospective study, PC (n = 146), ET-GBD (n = 124), EUS-GBD (n = 102)	Technical and clinical success were higher in both PC and EUS-GBD compared to the ET-GBD group. Hospital stay was lower with the EUS-GBD group. Complications and higher surgical interventions in the PC group
Mu et al[62], 2021	RCT, PC (n = 11), EN-GBD (n = 11)	The EN-GBD group presented less pain and less surgical difficulties (less haemorrhage, abdominal drain placement) during cholecystectomy procedures. Similar adverse events
Nassar et al[57], 2022	Meta analysis. 14 studies, PC = 11565, early cholecystectomy = 205361	Early cholecystectomy is preferred over PC. However, patient and disease-specific factors should be considered to avoid unfavourable outcomes with early LC
Kaneta et al[58], 2022	Retrospective study, PC = 26, ET-GBD = 7	No significant difference was observed between the ET-GBD and PC groups in terms of surgery duration or bleeding amount when surgery was performed after gallbladder drainage for acute cholecystitis. Therefore, ET-GBD was considered a useful preoperative drainage method that did not require a drainage bag
Tyberg et al[48], 2023	Retrospective cohort study, PC = 93, EUS-GBD = 46	EUS-GBD had a significantly shorter interval between gallbladder drainage and cholecystectomy, shorter surgical procedure times, and shorter length of stay for the cholecystectomy compared with PC
Boregowda et al[59], 2023	Meta analysis, 11 studies, PC = 698, EUS-GBD = 477	EUS-GBD is a safe and effective alternative to PC for treating acute cholecystitis in non-surgical patients with fewer adverse events and a lower reintervention rate than PC
Fanciulli et al[60], 2025	Meta analysis, 27 studies, 16 comparing PC and cholecystectomy, 11 comparing PC and PC with delayed cholecystectomy	Cholecystectomy is associated with better outcomes, including lower mortality and readmission rates, compared to both PC alone and PC followed by CC. The combined approach did not show a significant advantage over immediate CC
Pawa et al[61], 2025	Retrospective study, PC = 57, EUS-GBD = 57	EUS-GBD is superior to PC, requiring fewer gallbladder-related procedures and lower rates of adverse events. It has emerged as the preferred non-surgical alternative in the management of patients with AC who are poor surgical candidates
Hu et al[41], 2025	Meta-analysis of 17 trials and 2254 patients, PT-GBD vs ET-GBD vs EUS-GBD	Technical and clinical success lower in ET-GBD compared to other groups. Procedure related adverse events are similar across the groups

PC: Percutaneous cholecystostomy; LC: Laparoscopic cholecystectomy; RCT: Randomized controlled trial; ET-GBD: Endoscopic trans papillary gallbladder drainage; EUS-GBD: Endoscopic ultrasound-guided gallbladder drainage; EN-GBD: Endoscopic naso-gallbladder drainage; PT-GBD: Percutaneous transhepatic gallbladder drainage; CC: Cholecystectomy; AC: Acute cholecystitis.