In patients with calculous acute cholecystitis who are not candidates for surgery, gallbladder drainage represents an effective strategy to control infection and prevent complications. Among the available options, endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) stands out as a minimally invasive, safe, and effective approach for frail patients.Despite its established efficacy, EUS-GBD requires specialized expertise available only in a limited number of centres, underscoring the need for a standardized approach to this technique. Moreover, the long-term management of lumen-apposing metal stents (LAMS) remains a matter of debate and lacks shared guidelines.

This single-centre retrospective study describes the experience in frail, high-risk surgical patients (Charlson Comorbidity Index Age-adjusted, A-CCI ≥5), evaluating the efficacy and safety of EUS-guided gallbladder drainage and proposing a potential long-term management algorithm for these patients.

EUS-GBD procedures performed at a hub centre between November 2023 and September 2025 were considered. In 19 patients (median A-CCI 8; ASA III–V 100%), technical success was 100% and clinical success 95%, with a mean follow-up of 30 weeks. A transduodenal access was used in 84% of cases and a transgastric access in 16%. LAMS types included HOT AXIOS in 68% and HOT SPAXUS in 32% of procedures. One duodenal perforation occurred and was managed endoscopically during the same session. No bleeding events or buried LAMS syndrome were observed. Median hospital stay was 13 days. During long-term follow-up, three complications were recorded, all successfully treated endoscopically. Long-term mortality was 37%, mainly due to non-biliary causes. Stent removal was performed in 32% of patients after approximately 51 days, following complete gallbladder clearance, resulting in definitive treatment.In the most fragile patients, the LAMS was left in place,  no complications related to its permanence were observed.

EUS-GBD is a safe and effective definitive treatment option for patients with calculous acute cholecystitis who are not candidates for surgery. Planned LAMS removal is recommended in patients who experience recovery of performance status after the procedure and achieve complete gallbladder clearance, whereas in frail patients the stent can be safely maintained in place. The study highlights the importance of a tailored approach that balances safety, efficacy, and patient tolerance.