A non-negligible proportion of patients suffering from acute cholecystitis develop a perforated cholecystitis characterized by the formation of an encapsulated pericholecystic collection (PC). Current guidelines do not provide a specific indication for EUS-GBD in perforated cholecystitis with an encapsulate PC.  Currently, unfit patients presenting with perforated cholecystitis and encapsulated PC are generally managed via a percutaneous approach driven by safety concerns regarding EUS-GBD to avoid the theoretical risk of placing a LAMS into a perforated organ. Consequently, the presence of PC is often viewed as a relative or absolute contraindication for EUS-GBD. The aim of this retrospective study is to explore the safety   of EUS-GBD in patients with acute cholecystitis complicated by an encapsulated fluid collection.

This was a retrospective international study conducted in 10 tertiary centers. Acute choleystitis was defined and graded according to Tokyo criteria. Encapsulated PC was defined as collection adicent to gallbladder with clearly demarcated wall without detectable interruption at CT scan or intra-procedural echoendoscopic evaluation.The primary outcome was safety, evaluated by assessing adverse events according to the ASGE lexicon. Secondary outcomes were technical success, clinical success and the rate of PC resolution. Procedural features have also been reported. Technical success was defined as adequate LAMS placement confirmed by endoscopic and radiologic assessment, clinical success was defined as resolution of symptoms along with available objective improvements in biochemical and or radiological findings of cholecystitis within 3 days after. PC resolution was defined as the absence of the PC at the last radiological assessment performed during the available follow-up. 

The study included 57 patients (24 females 42.1% with a median age of 81 years IQR:73–85). Regarding the access route, 79% of procedures were performed via the transgastric approach, while 21% were performed via the transduodenal window. The most used LAMS diameter was 10 mm (60%). All LAMS were deployed using the intra-channel release technique for the distal flange, and 87% were placed using a free-hand technique. Technical success was achieved in all patients (100%).  Adverse events (AEs) occurred in 7 patients (12.3%), classified as mild in three cases, moderate in three, and fatal in one. One AE occurred intra-procedurally, while the remaining six were classified as post-procedural. The single intra-procedural event involved the misdeployment of the LAMS distal flange and it was managed endoscopically. Post-procedural AEs  included four bleeding episodes, one liver abscess and one perforation.  One bleeding was secondary to cystic artery pseudoaneurysm and it required radiological embolization;  the other three were treated endoscopically.  The perforation was diagnosed 36 h after the procedure and was treated conservatively with antibiotics therapy. Clinical success was achieved in 52 out of 54 patients (96%). The median length of hospital stay post-procedure was 6 days (range: 3–10). Resolution of the PC was observed in 94.4% of patients. Among the three patients who did not achieve PC resolution, one developed a liver abscess, and two required subsequent percutaneous drainage, which successfully resolved the collection. A total of five deaths were recorded during the study period. One death was considered procedure-related secondary to the liver abscess, while the remaining four were unrelated to either the procedure or the cholecystitis

This study suggests the feasibility to treat acute cholecystitis with encapsulate PC through LAMS placement in patients declared unfit for surgery