In elder patients with AC, SC is associated with a higher rate of adverse events (AEs), even in patients with low comorbidity. EUS-GD has emerged as a minimally invasive alternative for non-surgical candidates. The primary aim of this study was to compare clinical success between EUS-GD and SC in patients over 80 years old with AC. The Secondary aims included comparison of overall AEs rate, procedure-related AEs and biliary readmission (BR) between DVUSE and SC.

We design a multicenter retrospective cohort study including patients over 80 years old with AC who underwent either EUS-GD or SC between January 2020 and December 2024. To reduce bias due to differences in baseline characteristics (age, Charlson index) between groups, propensity score matching (PSM) was performed. The clinical success was defined as improvement in clinical symptoms and laboratory test. BR was defined as any hospital readmission due to biliary colic, recurrent cholecystitis, cholangitis, choledocholithiasis, or acute pancreatitis. AEs were classified according to AGREE classification.

A total of 179 patients were included (94 DVUSE vs. 85 SC). Initially, there were significant differences in baseline characteristics between groups in age (89.5 years DVUSE vs. 85.3 years SC), comorbidity (Charlson 3.6 vs. 2.4; p<0.001), and associated conditions such as heart failure, cerebrovascular accident, dementia, and hemiplegia (p<0.05) (Table 1). To adjust for these differences, PSM was applied, yielding 112 comparable patients (94 DVUSE vs. 18 SC). After matching (Table 2), clinical success was similar between groups (94.4 % SC vs 92.6 % DVUSE). The rate of adverse events was not statistically different between the two groups, although the SC group showed a higher tendency (44.4% vs 22.6%). However, the rate of procedure-related AEs was significantly higher in the SC group (75 % vs 44 %). There were no differences in severe or fatal AEs (AGREE IV-V) between groups. The cumulative BR after 12 moths was 6 % in SC and 16 % in EUS-GD (p=0.27).

EUS-GD provides similar clinical success compared to SC but is associated with fewer procedure-related adverse events. EUS-DGD should be considered a valid, safe, and effective alternative in patients over 80 years old with significant comorbidity (Charlson without age ≥3, according to our study results).