Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) using a lumen-apposing metal stent (LAMS) has become a minimally invasive alternative to percutaneous or surgical drainage in high-risk surgical candidates with acute cholecystitis. Initially reserved for extremely frail patients, its indications have progressively expanded. This study aimed to assess temporal changes in patient selection, procedural standardization, and clinical outcomes over a 10-year experience with EUS-GBD.

We conducted a retrospective, single-center analysis including all consecutive patients who underwent EUS-GBD between January 2014 and December 2024. Patients were divided into two cohorts: Group A (procedures ≤ December 2020) and Group B (procedures ≥ January 2021). Demographic, procedural, and outcome data were compared between groups. Technical success was defined as successful LAMS placement; clinical success was defined as symptom resolution and/or sepsis improvement without need for further drainage. Adverse events (AEs) were recorded according to the AGREE classification, and survival outcome was assessed at 30 days, 12 months, and 36 months.

Fifty patients were included (mean age 79.6 ± 12.8 years; 50% female). Technical and clinical success rates were 98% and 90%, respectively. Over time, baseline comorbidity decreased: median age-adjusted Charlson Comorbidity Index (a-CCI) was significantly lower in Group B (8.0 vs 9.5, p = 0.047), and biliopancreatic malignancies declined from 45.8% to 23.1%. The use of electrocautery-enhanced LAMS increased from 62.5% to 100% (p = 0.001), reflecting complete procedural standardization. Thirty-day survival improved significantly from 83.3% to 100% (p = 0.046), while 12-month (33.3% vs 56.2%) and 36-month (25.0% vs 60.0%) survival showed favorable, though non-significant, trends. Overall biliary AE rate was 24%, with both early and delayed events remaining infrequent.

Over the past decade, EUS-GBD has evolved from a rescue procedure for frail, high-risk patients to a well-standardized therapeutic option applicable to a broader population. This transition coincided with reduced baseline comorbidity, universal adoption of electrocautery-enhanced LAMS, and improved early survival. Long-term outcomes also trended positively, confirming the safety, reproducibility, and durability of the technique. Further prospective multicenter studies are warranted to refine patient selection criteria, define objective “frailty” thresholds, and optimize timing for stent management and removal. Within experienced centers, EUS-GBD should be considered a cornerstone in the minimally invasive management of acute cholecystitis in non-surgical candidates.