Therapeutic endoscopic ultrasonography (EUS) has become an essential tool in the management of gallbladder diseases. EUS-guided gallbladder drainage (EUS-GBD) using lumen-apposing metal stents (LAMS) have demonstrated efficacy and safety in the treatment of acute cholecystitis (AC) in patients unfit for surgery. With the progressive aging of the population and the rise of complex comorbidities, the number of individuals unfit for cholecystectomy is increasing. The role of permanent EUS-GBD remains insufficiently defined. We aim to describe a double center experience with permanent EUS-GBD following at least one episode of AC, in patients unfit for cholecystectomy.

Observational study. We prospectively collected data from all patients undergoing permanent EUS-GBD between 2023 and 2025. Demographics, comorbidities, technical, clinical outcomes and follow-up data were collected. Descriptive analyses were performed by reporting mean and standard deviation for continuous variables and frequencies with percentages for categorical variables.

A total of 41 patients were included (44% female). All had experienced one or more episodes of AC prior to the procedure. EUS-GBD was performed within 3 days of the AC episode in 76% of patients, and within one month in the remaining 24%. Two patients (6%) underwent EUS-GBD following percutaneous drainage. LAMS size were 10 x 10 mm or 10 x 15 mm. 21 patients (51%) required ERCP for cholangitis:10 in the same week as EUS-GBD, 5 within the preceding month, and 6 more than one month before the procedure. We reported one case of LAMS maldeployment (2%) that was successfully, conservatively managed.

Comorbidity burden was high: 37% of patients were ASA IV, 54% ASA III, and 9% ASA II. Mean age was 78±11.2 years, 34% of the patients were > 85 years old, including all the ASA II patients. Five people (12%) had Child-Pugh B or C cirrhosis, 29% NYHA III stage, 34% advanced neoplasia, and 15% had severe obesity. 30-days mortality was 0%. Three patients (7%) developed cholecystitis between 30 and 60 days after LAMS placement, in all cases conservatively treated.

Permanent EUS-GBD represents a safe and effective therapeutic option for patients not candidates for cholecystectomy due to severe conditions. It can be performed during the acute phase of AC or in an elective setting after clinical resolution. Despite of the need of longer follow up and larger series, data support the consideration of EUS-GBD as a long-term management strategy in presence of advanced age, severe comorbidities, high ASA class.