Treatment of acute cholecystitis in high-risk surgical patients

Introduction: acute cholecystitis (aC) is the most common biliary stone disease complication. While there is consensus regarding cholecystectomy for aC, gallbladder drainage is indicated in elderly or high-risk surgical patients. EVIDENCE ACQUISITION: We systematically reviewed available evidence in the field of EUS-guided gallbladder drainage (EUS-GBD) for AC in high-risk surgical patients. The studies were classified according to their level of evidence (LE) according to the Oxford Centre for Evidence Based Medicine classification. eviDenCe syntHesis: literature search retrieved 175 manuscripts; most of them were expert opinions (le v, n.=53) or case-series (le iv, n.=29). there was no meta-analysis of rCt (le ia), while two randomized controlled trials (le ib) demonstrated that EUS-GBD was superior to percutaneous transhepatic-GBD (Pt-GBD) regarding long-term outcomes (adverse events, recurrent cholecystitis, and reintervention). several meta-analyses of cohort studies (le iia, n.=11) were designed to compare the three available drainage strategies (endoscopic, echoendoscopic and percutaneous) and to assess the pooled risk of adverse events. Comparison between surgery and EUS-GBD was done in a single retrospective study with a propensity score analysis (le iii). the outcomes of conversion from Pt-GBD to EUS-GBD were covered by few retrospective studies (le iii). several manuscripts (n.=69) were published on EUS-GBD as a rescue strategy in case of malignant biliary obstruction. ConClUsions: the levels of evidence of EUS-GBD in the literature have evolved from initial descriptive studies to recent randomized controlled trials and meta-analysis of cohort studies. While several articles addressed the comparison among different techniques for GBD, in our opinion some topics and questions have not been adequately investigated. are still debated.