Comprehensive Review of the Management of Patients with Acute Cholecystitis Who Are Ineligible for Surgery

Objective: Review the current literature for available treatments for acute cholecystitis (AC) in non-surgical candidates and provide guidelines for the management of these patients. Background: Cholecystectomy is the gold standard treatment modality for AC. A considerable number of patients who are not eligible for surgery are managed by percutaneous and endoscopic techniques. There is recent data regarding endoscopic ultrasound-guided gallbladder drainage (EUS-GBD) and emerging percutaneous approaches to address cholelithiasis and remove drains. Methods: An expert panel of surgeons, gastroenterologists, and interventional radiologists reviewed the current literature and provided recommendations for AC management in non-surgical candidates. Recommendations were based on relevant evidence, with quality and strength assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) framework. Results: Percutaneous cholecystostomy (PC) is advised for patients ineligible for lumen-apposing metal stent (LAMS) or with reversible conditions, aiming to bridge to cholecystectomy. The optimal timing of cholecystectomy after PC remains unclear. In cases where surgery is not feasible, potential definitive treatments such as percutaneous cholecysto-lithotripsy/lithectomy and cholecystoduodenal stenting should be considered. For calculous AC, EUS-GBD with LAMS is recommended as a therapy for never-surgical candidates if they are eligible for monitored anesthesia care or general anesthesia and there is institutional expertise and minimal intervening ascites. Conclusions: The management of AC in non-surgical candidates remains a challenge, with institutional protocols varying based on physician preferences and expertise. The proposed protocol integrates percutaneous and endoscopic approaches and emphasizes the need for multidisciplinary collaboration. Further research is required to evaluate these evolving management techniques, as the current literature is limited.