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Background: Select patients with acute cholecystitis (AC) are not candidates for index cholecystectomy. We compared the influence of ERCP-guided transpapillary gallbladder drainage (ERGD) versus percutaneous cholecystostomy (PC) on delayed cholecystectomy outcomes. Methods: Consecutive patients undergoing ERGD or PC for AC from January 2007 to October 2018 were included. Primary outcome was the rate of conversion to open cholecystectomy and perioperative complications in groups.Results: The study included 52 patients with ERGD and 140 with PC prior to cholecystectomy (median 68 days [IQR: 47-105.5]). Technical success was higher in the PC group (100% vs 91%; P = 0.0004).There was a nonsignificant trend to lower postoperative complications with ERGD (30.7% vs 43.5%; P = 0.07). No difference in conversion to open cholecystectomy OR: 1.5 (95% CI: 0.68-3.65; P = 0.28) or severity of complications (Clavien-Dindo grade >2) OR: 0.60, (95% CI: 0.19-1.87; P = 0.38) was noted between the ERGD and PC groups. PC was associated with higher rates of unplanned repeat intervention (16.4% vs 7.7%; P = 0.02). Conclusion:ERGD is suitable for patients with AC who is candidates for delayed cholecystectomy and should be considered for gallbladder drainage in patients with concomitant choledocholithiasis or cholangitis who require ERCP.

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Introduction: Large walled-off necrosis (WON) are challenging to manage endoscopically even with the use of large caliber lumen-apposing metal stents (LAMS). Therefore, some experts suggest percutaneous drainage (PCD) to facilitate endoscopic management with LAMS. The aim of this study is to determine the impact of PCD on WON resolution in patients undergoing LAMS drainage. Methods: A retrospective cohort study was performed for patients who underwent Endoscopic Ultrasound (EUS)-guided LAMS drainage of WON from 4/2014 to 10/2019. Demographic and procedural information and patient clinical outcomes were recorded. Cross-sectional imaging was reviewed by two abdominal radiologists blinded to patient outcome to independently determine size and percentage of solid necrosis within the WON. Wilcoxon rank sum test and Fisher's exact tests were used to compare continuous and categorical variables, respectively. A 2-sided p-value <0.05 was regarded as statistically significant. Results: A total of 62 patients underwent LAMS drainage for WON >10cm during the study period, of whom 54 (87%) did not undergo PCD. Baseline characteristics were similar between both groups including size, rate of paracolic gutter extension, percentage of solid necrosis, and presence of disconnected pancreatic duct (Table 1). Both groups were noted to contain a median of 60% solid necrosis (pZ0.66). Although no statistical procedural differences were noted between the groups (Table 2), use of a multigateway technique was more common in those without PCD (30% vs 0%; pZ0.21). Patients with PCD had no observed improvement in time to WON resolution (103 vs 78 days; pZ0.63) and did not reduce the number of endoscopic necrosectomy procedures (3.5 vs 1.0; pZ0.12) compared to those without PCD. Conclusions: In this cohort study, the majority of patients with large WON were successfully managed endoscopically with LAMS drainage and necrosectomy without the need for additional percutaneous drainage. Further studies are needed to clarify the role of percutaneous drainage in the setting of LAMS placement for WON.