S2294 Implementation of a Multi-Disciplinary System Protocol for Management of Acute Cholecystitis in Patients Not Suitable for Cholecystectomy: Evidence That Teamwork Is Key to Changing System Practices and Paradigms

Introduction: Acute cholecystitis (AC) is a common problem for which cholecystectomy is typically offered, unless patients are ill-suited for cholecystectomy. Percutaneous cholecystostomy (PC) has been historically offered, but EUS-gallbladder drainage (EUS-GBD) is emerging as a technique for the non-surgical patient. Barriers exist with regard to acceptance of EUS-GBD as a primary modality in these patients. Methods: Our Multidisciplinary Protocol (MDP) was developed in January of 2023 with representatives from Acute Care and Trauma Surgery (ACS), Hepatopancreaticobiliary Surgery (HPB), Emergency Department (ED), General Gastroenterology (GI), Interventional Radiology (IR), Oncology (Onc), and Hospitalist and Internal Medicine Teaching Services (HIMT) to educate on published outcomes of EUS-GBD. We decided that EUS-GBD should be reserved to only non-surgical AC patients with: 1) Severe acute and/or chronic illness; 2) Malignant cystic duct obstruction (MCDO); 3) Any malignancy precluding safe surgery; 4) Adverse events related to Percutaneous cholecystostomy (PC) in those unable to have drain removed or those with recurrent AC after drain removal; 5) Failure of Percutaneous Endoscopic Biliary Lithotomy (PEBL) for PC removal. All patients referred for EUS-GBD had to have AC confirmed clinically and/or by imaging. Results: Sixty-four patients were referred for EUS-GBD, 61 of whom had technically successful EUS-GBD (95.3%). Twenty-four patients had acute and/or chronic illness precluding safe cholecystectomy. Thirteen patients had MCDO. Fourteen patients had malignancy without cystic duct obstruction. Ten patients had PC history (8 with active PC, 2 with recurrent AC after drain removal). Three patients had failed PEBL. Technical failures of EUS-GBD occurred in 3 patients (4.7%): one with intervening mass, one with intervening varices, and one with anesthesia-induced bradycardia resulting in termination of the procedure. From 2020-2022 (prior to implementation of the MDP), 24 EUS-GBD were performed (8 cases per year). After MDP (Jan 2023 through May 2025), 37 EUS-GBD were performed (14.8 cases per year). The majority of referrals were from surgical (50%), HITM/GI (20%), and IR (20%) services. Conclusion: Implementation of MDP with various subspecialty stakeholders requires significant education and collaboration after which acceptance—and resulting increases in referrals—of EUS-GBD is likely. Establishing clear parameters for candidacy is important to ensure collegiality and avoid competition with other specialties.