Why Would You Put a Stent in the Gallbladder?

Gallbladder stents are placed when the gallbladder is dangerously inflamed or blocked but surgery to remove it would be too risky for the patient. The standard treatment for acute cholecystitis, the most common gallbladder emergency, is surgical removal of the gallbladder entirely. But for a subset of patients who are too sick, too elderly, or too medically fragile for an operation, a stent can drain the infected bile and resolve the crisis without a single surgical incision. The approach has evolved considerably over the past decade, and what was once a last resort has become, for some patients, a preferred long-term solution.

When Removing the Gallbladder Is Not an Option

Acute cholecystitis happens when the cystic duct, the small tube that drains the gallbladder into the main bile duct, gets blocked. In roughly nine out of ten cases, a gallstone is the culprit. Bile builds up, the gallbladder wall swells, bacteria multiply, and the patient develops severe right-sided abdominal pain, fever, and sometimes life-threatening infection. The definitive fix is cholecystectomy, laparoscopic removal of the gallbladder, and for most people that surgery is safe and routine.

The trouble arises in patients for whom general anesthesia or surgery carries extreme risk. Think of an 85-year-old on blood thinners with advanced heart failure, or someone in the ICU on a ventilator after a stroke. For this small but real group, the risk of dying from surgery can exceed the risk of the disease itself.¹ In these patients, the goal shifts from curing the gallbladder problem permanently to controlling the immediate emergency, and that is where gallbladder stenting comes in.

What a Gallbladder Stent Actually Does

A gallbladder stent creates an alternative drainage path so that infected or trapped bile can flow out of the gallbladder, relieving the pressure and allowing the inflammation to settle. There is no single technique. Several approaches exist, each suited to different clinical situations, and the choice depends on the patient’s anatomy, the severity of the inflammation, and the expertise available at the hospital.

Endoscopic transpapillary gallbladder drainage is the oldest endoscopic approach. A gastroenterologist passes a thin scope down through the mouth, into the duodenum, and up into the bile duct through the natural opening called the papilla. From there, a guidewire is threaded into the cystic duct and up into the gallbladder, and a small plastic stent is left in place to keep bile flowing. One study using a dual-stent version of this technique reported a perfect technical and clinical success rate in 21 patients, with only one recurrence over a median follow-up of nearly a year.² The catch is that navigating a guidewire through a swollen, stone-impacted cystic duct is difficult. Ductal strictures can block access entirely, and the stent can clog or migrate over time.³

EUS-guided gallbladder drainage takes a completely different route. Instead of navigating through the bile ducts, the endoscopist uses an ultrasound-equipped scope positioned in the stomach or upper small intestine to locate the gallbladder through the gut wall. A special stent, usually a lumen-apposing metal stent (LAMS), is pushed directly through the stomach or duodenal wall into the gallbladder, creating a new fistula, essentially a small tunnel, between the gallbladder and the digestive tract. Bile drains directly through this tunnel. In a prospective multicenter trial, this approach succeeded in 28 of 30 patients, with drainage visible through the stent immediately after placement.⁴

Why Internal Stents Are Replacing External Drain Tubes

Before endoscopic stenting became widely available, the main alternative to surgery for high-risk patients was percutaneous cholecystostomy, a tube inserted through the skin directly into the gallbladder under imaging guidance. It works, but it leaves the patient with an external drainage bag taped to their abdomen. That bag needs regular flushing, can get infected at the skin entry site, can fall out accidentally, and often requires multiple return visits to the hospital for tube checks and exchanges. For frail, elderly patients already struggling with daily life, managing an external drain is a real burden.

Internal stents avoid all of that. There is nothing protruding from the body, no bag to manage, and no skin wound to keep clean. The clinical advantages go beyond comfort. A propensity-matched study comparing EUS-guided gallbladder drainage with percutaneous drainage found that patients with external tubes needed significantly more follow-up procedures (a median of three versus two) and experienced nearly triple the complication rate: roughly 44% for the percutaneous group compared with about 16% for the EUS-guided stent group.⁵ Clinical success, defined as resolution of the cholecystitis, trended higher with the internal stent as well, though the difference did not reach statistical significance in that particular study.

Pain is another factor. Patients who receive internal stents generally report less discomfort afterward than those with a tube through their abdominal wall, and hospital stays tend to be shorter. For patients who will never be healthy enough for gallbladder removal, the prospect of managing an internal stent indefinitely is far more practical than living with an external drain for months or years.

Bridge to Surgery or Permanent Solution

Gallbladder drainage does not always have to be a permanent arrangement. In many cases, the stent is placed to cool down the acute inflammation so that the patient can eventually undergo a safer, planned cholecystectomy weeks or months later. This is called a “bridge to surgery” approach, and it is common when the patient’s surgical risk is expected to improve once the acute illness resolves.⁶ A patient on a ventilator in the ICU, for example, may recover enough in a few weeks to tolerate an operation, and the stent buys that time.

For patients who will never be surgical candidates, whether because of permanent debility, advanced cancer, or simply personal choice, the stent can serve as a definitive treatment. A large single-center study tracked patients with EUS-guided transmural drainage over the long term and reported a mean stent patency of about 421 days without any recurrent cholecystitis among the group still alive at follow-up. In about 43% of those patients, the initial metal stent was eventually exchanged for permanent double-pigtail plastic stents.⁷ That exchange matters because the metal stents used for initial drainage are robust and create the fistula tract quickly, but they are not always ideal for years of continuous use. Plastic stents are less likely to cause tissue erosion over extended periods.

What Happens After the Stent Goes In

Expert consensus suggests that management after stent placement should be individualized. If a patient has gallstones and might benefit from stone clearance, a follow-up endoscopy can be scheduled about four to six weeks after the initial drainage. During that procedure, the doctor can pass a scope through the stent tract directly into the gallbladder, inspect it, and remove any remaining stones. The metal stent is then swapped for plastic ones to maintain the drainage fistula long-term, with a reported technical success rate for that exchange of up to 93%.⁸

For patients who are very frail or who simply do not want another procedure, the metal stent can be left in place indefinitely. The same expert consensus acknowledges that permanent indwelling of the initial stent is a reasonable choice when the alternatives are worse. This is medicine meeting the patient where they are: not every clinical scenario has a textbook-perfect next step, and sometimes the best option is to leave things alone when they are working.

Gallbladder Stenting Beyond Gallstones

Acute cholecystitis from gallstones is the most common reason for gallbladder stenting, but it is not the only one. Stents are also placed for conditions like gallbladder hydrops, where the gallbladder becomes distended with fluid without active infection, and for cholecystitis without stones (acalculous cholecystitis), which is especially common in critically ill ICU patients. A systematic review of EUS-guided gallbladder drainage found that the underlying causes included not just gallstones but also bile duct stones, acalculous cholecystitis, and malignancies such as pancreatic cancer, cholangiocarcinoma, and gallbladder cancer.⁹

In the case of unresectable gallbladder cancer that causes bile duct obstruction, stenting serves a purely palliative purpose: the goal is to relieve jaundice and itching by restoring bile flow, not to treat the cancer. Palliative endoscopic stenting remains the first-line approach for these patients.¹⁰ The stents used in malignant obstruction are typically placed in the bile ducts rather than directly in the gallbladder, but the principle is the same: create a channel for bile to flow past the blockage.

Complications and What Can Go Wrong

No procedure is without risk, and gallbladder stenting has its own set of potential problems. The cystic duct approach carries risks of stent occlusion (the stent gets clogged with sludge or stones), stent migration (the stent shifts out of position), and in rare cases, perforation of the duct or gallbladder wall.³ A study of cystic duct stenting reported a technical success rate of about 91% with a 10% complication rate within 30 days.

EUS-guided transmural drainage has its own risks. During stent placement, there is a small chance of puncturing a blood vessel between the gut wall and the gallbladder, or of the stent dislodging before it is fully deployed. In the multicenter trial mentioned earlier, one procedure was aborted because of intervening vessels, and one stent dislodged during placement, though the puncture site was closed with clips without further harm.⁴ Once a stent is in place and working, the main long-term concerns are recurrent cholecystitis and cholangitis (bile duct infection). A prospective pilot study following 66 patients with gallbladder stents found a recurrence rate of cholecystitis of about 4.5%, with an overall late adverse event rate, including cholangitis and one liver abscess, of roughly 11% over three years.¹¹

Stent migration, the fear that keeps gastroenterologists up at night with any internal stent, has been addressed by newer stent designs. One study of an improved self-expandable metal stent with an anti-migration system found no migration in any patient over a median follow-up of about six months, with clinical success in every case.¹² The technology is still evolving, and newer stent designs continue to address the weak points of earlier models.

How the Procedure Is Performed

For EUS-guided drainage, the patient is sedated and a specialized ultrasound-equipped endoscope is advanced through the mouth into the stomach or the first part of the small intestine. The endoscopist uses ultrasound imaging to locate the gallbladder and identify a puncture site that avoids blood vessels. A needle punctures through the gut wall into the gallbladder, a guidewire is threaded through, and then the stent is deployed across the new channel. Newer “hot” stents have a built-in cautery tip that creates the puncture and deploys the stent in a single step, streamlining the process. The stent has flanges on both ends, mushroom-like rims that hold it in place on the gallbladder side and the gut side, preventing it from migrating.¹³

The entire procedure typically takes less than an hour. Most patients notice improvement in their pain and fever within a day or two as the gallbladder decompresses. Compared to having a tube inserted through the skin, there is no wound to care for afterward, and many patients can be discharged sooner.

The Cost Question

Internal stents are more expensive upfront than percutaneous drain tubes. The lumen-apposing metal stent alone can cost several thousand dollars, and the EUS equipment and expertise add to the bill. A budget impact analysis found that the total procedure cost per patient was roughly $9,400 for EUS-guided drainage compared with about $4,400 for percutaneous drainage.¹⁴

But the story changes when you look at the total cost of care rather than just the initial procedure. Patients with external drains come back to the hospital more often: for tube replacements, for complications at the tube site, and for unplanned readmissions. That same budget analysis found the expected cost per patient for re-procedures was dramatically lower in the EUS group (about $108) compared with the percutaneous group (roughly $1,600), and unplanned readmission costs followed a similar pattern. A separate cost-effectiveness analysis concluded that EUS-guided gallbladder drainage, despite its higher initial price, was cost-effective compared to percutaneous drainage, with the savings driven largely by fewer repeat interventions.¹⁵ Another economic analysis found that endoscopic approaches were cost-saving compared to percutaneous drainage, with additional costs offset by shorter hospital stays.¹⁶

Who Should and Should Not Get a Gallbladder Stent

Gallbladder stenting is not a replacement for cholecystectomy in people who can safely undergo surgery. A healthy person with an acute gallbladder attack should still have the gallbladder removed. The stent option exists specifically for patients in whom the surgical risk is unacceptably high. Both endoscopic transpapillary and EUS-guided approaches have been proposed as safe and effective in debilitated or high-risk patients.¹⁷

Candidacy depends on more than just surgical risk. Anatomy matters: if the gallbladder is shrunken, severely scarred, or sitting in an unusual position, the endoscopist may not be able to reach it safely. Patients on strong blood thinners face higher bleeding risk from any puncture procedure. And EUS-guided drainage requires specific expertise and equipment that not every hospital has, so availability varies widely by region and institution.

There is also a philosophical dimension to the decision. Some patients, even when told they could tolerate surgery, prefer not to undergo an operation. The systematic review of EUS-guided drainage noted that some patients had “refused to undergo PT-GBD or preferred to undergo EUS-GBD,” suggesting that patient preference plays a legitimate role in the decision.⁹ As the evidence for long-term stent outcomes grows, the line between “can’t have surgery” and “doesn’t need surgery” may continue to shift.

Living with a Gallbladder Stent

For patients who keep their stent permanently, daily life is surprisingly normal. Internal stents are not felt by the patient, require no external care, and impose no dietary restrictions beyond what the underlying condition demands. The main practical concern is follow-up: patients need periodic check-ins to make sure the stent is still functioning and the gallbladder remains quiet. If a stent becomes blocked or a new problem develops, a repeat endoscopy can address it without surgery.

The three-year data from the prospective pilot study offers some reassurance. While the cumulative rate of late complications climbed to about 19% by the three-year mark, the majority of those events were manageable with repeat endoscopy or antibiotics, and none were reported as fatal.¹¹ For a population that was already too sick for surgery, a roughly one-in-five chance of needing a repeat procedure over three years compares favorably with the risks of the alternatives. The 23 patients in that study who died during follow-up all died from causes unrelated to the procedure, a reminder that these stents are being placed in people who are already seriously ill with other conditions.