<p>Acute cholecystitis frequently occurs in elderly or medically fragile patients. While early cholecystectomy remains the standard treatment for operable patients, gallbladder drainage plays a critical role in those who are poor candidates for immediate surgery. Over the past decade, gallbladder drainage has evolved from reliance on percutaneous transhepatic gallbladder drainage (PT-GBD) to a spectrum of endoscopic alternatives, including endoscopic transpapillary gallbladder drainage (ET-GBD) and endoscopic ultrasound-guided gallbladder drainage (EUS-GBD). Although PT-GBD provides rapid and reliable decompression, its use is limited by external catheter-related complications, impaired quality of life, and frequent recurrence when employed as definitive therapy. ET-GBD offers internal physiologic drainage and is particularly useful when transmural access is contraindicated; however, technical success remains highly dependent on cystic duct anatomy and operator experience. In contrast, EUS-GBD, facilitated by lumen-apposing metal stents, has emerged as a transformative technique, consistently achieving high technical and clinical success with fewer reinterventions and superior patient-centered outcomes compared with PT-GBD and ET-GBD in appropriately selected patients. Beyond acute drainage, EUS-GBD enables peroral cholecystoscopy, durable internal drainage, and interval cholecystectomy in selected individuals, although concerns persist regarding long-term stent-related adverse events and the potential impact on subsequent minimally invasive surgery. This review summarizes current evidence, technical considerations, and evolving clinical roles of contemporary gallbladder drainage modalities, emphasizing the need for individualized, multidisciplinary decision-making and further high-quality studies to refine long-term management strategies.</p>