Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography or No Intervention After Gallstone-Related Acute Pancreatitis

Abstract

IMPORTANCE Same-admission cholecystectomy is recommended by guidelines for mild gallstone-related acute pancreatitis, yet surgery is often deferred. Endoscopic retrograde cholangiopancreatography (ERCP) is often used as an interim strategy, but its effectiveness compared with cholecystectomy is uncertain. OBJECTIVE To compare cholecystectomy, ERCP only, and no intervention in association with recurrent acute pancreatitis and other gallstone-related complications, accounting for death as a competing event. DESIGN, SETTING, AND PARTICIPANTS This population-based cohort study used nationwide Swedish registries (2006-2019). Adults with first episodes of gallstone-related acute pancreatitis and a length of hospital stay 10 days or less were included. Follow-up began on the day after discharge. Fine-Gray subdistribution hazard models were applied in prespecified time windows (≤7, 8-14, 15-30, 31-90, 91-365, and >365 days), adjusted for age, sex, socioeconomic factors, and comorbidities. These data were analyzed from September 2025 through January 2026. EXPOSURES Index-admission cholecystectomy, ERCP only, or no intervention; elective postdischarge cholecystectomy was modeled as a time-varying covariate. MAIN OUTCOMES AND MEASURES The primary outcome was recurrent acute pancreatitis. The secondary outcome was other gallstone-related complications (acute cholecystitis and/or choledocholithiasis). RESULTS Among 9593 patients (median [IQR], age 61 [44-75] years; 60.3% female and 39.7% male), 28.7% underwent cholecystectomy, 16.9% ERCP only, and 54.4% no intervention during index hospital stay. Recurrence of acute pancreatitis in the 3 groups was 3.4%, 4.9%, and 17.5%, respectively. Similar differences were seen in adjusted models (overall subdistribution hazard ratio [sHR] for ERCP only, 1.40; 95% CI, 1.02-1.92 and for no intervention, 6.06; 95% CI, 4.85-7.56 compared with cholecystectomy). The risk of recurrence peaked 8 to 14 days after discharge among patients treated with ERCP only; beyond 15 days, there was no evidence of higher recurrence after ERCP only compared with cholecystectomy. Other gallstone-related complications occurred in 1.6% in the cholecystectomy group, 19.9% in the ERCP only group, and 16.3% in the no intervention group. CONCLUSIONS AND RELEVANCE In this study, same-admission cholecystectomy was associated with the lowest recurrence in acute pancreatitis and the lowest rate of other gallstone-related complications. ERCP only was associated with low long-term risk of recurrence but other gallstone-related complications remained common. These findings support prioritizing same-admission cholecystectomy in all individuals with acute gallstone-related pancreatitis, provided they are fit for surgery.