Same-Admission Cholecystectomy Is Preferred Treatment for Gallstone-Related Acute Pancreatitis

Selin D, Oskarsson V, Maret-Ouda J, Valente R, et al. Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography or No Intervention After Gallstone-Related Acute Pancreatitis. JAMA Surg. June 2026.

Despite longstanding recommendations for same-admission cholecystectomy, surgery is often deferred, with endoscopic retrograde cholangiopancreatography (ERCP) frequently used as an interim strategy. This study evaluated whether ERCP alone offers comparable protection against recurrent biliary events.

Investigators in this population-based, Swedish cohort study of 9,593 patients analyzed nationwide registry data from 2006 to 2019. The study included adults hospitalized for a first episode of gallstone-related acute pancreatitis with a hospital stay of 10 days or less. Patients were grouped according to treatment during index admission: cholecystectomy (28.7%), ERCP only (16.9%), or no biliary intervention (54.4%).

The primary outcome was recurrent acute pancreatitis, while secondary outcomes included acute cholecystitis and choledocholithiasis. Analyses adjusted for demographic, socioeconomic, and clinical factors, with death treated as a competing risk.

Recurrent pancreatitis occurred in just 3.4% of patients who underwent cholecystectomy, compared with 4.9% following ERCP alone and 17.5% among patients who received no intervention. After adjustment, ERCP alone was associated with a modestly higher risk of recurrence than cholecystectomy (subdistribution hazard ratio [sHR], 1.40), while the absence of any intervention increased recurrence risk more than sixfold (sHR, 6.06).

The timing of recurrence also proved clinically relevant. Patients treated with ERCP alone experienced the greatest risk of recurrent pancreatitis during the first 8 to 14 days after discharge. Beyond the first 2 weeks, recurrence rates were similar to those observed after cholecystectomy, suggesting ERCP provides durable protection against recurrent pancreatitis once the immediate postdischarge period has passed.

However, ERCP did not protect against other biliary complications. Acute cholecystitis or choledocholithiasis developed in 19.9% of patients treated with ERCP alone, compared with only 1.6% of those undergoing same-admission cholecystectomy. 

Overall, the findings reinforce that index-admission cholecystectomy remains the most effective strategy for preventing both recurrent pancreatitis and subsequent gallstone-related complications and should be prioritized whenever patients are appropriate surgical candidates.