Highlight
This large population-based study from Sweden (2006–2019) directly compares three management strategies following gallstone-related acute pancreatitis: same-admission cholecystectomy, ERCP alone, and no intervention. The findings demonstrate that same-admission cholecystectomy is associated with the lowest risk of recurrent pancreatitis and other gallstone-related complications. While ERCP alone reduces the short-term recurrence risk, it does not prevent longer-term biliary complications effectively. Many patients still receive no intervention during index admission, reinforcing the need to prioritize early surgery where feasible.
Study Background
Gallstone-related acute pancreatitis (AP) is a common and clinically significant condition. Gallstones obstruct the bile or pancreatic ducts causing inflammation of the pancreas, which can range from mild to severe. Recurrent AP and other complications like acute cholecystitis and choledocholithiasis (common bile duct stones) pose substantial morbidity risks. Current guidelines recommend same-admission cholecystectomy for mild cases to prevent recurrence and complications. Despite this, surgery is often deferred due to clinical or logistical reasons. Endoscopic retrograde cholangiopancreatography (ERCP) is sometimes used as an interim measure, mainly to clear bile duct stones or treat cholangitis, but its comparative effectiveness as sole treatment against cholecystectomy or conservative management remains uncertain. This study addresses the clinical dilemma by comparing these three strategies using robust nationwide registry data.
Study Design
This was a nationwide, population-based cohort study conducted in Sweden from 2006 to 2019, involving adults with a first episode of gallstone-related acute pancreatitis with hospital stays of 10 days or less. Participants were classified into three exposure groups during their index admission: same-admission cholecystectomy, ERCP only, or no intervention. Elective cholecystectomy after discharge was analyzed as a time-varying covariate. The primary endpoint was recurrent acute pancreatitis; secondary endpoints included other gallstone-related complications such as acute cholecystitis and choledocholithiasis.
Fine-Gray subdistribution hazard models accounted for death as a competing risk and evaluated outcomes in predefined postdischarge time windows (≤7, 8-14, 15-30, 31-90, 91-365, and >365 days). Models adjusted for age, sex, socioeconomic status, and comorbidities ensured robustness. Follow-up commenced the day after hospital discharge, allowing real-world assessment of post-hospitalization outcomes.
Key Findings
A total of 9,593 patients met inclusion criteria (median age 61 years, 60.3% female). Their management during index admission was as follows: 28.7% underwent same-admission cholecystectomy, 16.9% underwent ERCP only, and 54.4% received no intervention.
Recurrent pancreatitis rates were strikingly different among groups: 3.4% in the cholecystectomy group, 4.9% in the ERCP only group, and 17.5% in the no intervention group. Adjusted subdistribution hazard ratios (sHR) using cholecystectomy as the reference were 1.40 (95% CI, 1.02-1.92) for ERCP only and 6.06 (95% CI, 4.85-7.56) for no intervention, indicating a substantial protective effect of cholecystectomy against recurrence.
Timing analysis demonstrated the highest risk of early recurrence (8–14 days postdischarge) among the ERCP only group; however, beyond 15 days, the risk equalized between ERCP only and cholecystectomy groups, suggesting ERCP primarily mitigates short-term risk.
Regarding secondary outcomes, other gallstone-related complications occurred in 1.6% of patients who had cholecystectomy, whereas complications were significantly more common with ERCP only (19.9%) or no intervention (16.3%). This indicates that while ERCP can help temporarily, it does not definitively prevent subsequent biliary morbidity.
The safety profile and duration of follow-up were not explicitly detailed; however, the large sample and comprehensive registry linkage lend credence to the generalizability of results.
Expert Commentary
The findings of this study align well with established guidelines advocating for same-admission cholecystectomy in mild gallstone pancreatitis. Prompt removal of the gallbladder eliminates the source of stones and reduces recurrence risk effectively.
ERCP, although useful for clearing bile duct stones or treating cholangitis, should not be considered a substitute for cholecystectomy. The residual gallbladder remains a nidus for recurrent stones and inflammation, as demonstrated by the high rate of other gallstone-related complications following ERCP alone.
The high proportion of patients receiving no definitive intervention during index admission is concerning. It reflects potential clinical inertia, resource limitations, or patient-related factors that warrant further attention to implementation strategies in clinical practice.
Limitations include lack of detailed clinical severity data, potential selection biases (sicker patients may not be surgical candidates), and absence of quality-of-life or cost-effectiveness analyses. Nonetheless, the large nationwide cohort and sophisticated statistical methods mitigating competing mortality risks strengthen the evidence base.
Conclusion
Same-admission cholecystectomy after gallstone-related acute pancreatitis is associated with the lowest risk of recurrent pancreatitis and other gallstone-related complications. ERCP alone may reduce early recurrence but fails to prevent long-term biliary disease effectively. No intervention confers the highest risk of adverse outcomes.
These results reinforce guideline recommendations to prioritize early surgical management of all patients with mild gallstone pancreatitis who are fit for surgery. Health systems should focus on increasing timely access to cholecystectomy to reduce disease burden and improve patient outcomes.
Funding and ClinicalTrials.gov
No specific funding details were provided. This was an observational cohort study using registry data. The study was analyzed between September 2025 and January 2026.
References
- Selin D, Oskarsson V, Maret-Ouda J, et al. Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography or No Intervention After Gallstone-Related Acute Pancreatitis. JAMA Surg. 2026 Jun 24. PMID: 42340741.
- Working Group IAP/APA Acute Pancreatitis Guidelines. IAP/APA evidence-based guidelines for the management of acute pancreatitis. Pancreatology. 2013;13(4 Suppl 2):e1-15.
- Tenner S, Baillie J, DeWitt J, et al. American College of Gastroenterology Guideline: Management of Acute Pancreatitis. Am J Gastroenterol. 2013 Sep;108(9):1400-15.
