Cholecystectomy During Index Admission
For this patient with first-episode gallstone pancreatitis and no complications, cholecystectomy should be performed during the same hospital admission after the pancreatitis resolves, before discharge. 1
Rationale for Same-Admission Cholecystectomy
The most recent and highest quality evidence strongly supports early intervention:
The 2018 AGA guideline provides a strong recommendation (based on moderate quality evidence from an RCT) that cholecystectomy should be performed during the initial admission rather than after discharge for acute biliary pancreatitis 1
This approach substantially reduces mortality and gallstone-related complications (OR 0.24; 95% CI 0.09-0.61), readmission for recurrent pancreatitis (OR 0.25; 95% CI 0.07-0.90), and pancreaticobiliary complications (OR 0.24; 95% CI 0.09-0.61) 1
Same-admission cholecystectomy does not increase surgical difficulty or conversion rates to open surgery compared to delayed approaches 1
Risk of Delayed Surgery
Waiting until after discharge exposes patients to unacceptably high risks:
32.8% of patients experience gallstone-related events (including recurrent pancreatitis) while waiting for cholecystectomy after discharge 2
31.3% of recurrences occur within the first 2 weeks after discharge, making even short delays dangerous 2
Overall, 18% of patients are readmitted for recurrent biliary events before interval cholecystectomy, including 8% with recurrent pancreatitis 3
The risk of recurrent pancreatitis is significantly lower when cholecystectomy is performed within 8 weeks after discharge (risk ratio 0.14; 95% CI 0.02-1.0) 4
Guideline Consensus
Multiple authoritative guidelines align on this recommendation:
The 2007 AGA position statement recommends cholecystectomy during the same hospital admission if possible, and otherwise no later than 2-4 weeks after discharge 1
The British Society of Gastroenterology recommends definitive management within 2 weeks and no longer than 4 weeks, preferably during the same admission to prevent avoidable recurrent pancreatitis 1
Important Caveats
This recommendation applies specifically to mild, uncomplicated gallstone pancreatitis:
In severe pancreatitis with necrosis or systemic complications, cholecystectomy should be delayed until inflammatory signs resolve and the patient is clinically stable 1, 5
If local complications develop (pseudocyst, infected necrosis), cholecystectomy should wait until these are treated or resolved 1
Patients with persistent peripancreatic collections should not undergo cholecystectomy until collections resolve, as this increases risk of infected necrosis 4
Operative Approach
Laparoscopic cholecystectomy is preferred 1
Operative cholangiography should be performed to assess for common bile duct stones 1
The procedure should be performed once acute symptoms have subsided, typically 5-6 days after onset minimizes the chance of finding choledocholithiasis 6
Answer: A - Cholecystectomy after the pancreatitis resolves before discharge