S6 Early vs Delayed Cholecystectomy in Patients Admitted for Choledocholithiasis: Impact on Biliary Complications and Role of Sphincterotomy or Stenting

Introduction: Choledocholithiasis complicates up to 20% of symptomatic cholelithiasis cases and is typically managed with endoscopic retrograde pancreatography (ERCP) followed by cholecystectomy. Although early cholecystectomy (EC) is guideline-recommended, delays are common due to clinical and logistical barriers. We aimed to examine biliary complication rates in EC vs delayed cholecystectomy (DC), the role of ERCP with sphincterotomy or stent placement, and barriers to timely surgery. Methods: We conducted a retrospective cohort study of adults admitted with choledocholithiasis in a large healthcare system from 2005 to 2023 with ≥12 months follow-up. EC was defined as surgery during the index admission, while DC was defined as post-discharge cholecystectomy or if cholecystectomy was not performed. Primary outcomes were biliary complications, readmissions, and mortality within 1 year. Secondary outcomes included biliary complications in ERCP with and without sphincterotomy or stent placement, and reasons for DC. All study outcomes were adjudicated via independent chart review. A Sankey plot illustrated biliary complications over time in EC vs DC groups. Univariable regression was used to assess whether ERCP with sphincterotomy or stent placement reduced biliary complications. Results: We included 507 patients (median age 59, 59.4% women), among which 265 (52.3%) underwent EC and 242 (47.7%) underwent DC. Biliary complications occurred in 23% of DC vs 0.8% of EC patients (P < 0.001). Among DC patients, 15.5% developed complications within 3 months, 6.5% by 6 months, and 1% by 12 months. Neither ERCP with sphincterotomy (26% vs 21%, P = 0.74) nor stenting (25% vs 27%, P = 0.81) significantly reduced biliary complication rates in patients that had DC. The top reasons for DC included high surgical risk (27.3%), concurrent biliary pathology (19.2%), and physician preference (14%). Conclusion: Delayed cholecystectomy is associated with a >17-fold increase in biliary complications, most occurring within 90 days of discharge. Neither sphincterotomy nor stenting during ERCP mitigates this risk. Common reasons for DC include high surgical risk, concurrent pathology, and physician preference. EC during the index admission remains the most reliable strategy to reduce recurrent events. These findings suggest an opportunity for systemic interventions, including prioritization algorithms and better perioperative coordination, to address preventable delays.