Optimal Timing of Cholecystectomy Following Moderate-to-Severe Acute Biliary Pancreatitis: Evidence Gaps, Clinical Framework, and Future Directions

Abstract Background: Gallstones account for 40–50% of all acute pancreatitis cases globally. Cholecystectomy is the only definitive strategy to eliminate the biliary source and prevent disease recurrence. For mild acute biliary pancreatitis (ABP), same-admission cholecystectomy is the established standard of care. For moderate-to-severe ABP — classified by the Revised Atlanta Classification (RAC) 2012 — current guidelines recommend delayed cholecystectomy, yet this recommendation is grounded in expert opinion rather than prospective severity-stratified evidence. Critically, observational data demonstrate that 10–35% of patients experience recurrent biliary events during the waiting period for interval surgery — a risk systematically underrepresented in guideline language. Methods: We performed a critical narrative review of published RCTs, prospective and retrospective cohort studies, and major guideline statements addressing cholecystectomy timing in ABP. Evidence was evaluated with explicit reference to RAC 2012 severity stratification, preoperative imaging, ERCP timing, special populations, and patient-centered outcomes. Results: The PONCHO trial — the primary RCT informing current recommendations — explicitly excluded patients with peripancreatic necrosis, leaving a critical evidentiary void for moderate-to-severe disease. The RAC 2012 distinguishes moderate ABP (transient organ failure, <48 hours; and/or local complications) from severe ABP (persistent organ failure, >48 hours), yet this biologically meaningful distinction is not operationalized in any major guideline's cholecystectomy timing recommendation. Guideline evidence levels for the 'delay' recommendation range from Grade 1C to Grade C — designations that reflect low-quality evidence or expert consensus, not prospective trial data. Waiting-period recurrence rates and rates of non-completion of interval cholecystectomy represent a quantifiable burden of preventable morbidity that existing guidelines do not adequately account for. Conclusions: The current uniform 'delay' recommendation for all moderate-to-severe ABP conflates two clinically distinct severity categories without an adequate evidence basis. A severity-differentiated, individualized approach — incorporating RAC 2012 classification, CT imaging findings, organ failure trajectory, ERCP status, and patient-specific factors — is advocated. A clinical decision algorithm, evidence critique tables, and a detailed framework for future severity-stratified RCTs and prospective registries are provided. Keywords: acute biliary pancreatitis; cholecystectomy timing; Revised Atlanta Classification; moderate pancreatitis; severe pancreatitis; delayed cholecystectomy; same-admission cholecystectomy; narrative review; biliary surgery; PONCHO trial