Closing the Gap Between Evidence and Practice: Underutilization of Same-Admission Cholecystectomy in Mild Acute Biliary Pancreatitis - a multicenter prospective study.

Background Mild acute biliary pancreatitis (MABP) represents the most frequent form of acute pancreatitis, primarily caused by gallstones or biliary sludge. Although considered the least severe presentation, MABP carries a substantial risk of recurrence. International guidelines strongly recommend same-admission cholecystectomy (SAC) as the standard of care for MABP, supported by evidence from randomized controlled trials and meta-analyses demonstrating its efficacy and safety. Nevertheless, clinical practice often deviates from these recommendations, with interval cholecystectomy (IC)—performed weeks after discharge—remaining widely adopted. This discrepancy between evidence and practice exposes patients to preventable complications and repeated hospitalizations. Methods The Cholecystectomy TIming for Mild Acute biliary Pancreatitis (CTIMAP) study was designed as a prospective, multicenter observational investigation across 66 hospitals worldwide between June 2022 and November 2023. Adults diagnosed with MABP according to the Revised Atlanta Classification (2012) were stratified into SAC and IC groups, while a third cohort included patients who did not undergo cholecystectomy within six months. The primary endpoint was six-month readmission due to GRE. Secondary endpoints included 30-day postoperative complications, mortality, intraoperative events, bail-out procedures, operative time, postoperative length of stay (LOS), and total LOS. Data were recorded in a centralized REDCap database and propensity score weighting to minimize confounding. Results A total of 445 patients with MABP were enrolled, of whom 413 underwent cholecystectomy. Among these, 235 (57%) received SAC, while 178 (43%) underwent IC; 116 patients (26% of the total cohort) did not receive cholecystectomy within six months. SAC was associated with a significantly lower risk of six-month readmission for GRE compared with IC (hazard ratio [HR] 0.26; 95% CI 0.07–0.97; p = 0.046). After propensity score weighting, the benefit of SAC was even more pronounced (HR 0.11; 95% CI 0.02–0.55; p = 0.007). Rates of postoperative complications, conversions to open surgery, bail-out procedures, and intraoperative complications were comparable between SAC and IC, confirming the safety of early intervention. While postoperative LOS was slightly longer for SAC, total hospital LOS did not differ significantly between groups. Operative times were longer for SAC, largely due to the higher frequency of concomitant intraoperative ERCP or biliary exploration. Conclusion The CTIMAP study provides robust, real-world prospective evidence that same-admission cholecystectomy is safe and significantly reduces the risk of recurrent gallstone-related events compared to interval cholecystectomy. Despite these advantages, SAC remains underutilized, with nearly half of patients in the study managed with IC and one-quarter not undergoing surgery at all within six months. These findings underscore the persistent evidence–practice gap in the management of MABP. Overcoming logistical barriers, standardizing protocols, and promoting adherence to guidelines are essential steps toward ensuring that a greater proportion of patients benefit from timely surgical intervention.