Optimal Timing of Cholecystectomy in Pediatric Acute Biliary Pancreatitis: A Prospective Comparative Analysis of Early Versus Deferred Surgical Intervention

Abstract

Background: Acute biliary pancreatitis (ABP) is a clinically important and rising disease in the pediatric and adolescent age group, especially in low- and middle-income countries experiencing epidemiological changes in biliary disease. The most common etiological mechanism is cholelithiasis-mediated pancreatic ductal obstruction. Although the use of international guidelines in promoting early definitive surgical intervention has been a constant agenda, in resource constrained systems like the public health infrastructure in Iraq, application has remained patchy because of multifactorial structural and logistical impediments.

Purpose: To determine the difference in the 90-day pancreatitis recurrence and cumulative healthcare resource use between pediatric patients (aged 6–18 years) with mild-to-moderate ABP who underwent early cholecystectomy (≤72 hours of diagnosis) and those with deferred surgery (>6 weeks post-discharge).

Methods: It was a prospective observational cohort study carried out at Al-Zahra Teaching Hospital, Wasit, Iraq (January 2021 September 2024). Patients meeting the Revised Atlanta Classification criteria of mild-to-moderate ABP were divided into an early cohort (Group E: n = 58) or a deferred cohort (Group D: n = 54). The most important endpoint was 90-day recurrent pancreatitis; others were cumulative inpatient days, 30-day readmission, postoperative complication per Clavien-Dindo grading, and systematic characterization of delay determinants.

Results Recurrent pancreatitis was found in 3.4% of Group E and 24.1% of Group D (p < 0.001), with an absolute risk reduction of 20.7 percentage points and a number-needed-to-treat of five. Although the initial picture showed a slightly prolonged stay in Group E (4.2 vs. 3.1 days; p = 0.012), the total inpatient burden at 90 days was significantly less (5.3 vs. 8.9 days; p < 0.001). The profiles of perioperative complications were similar (1.7% vs. 3.7%; p = 0.59). Multivariable analysis established that early cholecystectomy is an independent protective factor (aOR = 0.11; 95% CI: 0.02-0.54; p =0.007). Health system-level factors accounted for 74% of all procedural delays.

Conclusion: The early cholecystectomy within 72 hours of ABP diagnosis offers significant clinical and economic advantages in children in the Iraqi tertiary public hospital without increasing perioperative complication risk. To scale this approach, it is necessary to have targeted structural reforms in the health system, which is in keeping with Sustainable Development Goal 3.