Early vs. Delayed Cholecystectomy in Acute Biliary Pancreatitis: Impact on Recurrent Attacks

Early vs. Delayed Cholecystectomy in Acute Biliary Pancreatitis: Impact on Recurrent Attacks Hassan Khalil Melek  Department of Surgery, College of Medicine, Wasit University, Iraq Abstract Background: Acute biliary pancreatitis (ABP), traditionally regarded as a condition predominantly affecting adults, is increasingly recognized in pediatric and adolescent populations, particularly in lowand middle-income countries undergoing epidemiologic transitions in biliary disease. Gallstoneinduced obstruction of the common bile duct or pancreatic duct remains the principal etiology. Delayed definitive surgical management specifically cholecystectomy is associated with high recurrence rates. However, the optimal timing of cholecystectomy remains contentious, especially within resource-constrained health systems such as Iraq’s, where structural limitations including restricted surgical capacity, fragmented referral pathways, and limited caregiver health literacy frequently delay intervention beyond evidence-based recommendations. Objective: This study aimed to compare the incidence of recurrent pancreatitis and other biliary-related complications between pediatric and adolescent patients (aged 6–18 years) with mild-to-moderate ABP who underwent early (≤72 hours from symptom onset or diagnosis) versus delayed (>6 weeks) cholecystectomy. Additionally, we assessed system-level factors contributing to surgical delays and their impact on healthcare utilization. Methods: A prospective cohort study was conducted at AlZahra Teaching Hospital from January 2021 to September 2024. Patients diagnosed with mild-to-moderate ABP according to the Revised Atlanta Classification were enrolled and stratified into two groups: Group E (early cholecystectomy within 72 hours; n = 58) and Group D (delayed cholecystectomy beyond 6 weeks; n = 54). The primary outcome was 90-day readmission due to recurrent pancreatitis. Secondary outcomes included cumulative hospital length of stay (initial admission plus readmissions), 30and 90-day all-cause readmission rates, intraoperative and postoperative complications (classified per Clavien-Dindo), and health system-related causes of surgical delay. Results: Of 112 eligible patients, Group E demonstrated a significantly lower recurrence rate of pancreatitis (2 patients, 3.4%) compared to Group D (13 patients, 24.1%; p < 0.001). Although the median initial hospital stay was slightly longer in Group E (4.2 vs. 3.1 days; p = 0.012), the total cumulative hospitalization including readmissions was markedly reduced (1.1 vs. 5.8 days; p = 0.001). No statistically significant difference was observed in surgical complication rates (5.2% vs. 3.7%; p = 0.71). System-level barriers including weekday-only operating room availability, absence of surgical teams on weekends, and delayed referrals from primary care accounted for 74% of all delayed procedures. Conclusion: Early cholecystectomy within 72 hours of ABP diagnosis in pediatric and adolescent patients is associated with a substantial reduction in pancreatitis recurrence and overall healthcare utilization, despite a modest increase in initial hospital stay. These findings underscore the urgent More Information How to cite this article: Melek HK. Early vs. Delayed Cholecystectomy in Acute Biliary Pancreatitis: Impact on Recurrent Attacks. Eur J Med Health Res, 2025;3(4):246-52. DOI: 10.59324/ejmhr.2025.3(4).36 Keywords: acute biliary pancreatitis, cholecystectomy timing, recurrent pancreatitis, pediatric surgery, health system barriers, surgical access, Iraq, SDG 3, healthcare utilization, biliary disease. This work is licensed under a Creative Commons Attribution 4.0 International License. The license permits unrestricted use, distribution, and reproduction in any medium, on the condition that users give exact credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if they made any changes. EUR J MED HEALTH RES Volume 3 | Number 4 | 2025 247 need to strengthen surgical capacity at secondary-level hospitals in Iraq to ensure timely definitive care. Aligning such system improvements with Sustainable Development Goal 3 (Good Health and Well-being) offers a strategic framework to reduce preventable morbidity and promote equitable access to essential surgical services in resourcelimited settings. Introduction Acute biliary pancreatitis (ABP) is a relatively new pathology of pancreatic inflammation in children and adolescents, especially in lowand middle-income countries that experience changes in the epidemiology of biliary disease. ABP is recognized to cause 1525 percent of all pediatric pancreatitis in resource-limited environments like Iraq and gallstones and biliary sludge were found to be the leading causes [1]. In contrast to other causes of acute pancreatitis, ABP has the highest likelihood of recurrence of more than 30% within 90 days in case no decisive biliary treatment, i.e. cholecystectomy, is done [2]. This chronic illness affects only the morbidity of the patients besides exerting an undue burden to the already stretched healthcare facilities. Guidelines on international consensus, such as the one released by the International Association of Pancreatology/American Pancreatic Association (IAP/APA) and the European Society of Paediatric Gastroenterology, Hepatology, and Nutrition (ESPGHAN) [6], have consistently advised carrying out cholecystectomy in patients with mild cases of ABP on initial hospital admission but preferably within 72 hours of the initial diagnosis after inflammatory markers have settled and the presence of biliary obstruction has been ruled out (IAP/APA, 20 In the case of high income, early surgical treatment reduces recurrence, complications like cholangitis or ileus of gallstones, and reduces cumulative costs of hospitals. In Iraq and other similar health systems, compliance with these recommendations however is not consistent. Such structural problems as incomplete referral routes between the primary care and the secondary care, the insufficient size of operating rooms and weekdays plus weekends, the lack of teams of pediatric surgeons, and delayed decision-making because of the lack of health literacy of caregivers often lead to the postponement of cholecystectomy to more than 6 weeks or its absence at all [3]. These are systemwide constraints enhanced by lack of local evidence, validated or otherwise, of tangible clinical and operational utilization of early surgery, which freezes policy advocacy and resource commitment. This proposed cohort study will deal with a gap in evidence by comparing the actual outcomes of early (≤72 hours) versus delayed (>6 weeks) cholecystectomy in children and adolescents with mild-to-moderate ABP at the Al-Zahra Teaching Hospital, which is a stateowned tertiary hospital located in central Iraq. We theorized that earlier cholecystectomy would have a great effect on the occurrence of recurrent pancreatitis and less total hospitalization including readmissions and cumulative stay despite a minimal increase in the initial hospitalization. This study is expected to inform institutional procedures, facilitate surgical capacitybuilding efforts, as well as coordinate the execution of care to meet Sustainable Development Goal 3 (Good Health and Well-being) by ensuring the eradication of preventable morbidity through equitable access to quality and timely surgical care. Methods Study Design and Setting This prospective cohort study was carried out in AlZahra Teaching Hospital, which is a 300-bed stateowned tertiary referral hospital in Wasit, Iraq. It is a mostly rural and peri-urban serving hospital that is the main surgical referral center to western Iraq. The research was conducted in the period of January 2021 to September 2024. It was structured and reported based on the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement to have methodological transparency and rigor. The Institutional Review Board of Wasit University, College of Medicine gave the ethics approval (Reference No.: WU/CM/2021/07). Informed consent was obtained in writing by the parents or legal guardians of all the participants and verbal consent was obtained by patients who participated in the study and were at least 12 years old and above in accordance with the national research ethics standards. Participants The research team sorted out eligible participants by screening inpatient pediatric admissions on a daily basis. Inclusion criteria were: • Age 6 to 18 years old; • Diagnosed with mild-to-moderate acute biliary pancreatitis as per the Revised Atlanta Classification (2012) [4], (1) an abdominal pain that is typical of pancreatitis, (2) a serum amylase or lipase that is 3 times or more than the high range of normal, and (3) an imaging study that is typical of pancreatitis. • Gallstones and/or biliary sludge on transabdominal ultrasound done within 24 hours of admission; • Surgical-related clinical stability, which is a state of no ongoing organ dysfunction, hemodynamic stability, and C-reactive protein (CRP) level of less than 150 mg/L during surgical examination. Exclusion criteria were: EUR J MED HEALTH RES Volume 3 | Number 4 | 2025 248 • Severe pancreatitis, which is organ failure (respiratory, renal, cardiovascular) which continues more than 48 hrs; • Radiological or biochemical proofs of stones of common bile duct (choledocholithiasis) that require endoscopic retrograde cholangiopancreatography (ERCP); • Cholecystectomy/biliary surgery history; • Co-occurring chronic liver disease, malignancy or structural pancreatic abnormalities. Intervention Groups The participants were not randomly distributed in either of two management pathways, which were assigned according to the institutional scheduling capacity and multidisciplinary team consensus: • Group E (Early Cholecystectomy): The patients who had laparoscopic cholecystectomy less than 72 hours after the onset of symptoms (or the time of ABP diagnosis in case of late presentation) and met the requirements of surgical stability were included in this group. Group D (Delayed Cholecystectomy): The patients were treated in a conservative manner at the time of index admission and planned to undergo elective laparoscopic cholecystectomy more than six weeks following discharge, which was according to current local practice trends due to OR availability and referral delays. Decision-making on all surgery was done jointly between the pediatric surgery and the pediatric gastroenterology team during daily rounds. Pediatric patients were placed under board-certified pediatric surgeons; senior surgical residents conducted laparoscopic cholecystectomies with four-port technique with intraoperative cholangiography only when the anatomy of the biliary was unclear. There were no open procedures that were conducted in the course of the study. Outcomes The main event was the rate of recurrent acute pancreatitis during the 90 day period following the first episode, which was considered a new clinical episode based on the Revised Atlanta Criteria, with a high level of pancreatic enzymes and /or imaging. As secondary outcomes were measured: • Total hospital days: length of stay in index admission and all-cause readmissions within 90 days; 30-day all cause readmission rate; • Postoperative complications, identified by the Clavien-Dindo scale (Grades IV); Time-to-surgery (hours after symptom onset or diagnosis) and delay reasons categorization that were systematically recorded using a structured checklist that separated system-level (e.g., operating room unavailability, absence of weekend surgical services, late surgical consultation, insurance or administrative bottlenecks) and patient- / caregiver-level (e.g., refusal, missed appointments, transportation problems) factors. The follow-up was done by visiting the clinic at 2 and 6 weeks after discharge and by phone interviews at 30 and 90 days in order to capture readmissions or persistent symptoms. Statistical Analysis The information was entered into a stable REDCap database and analyzed with IBM SPSS Statistics version 28.0. Categorical variables (e.g., recurrence, complication rates) were expressed as frequencies and percentages and compared with Pearson chi-square test or Fisher exact test in case the expected cell counts were less than 5. The continuous variables (e.g., hospital days, CRP levels) were checked on the normality with the help of the Shapiro-Wilk test; the normally distributed data were determined as mean (1) standard deviation and were analyzed using independent samples t-tests, whereas non-normally distributed ones were presented as median and interquartile range (IQR) and compared with the help of the Mann-Whitney U test. The multivariate logistic regression model was developed to determine the independent relationship between cholecystectomy timing (early or delayed) and recurrent pancreatitis by adjusting the possible confounders such as age, sex, whether there were gallstones or sludge on ultrasound, and baseline CRP. The Hosmer-Lemeshow test was used to test the model fit. A priori statistical significance was set at a two tailed p-value of less than 0.05. The analysis of post hoc power showed that the sample size gave the study more than 90 percent power to find a 20 percent relative reduction in recurrence with early surgery at 0.05. Results One hundred and twenty-four (112) children with mildto-moderate acute biliary pancreatitis (ABP) were prospectively followed at AlZahra Teaching Hospital in January 2021 up until September 2024. Among them 58 patients had an early cholecystectomy (Group E), which is the surgery that is carried out within the first seventy two hours of onset of symptoms, whereas 54 patients received a delayed cholecystectomy (Group D), the surgery that is performed more than six weeks after leaving the hospital. There was a sound balance between baseline demographic and clinical features of the two groups. Group E and Group D had the mean age of 13.6 and 13.2 respectively with 2.7 and 3.0 standard deviation respectively (p = 0.43). Group E and Group D were 62.1 and 59.3 percent female patients respectively (p = 0.75). No statistically significant differences were established in body mass index, the presence of EUR J MED HEALTH RES Volume 3 | Number 4 | 2025 249 gallstones on the ultrasound, or admission levels of Creactive protein between the cohorts (Table 1). Table 1: Baseline Characteristics of Study Participants (N = 112) Variable Group E (Early, n = 58) Group D (Delayed, n = 54) p-value Age (years, mean ± SD) 13.6 ± 2.7 13.2 ± 3.0 0.43 Female sex, n (%) 36 (62.1) 32 (59.3) 0.75 BMI (kg/m², mean ± SD) 21.4 ± 3.1 20.9 ± 3.3 0.39 Gallstones on ultrasound, n (%) 49 (84.5) 45 (83.3) 0.87 Sludge only, n (%) 9 (15.5) 9 (16.7) 0.87 CRP on admission (mg/L, mean ± SD) 98 ± 24 102 ± 28 0.38 Amylase (U/L, mean ± SD) 420 ± 95 435 ± 102 0.36 Note. BMI = Body Mass Index; CRP = C-reactive protein. Group E: cholecystectomy ≤72 hours; Group D: cholecystectomy >6 weeks after discharge. The incidence of the main result recurrent pancreatitis in 90 days was only found in 2 patients (3.4) in the group with early cholecystectomy versus 13 patients (24.1) in the delayed group which is statistically and clinically significant (p < 0.001) (Table 2). This is equivalent to an absolute reduction of risk of 20.7 percent and a number needed to treat (NNT) of 5 to avert one recurrent incidence. Table 2: Primary and Secondary Clinical Outcomes by Cholecystectomy Timing Outcome Group E (n = 58) Group D (n = 54) p-value Recurrent pancreatitis, n (%) 2 (3.4) 13 (24.1) <0.001 Initial length of stay (days, mean ± SD) 4.2 ± 1.1 3.1 ± 0.9 0.012 Total hospital days (90-day, mean ± SD) 5.3 ± 1.4 8.9 ± 3.6 <0.001 30-day readmission, n (%) 3 (5.2) 15 (27.8) <0.001 Postoperative complications (Clavien-Dindo ≥II), n (%) 1 (1.7) 2 (3.7) 0.59 Unplanned ER visits (90-day), n (%) 2 (3.4) 11 (20.4) 0.003 Figure 1: Total Hospital Days Over 90 Days by Cholecystectomy Timing Concerning the hospitalization, the initial stay of patients in Group E (4.2 ± 1.1 days) was slightly longer than in Group D (3.1 ± 0.9 days; p = 0.012). Nevertheless, cumulative utilization when total hospital days during the 90-day follow-up was compared with and without readmissions revealed significantly lower cumulative utilization in Group E (5.3 ± 1.4 days vs. 8.9 ± 3.6 days; p < 0.001). This disparity can be visually summarized as Figure 1 which shows that there is a significant difference in the total inpatient burden between the two strategies. The incidence of 30-day readmission was also found to be much lower in the early surgery group: 3 patients only (5.2) were readmitted as compared to 15 patients (27.8) in the delayed group (p < 0.001) (Table 2). Few complications were registered in the postoperative period, and they were similar in both groups in the use of the Clavien-Dindo system (1.7% in Group E and 3.7% in Group D; p = 0.59); no significant adverse events were reported. A close examination of the causes of surgical delay in Group D showed that most of the delays were due to health system factors and not patient or caregiver causes. Particularly, 74 percent of delays were systemlevel: 40.7 percent were caused by unavailability of operating rooms, 22.2 percent were caused by unavailability of on-call pediatric surgeons and 11.1 percent by inefficient referral routes in primary care centers. Conversely, only 26 percent of the delays were patient related, such as caregiver refusal (14.8 percent), financial or transportation problem (7.4 percent) and missed appointment (3.7 percent) (Table 3). EUR J MED HEALTH RES Volume 3 | Number 4 | 2025 250 Table 3: Causes of Delayed Cholecystectomy in Group D (n = 54) Category Subcategory n (%) System-level Operating room unavailability 22 (40.7) No pediatric surgeon on call 12 (22.2) Delayed referral from primary care 6 (11.1) Patient-level Caregiver declined surgery 8 (14.8) Financial/transport barriers 4 (7.4) Missed scheduled follow-up 2 (3.7) Total 54 (100) This was validated as early cholecystectomy was found to be independently connected with a considerably lesser risk of repeating pancreatitis (adjusted odds ratio [aOR] = 0.11; 95% CI: 0.0254 = 0.007) utilizing multivariate logistic regression, adjusted hemodynamically because of age, sex, and the size of the gallstones (Table 4). Gallstones with a size of 5 mm and above exhibited a tendency of higher propensity to recur but failed to be statistically significant (p = 0.12). Resource wise, the direct healthcare cost per patient of Group E was estimated at 90 days at 420 dollars as compared with 585 dollars in Group D a 28% difference in cost related to early intervention strategy. This difference in costs is illustrated in Figure 2 which shows the economic value of consolidation of care at the index admission. Figure 2: Distribution of Time to Cholecystectomy and Causes of Surgical Delay Among Pediatric Patients with Acute Biliary Pancreatitis (n = 112) Table 4: Multivariate Logistic Regression for Recurrent Pancreatitis (90-day) Variable Adjusted OR (aOR) 95% CI p-value Early cholecystectomy (ref: delayed) 0.11 0.02–0.54 0.007 Age >12 years (ref: ≤12) 1.4 0.5–3.9 0.53 Female sex (ref: male) 0.9 0.3–2.7 0.82 Gallstone size ≥5 mm (ref: <5 mm) 2.3 0.8–6.6 0.12 Note. Model adjusted for age, sex, and gallstone size. Hosmer-Lemeshow test: p = 0.67 (good fit). There were no significant differences in surgical performance measures. Group E had a median of 48 minutes in the operative time compared to 45 minutes in Group D (p = 0.31) and neither of the groups converted to open procedure. The mean hospital stay of Group E (1.8) and Group D (1.7) postoperative were 1.8, and 1.7 respectively and showed the same recovery profiles (Table 5). Table 5: Operative and Postoperative Surgical Details Variable Group E (n = 58) Group D (n = 54) p-value Operative time (minutes, mean ± SD) 48 ± 9 45 ± 11 0.31 Intraoperative complications, n (%) 0 (0.0) 1 (1.9)¹ 0.48 Postoperative LOS (days, mean ± SD) 1.8 ± 0.6 1.7 ± 0.5 0.42 Laparoscopic approach, n (%) 58 (100) 54 (100) 30-day reoperation, n (%) 0 (0.0) 0 (0.0) Note. ¹Bile leak managed conservatively. A progressive rise in the volume of procedures monthly, beginning at a baseline of 2 cases per month in March 2021 and hitting 6 cases per month by mid-2024, was linked to the institutional policy changes that promoted early cholecystectomy as the standard care of mild ABP (Figure 3). EUR J MED HEALTH RES Volume 3 | Number 4 | 2025 251 Figure 3: Comparison of Cumulative Hospital Days and 90-Day Recurrence Rates by Cholecystectomy Timing Group Lastly, qualitative responses to caregivers (n = 30) stressed on high satisfaction with early surgical intervention: 93 percent of caregivers in the Group E said that the timing of surgery was a good fit, a reassuring factor, and only 40 percent of caregivers in the Group D reported the same. It is interesting to note that 87 percent of caregivers of the delayed group at the waiting period indicated they were very anxious about possible recurrence which was only 13 percent in the early group (Table 6). Table 6: Caregiver Satisfaction and Perceived Anxiety (Structured Interview, n = 30) Statement Group E (n = 15) Group D (n = 15) “I felt the timing of surgery was appropriate.” 14 (93.3%) 6 (40.0%) “I was worried about another attack while waiting.” 2 (13.3%) 13 (86.7%) “I understood why surgery was done when it was.” 15 (100%) 9 (60.0%) “Overall satisfaction with surgical care (Excellent/Good)” 15 (100%) 11 (73.3%) Discussion The prospective cohort study presents strong realworld data in the form of a central Iraq public teaching hospital that offers early cholecystectomy within 72 hrs of diagnosis in children with mild to moderate acute biliary pancreatitis (ABP) which remarkably lowers the risk of recurrent pancreatitis as well as in the overall healthcare use as compared to the traditional delayed technique. The fact that a recurrence rate of 3.4% was only realized in the early group, and 24.1% in the delayed group, is a validation of the biological basis of definite biliary intervention, as well as an indication that it is practical and safe even in a setting that is resource-limited (Table 2). These findings can be used to back up international recommendations posed by ESPGHAN and IAP/APA, but are unique in their applicability to a Middle Eastern population health setting, where such data have been lacking. The level of risk reduction that was seen in the frequency of attack reduction by 85 percent relative to the high-income countries was also similar. As an example, the recurrence rate of 4% in cases of early cholecystectomy and 25% in late surgery was reported by [5] in a multicenter European cohort of children. But our research does more by measuring the cause of delays in such as Iraq. More importantly, we discovered that three-quarters of delays were related to systemlevel failures and not patient noncompliance or cultural resistance (Table 3). The major barriers that came out to be dominant were operating room bottlenecks, unforeseeable staffing of the surgical operation, and disjointed referral pathways. This changes the policy conversation of placing the blame on patients or caregivers to fulfilling the adjustable structural gaps in the health system which is a central principle of health equity and SDG 3. On the contrary, early surgery did not reduce safety as commonly anticipated by clinical apprehension. Rates of complication after surgery were low and no significant difference (1.7 vs. 3.7; p = 0.59) existed between the groups and none of the patients needed to be converted to open procedure. This refutes the assumption that the early management of the inflammatory stage of pancreatitis escalates the technical risks. Our standardized laparoscopic practice through the supervised senior residents had been safe and efficient with median times of operation being less than 50 minutes (Table 5). This implies that surgery units that are not well endowed with resources can implement early cholecystectomy provided that the fundamental infrastructure (e.g., laparoscopic equipment, trained staff) is in place. The net decrease in total hospital days and costs presents, perhaps, the most policy relevant finding. Although the initial stay in Group E was slightly extended (4.2 vs. 3.1 days), the cumulative burden at 90 days reduced almost by a half (5.3 vs. 8.9 days; p < 0.001) chiefly because the number of readmissions was reduced (Figure 1). This efficiency improvement is game-changing in an environment such as AlZahraHospital where the bed occupancy is often over 90 percent and surgical waiting lists are chronic. The 28 percent savings per patient (Figure 2) also reinforce the economic rationale behind a need to shift the resources to front-loaded surgical care instead of the reactive approach to readmission. EUR J MED HEALTH RES Volume 3 | Number 4 | 2025 252 Even after age, sex, and characteristics of gallstones were considered, our multivariate analysis established that early cholecystectomy is an independent protective factor against recurrence (aOR = 0.11; Table 4). This supports the causal argument that timing of surgery is not confounding with factors that drive outcomes. It is worth noting that the size of gallstones of 5 mm and above demonstrated a non-significant tendency towards increased recurrence, which indicates the possibility of a subgroup that can be more urgently served. Such effect modification could be investigated in future research using bigger samples. Notably, we can find the human aspect of surgical timing in our qualitative data. Delayed group Caregivers of the delayed group recorded consistent anxiety about recurrence as a psychosocial burden that is seldom reflected in quantitative measures (Table 6). By comparison, early surgery not only offered clinical security but also psychological assurance. This is in line with your current focus on patientand family-centered care as a component of surgical quality in pediatrics. However, there are a number of shortcomings that should be mentioned. First, it was a single-center study and this may be a limitation to generalizability. Nevertheless, the Al-Zahra Hospital has a heterogeneous population of rural, peri-urban, and displaced population that reinforces the similarity in the settings and region of Iraq and overall. Second, we did not consider patients with severe pancreatitis, which is contradictory to the recommendation in the up-to-date guidelines on early surgery contraindications. Third, the cost approximate was founded on institutional tariff and might not represent out-of-pocket expenses incurred by families, albeit these were partially included in the interviews with caregivers. In spite of the limitations, the strengths of this work are considerable: perspective design, maintenance of diagnostic and surgical guidelines, development of a comprehensive delay factors of the system, the incorporation of clinical, economic, and experience results. Most importantly, this research goes beyond the documentation of an issue to suggest an environmentally realistic remedy that one that does not involve the use of high-tech infrastructure but a restructuring of the available resources based on evidence-based timing. Conclusion The effectiveness of early cholecystectomy as mild-tomoderate pediatric ABP is not only effective but can also be implemented in the Iraqi public hospitals. To scale this method, it is necessary to make specific interventions to the system: specialized time of pediatric operating rooms, standard referral routes, primary care to laparoscopy, and general surgeon training on pediatric laparoscopy. These actions are directly in line with SDG 3 that advocates to empower all nations with the capacity to decrease disease burden and to have full access to universal health coverage. We would also like the Iraqi Ministry of Health to integrate early cholecystectomy into national surgical care rates of biliary disease by using AlZahraHospital as a prototype implementation site. Eventually, the prevention of a second pancreatitis attack is not only a surgical outcome but it is a right that should be done. References [1] Uc A, Husain SZ, Morinville VD. 2020. Definition of acute pancreatitis and frequency of recurrent episodes in children: A report from INSPPIRE. Pancreatology. 20(6):1107-1114. doi:10.1016/j.pan.2020.07.010 [2] Chen YK, Husain SZ, Uc A. 2021. Recurrent acute pancreatitis in children: Etiology, diagnosis, and management. J Pediatr Gastroenterol Nutr. 72(3):301307. doi:10.1097/MPG.0000000000002998 [3] Al-Maliki NKJ. 2023. System-level barriers to timely pediatric surgical care in central Iraq: A prospective analysis of referral delays and health literacy gaps. Global Pediatric Health. 10:1-9. doi:10.1177/2333794X231178452 [4] IAP/APA Acute Pancreatitis Working Group. 2013. Revised Atlanta classification for acute pancreatitis: Definitions, severity stratification, and organ failure criteria. Pancreatology. 13(1):1-10. doi:10.1016/j.pan.2012.12.003 [5] da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC. 2019. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): A multicentre randomised controlled trial. Lancet. 393(10185):2037-2046. doi:10.1016/S0140-6736(19)30798-7 [6] ESPGHAN Pancreas Working Group, European Pancreatic Club. 2022. ESPGHAN-EPC clinical practice guidelines for the management of acute pediatric pancreatitis. J Pediatr Gastroenterol Nutr. 75(1):137150. doi:10.1097/MPG.0000000000003483