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IntroductionUK guidelines recommend that patients with gallstone pancreatitis have cholecystectomy within two weeks of their pancreatitis. A proportion of these patients are elderly with significant co morbidities rendering them high risk for general anaesthesia and surgery. ERCP and ES followed by a low fat diet may offer a safe alternative to cholecystectomy as definitive treatment in these patients.MethodWe performed a retrospective review of all cases of pancreatitis presenting to a single institution between 1999 and 2009. Results1094 patients were admitted to the single institution with pancreatitis during the study period of which 526 cases were secondary to gallstones. There were 23 deaths as a result of the acute episode of gallstone pancreatitis and five patients have been lost to follow up leaving 498 patients available for analysis.The median age at presentation was 66 years (range 16-96 years), with a female to male ratio of 2:1. 324 patients (65%) underwent early cholecystectomy. Of the remaining 174 patients; 44 (25%) underwent ERCP and cholecystectomy, 86 (50%) were managed with ERCP and ES. The remaining 44 (25%) were managed with a ‘wait and watch’ policy. The 86 patients who underwent ERCP and ES as a definitive treatment for gallstone pancreatitis had a median age of 76 years (range 43-91 years) and a median ASA of 2. Four of the 86 (4%) patients had a failed ERCP for technical reasons. Two patients were managed with a laparoscopic cholecystectomy and the remaining two, who were deemed unfit for surgery, were managed expectantly with no recurrence of pancreatitis. Of the successful ERCPs, six required two attempts to cannulate the ducts and this was due to oedema surrounding the ampulla at the initial ERCP. 76 patients (93%) had no recurrence of pancreatitis with a mean follow-up of 36 months (+/- 29 months, range 1-118 months). The total patient follow-up was 2527 months. 27 patients (33%) died within the follow-up period of unrelated causes, explaining the lower than expected median follow-up. Five patients had a recurrence of pancreatitis during follow-up (7%). The length of their follow-up ranged from 4-89 months (median - 35 months). Three of these patients were treated with cholecystectomy, one was managed expectantly and the other refused surgery.ConclusionERCP with ES, combined with a low fat diet is a safe alternative to laparoscopic cholecystectomy and on table cholangiogram to prevent further attacks of gallstone pancreatitis in patients who are unfit for surgery.