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The aims of the study were to compare the outcomes of biliary pancreatitis after endoscopic and surgical treatment and define the demographic and clinical characteristics that affect the outcomes. All inpatients with biliary pancreatitis followed at hospitals of the Department of Veterans Affairs during 1988-1994 were included in a case-control study. Of 2075 patients with biliary pancreatitis, 650 were first treated by biliary endoscopy and 1425 by cholecystectomy. Compared with cholecystectomy, biliary endoscopy was associated with older age, admission to nonsurgical service, more complicated pancreatitis, and choledocholithiasis. Seventy-one patients died. Death occurred more often in older patients with multiple comorbid conditions and complications of biliary pancreatitis. Overall length of hospital stay was positively correlated with complications, choledocholithiasis, comorbidity, and deferment of endoscopic or surgical procedure. After adjusting for other confounding variables, both types of treatment resulted in similar death rates and lengths of hospitalization. In conclusion, compared with cholecystectomy, biliary endoscopy is chosen preferentially in older patients with choledocholithiasis or a complication of their pancreatitis. Despite such selection bias, biliary endoscopy results in similar outcomes as surgery. Early intervention by either strategy reduces the length of hospital stay.