Association Between Trimester and Outcomes after Cholecystectomy During Pregnancy

SAGES guidelines for the use of laparoscopy during pregnancy

BACKGROUND

When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD).

METHODS

The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient.

RESULTS

The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy.

CONCLUSIONS

Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.

Pregnant patients undergoing cholecystectomy: nationwide assessment of clinical characteristics and outcomes

BACKGROUND

Gallstone disease in pregnancy is one of the most common indications for nonobstetrical surgery during pregnancy. National-level data on contemporary surgical practice and outcomes are limited.

OBJECTIVE

This study aimed to assess the clinical characteristics and outcomes of patients undergoing cholecystectomy during pregnancy.

STUDY DESIGN

This cross-sectional study examined the Healthcare Cost and Utilization Project's 2 nationwide databases in the United States: the National Inpatient Sample and the Nationwide Ambulatory Surgery Sample. The study population included 18,630 patients who had cholecystectomy during pregnancy from January 2016 to December 2020. The exposure was gestational age, grouped sequentially into the following 5 groups: first trimester (<14 weeks), early second trimester (14-20 weeks), late second trimester (21-27 weeks), early third trimester (28-36 weeks), and late third trimester (≥37 weeks). The main outcomes were clinical demographics, medical comorbidities, surgical information, and pregnancy characteristics and outcomes, assessed by gestational age.

RESULTS

Cholecystectomy was most common in the early second trimester (32.1%), followed by the first trimester (25.2%), late second trimester (23.1%), early third trimester (12.4%), and late third trimester (7.2%). Patients in the first-trimester group were more likely to be aged ≥35 years, to smoke, and to have acute cholecystitis, severe hyperemesis gravidarum including metabolic disturbance, pregestational diabetes, multifetal gestation, and sepsis/shock (P<.001). Patients in the early-third-trimester group were more likely to be obese and have gestational diabetes, Charlson Comorbidity Index of ≥1, premature rupture of membranes, and intrauterine growth restriction, whereas those in the late-third-trimester group were more likely to have gallstone pancreatitis, biliary colic, chorioamnionitis, gestational hypertension, preeclampsia, and severe maternal morbidity including sepsis (P<.001). At the cohort level, a laparoscopic approach was used in most cholecystectomy procedures (97.5%), and bile duct injury was uncommon (<0.1%). Delivery during the admission occurred in 0.3%, 0%, 0.6%, 17.8%, and 60.6% in the 5 gestational age groups, respectively (P<.001). Among the cases that had delivery in the early- and late-third-trimester groups, the delivery event preceded cholecystectomy in 61.4% and 86.2%, respectively, whereas both delivery and cholecystectomy occurred on the same day in 34.3% and 13.8%, respectively.

CONCLUSION

This nationwide analysis suggests that clinical and pregnancy characteristics and outcomes of patients undergoing cholecystectomy differ by pregnancy stage with a bimodal distribution. Although patients in the first and third trimesters have distinct medical conditions, more clinically significant pregnancy and maternal outcomes were found in both groups compared with patients in the second trimester.

Operative vs Nonoperative Management of Acute Cholecystitis During the Different Trimesters of Pregnancy

Importance

Acute cholecystitis (AC) management during pregnancy requires balancing the risk of pregnancy loss or preterm delivery (adverse pregnancy outcomes [APOs]) with or without surgery. Guidelines recommend cholecystectomy across trimesters; however, trimester-specific evidence on the risks of AC and its management is lacking.

Objective

To assess cholecystectomy frequency in pregnant people with AC, compare the rates of APOs in pregnant people with or without AC, and compare the rates of APOs in people with AC who did or did not undergo cholecystectomy.

Design, Setting, and Participants

This retrospective, population-based cohort study used data for pregnant people with AC from the IBM MarketScan Commercial Claims and Encounters Database from January 1, 2007, to December 31, 2019, and a propensity score-matched cohort of pregnant people without AC. Trimester status (first [T1], second [T2], and third [T3]), APOs, and cholecystectomy were defined by administrative claims. Data were analyzed from October 2021 to July 2022.

Exposures

Pregnant patients with or without AC. Pregnant patients with AC who did or did not receive cholecystectomy.

Main Outcomes and Measures

The main outcomes were cholecystectomy during pregnancy and APOs (ie, preterm delivery and pregnancy loss). Pregnant patients with and without AC were compared to assess the association of AC with risk of APOs. Propensity score inverse-probability weighting was used to calculate treatment-associated APO risk among patients with 1-year follow-up.

Results

The study included 5759 pregnant patients with AC (mean [SD] age, 30.1 [6.6] years) and 23 036 controls (mean [SD] age, 29.9 [6.7] years) after propensity score matching. Among 3426 pregnant patients with AC and 1-year follow-up, 1182 (34.5%) underwent cholecystectomy during the pregnancy (684 [41.7%] presenting with AC in T1, 404 [40.4%] in T2, and 94 [12.0%] in T3). Acute cholecystitis during pregnancy, irrespective of treatment, was associated with higher odds of APO compared with no AC during pregnancy across all trimesters (odds ratio [OR], 1.69 [95% CI, 1.54-1.85]). Compared with nonoperative management, receipt of surgery was associated with lower odds of APOs across all trimesters (OR, 0.75 [95% CI, 0.63-0.87]), in T1 (OR, 0.81 [95% CI, 0.66-1.00]), in T2 (OR, 0.71 [95% CI, 0.50-1.00]), and in T3 (OR, 0.45 [95% CI, 0.28-0.70]).

Conclusions and Relevance

In this study, cholecystectomy was associated with lower risk of APO in patients with AC across all trimesters, with the greatest benefit in T3. However, only 34.5% overall and 12.0% of patients in T3 had a cholecystectomy. These findings support guidelines recommending cholecystectomy during pregnancy and should inform decision-making discussions. Greater guideline adherence and surgery use, especially in T3, may represent an opportunity to improve outcomes for pregnant people with AC.

Maternal and fetal outcomes of acute pancreatitis in pregnancy: a population-based study

BACKGROUND

Acute pancreatitis during pregnancy can have negative effects on both the mother and the fetus. The primary aim of this study is to evaluate the trends, maternal and fetal outcomes, and associated comorbidities of acute pancreatitis during pregnancy using data from the USA National Inpatient Sample (NIS) database.

METHODS

This study is a retrospective analysis of hospital discharge records from the NIS database from 2009 to 2019.

RESULTS

Delivery patients with acute pancreatitis faced a higher risk of maternal mortality (AOR 91.02, 95% CI 28.47-291.06), postpartum hemorrhage (AOR 1.59, 95% CI 1.02-2.49), and hypertensive complications (defined as preeclampsia, eclampsia, or HELLP syndrome) (AOR 3.42, 95% CI 2.56-4.56) compared to those without acute pancreatitis. Moreover, we saw an increased incidence of preterm labor (AOR 3.94, 95% CI 3.02-5.12) and fetal death (AOR 3.12, 95% CI 1.76-5.53). Rates of fetal restriction and large fetal size were comparable. Additionally, the acute pancreatitis group showed higher rates of acute kidney injury (4.2% vs. 0.06%; AOR, 31.02, 95% CI 12.50-76.98), severe sepsis (0.8% vs. 0.01%; AOR, 34.49, 95% CI 7.67-155.14), and respiratory failure (2.4% vs. 0.06%; AOR, 20.77, 95% CI (8.55-50.41). There were no significant differences in maternal and perinatal outcomes in biliary pancreatitis after the intervention compared to conservative treatment.

CONCLUSION

Acute pancreatitis during pregnancy can have negative effects on both the mother and fetus. Treatment for biliary pancreatitis does not affect maternal and fetal outcomes. An interdisciplinary approach is essential to ensure optimal outcomes for mothers and their offspring in these cases.

Laparoscopic Cholecystectomy in Pregnancy: A Seven-Year Retrospective Study From an Australian Tertiary Center

Background Cholecystectomy is the second most common non-obstetric indication for surgery during pregnancy; however, there is little recent literature specifically exploring perioperative care approaches, and a paucity of Australian data exists. This study investigates the incidence of laparoscopic cholecystectomy (LC) during pregnancy, peri-operative management, and post-operative outcomes in a single Australian tertiary center. Methods A retrospective analysis of LCs performed on pregnant patients between the ages of 16 and 50 years at a tertiary hospital between 2016 and 2023 was completed. Results Twenty-three patients underwent LC. The median gestational age was 17+4 weeks (4+3-30+6). Cases were performed in all three trimesters, with the majority in the second trimester (n=12, 52.2%). Surgery indications were recurrent biliary colic (n=11, 47.8%), acute cholecystitis (n=8, 34.8%), and gallstone pancreatitis (n=4, 17.4%). Obstetrics and Gynecology (O&G) consultations occurred in 56.5% (n=13) of cases. Fetal heart rate (FHR) was recorded perioperatively in 82.6% (n=19) of cases. Preoperative steroids were given to 40% of eligible patients. An intraoperative cholangiogram was performed in 12 (52.2%) cases, of which eight (66.7%) utilized abdominal shielding. There was no perioperative maternal mortality nor fetal loss. Surgical morbidities were pancreatitis (n=1), bile leak (n=1), and intraoperatively recognized bile duct injury (n=1). Two threatened preterm labors and five (26.3%) preterm deliveries occurred. Conclusion Performing LC in pregnancy does carry a risk of major morbidity; however, there was no mortality or fetal loss across all trimesters. The decision to perform abdominal shielding during an intraoperative cholangiogram should be approached sensitively in a case-by-case manner, given recent paradigm shifts in radiology. A multidisciplinary approach with standardized local perioperative care policies regarding procedures such as O&G consultation, perioperative steroid use, and FHR monitoring is strongly recommended.

Neurocognitive Effects of Fetal Exposure to Anesthesia

Surgery during pregnancy occurs when maternal or fetal needs outweigh the status quo, yet much uncertainty remains regarding the effects of anesthesia and surgery on fetal neurodevelopment. This article will review common maternal and fetal indications for invasive procedures, along with contemporary research on fetal neurodevelopment following anesthesia and surgery, focusing on future areas of investigation.