Outcome study of cholecystectomy during pregnancy

Optimal treatment strategies for gallbladder disease in pregnancy: a systematic review with dual network meta-analyses

BACKGROUND

This study sought to determine the optimal treatment strategy and timing for cholecystectomy in managing gallbladder diseases during pregnancy. It evaluated the effectiveness of conservative management (CM), laparoscopic cholecystectomy (LC), and open cholecystectomy (OC) in pregnancy and compared cholecystectomy outcomes across three trimesters.

METHODS

Studies comparing CM, LC, and OC or evaluating cholecystectomy outcomes across trimesters were included in a literature search until February 2024. Studies included were required to have at least 10 cases per treatment group and perform statistical comparisons. Two Bayesian network meta-analyses (NMAs) were conducted, and surface under cumulative ranking area (SUCRA) values, risk ratio (RR), mean difference (MD), and 95% credible intervals (CrIs) were calculated for outcomes of interest.

RESULTS

Our study included 17 studies with 63,523 pregnant patients. The first NMA included data from 12 studies involving 29,052 pregnant women, revealing that LC had the lowest risk for preterm delivery, significantly lower than CM (RR: 0.23, 95% CrI: 0.07-0.55). LC also had a significantly reduced risk of fetal complications (RR: 0.42, 95% CrI: 0.16-0.57) and maternal complications (RR: 0.44, 95% CrI: 0.15-0.50) compared to OC. LC was associated with a significantly shorter length of stay than OC (MD: -2.77, 95% CrI: -8.37 to -2.87). The second NMA analyzed data from five population-based studies with 34,471 pregnant patients, finding no significant differences in preterm delivery and abortion rates across the three trimesters following cholecystectomy. Cholecystectomy performed in the third trimester significantly increased the risk of maternal complications, with relative risks compared to first (RR: 0.48, 95% CrI: 0.22-1.00) and second trimesters (RR: 0.42, 95% CrI: 0.21-0.93).

CONCLUSIONS

LC is deemed the optimal treatment for gallbladder diseases during pregnancy. While cholecystectomy is safe to be performed across all trimesters, careful deliberation is recommended during the third trimester due to an increased risk of maternal complications.

Acute Pancreatitis during and after Pregnancy: A Review

During pregnancy and in the post-partum period, several diseases may arise or become exacerbated. Acute pancreatitis is an inflammatory disease with an increasing incidence in Western countries. The incidence of acute pancreatitis during pregnancy is not different with respect to the general population, but this incidence increases in the first 2 years after delivery. Biliary sludge and stones are the most frequent aetiologies, followed by hypertriglyceridemia. Taking care of the mother and foetus through a potentially severe disease requires a team consisting of an obstetrician, a gastroenterologist, an anaesthesiologist, and a surgeon. It is necessary to monitor the health of the foetus/child and the mother during pregnancy, childbirth, and puerperium. The management of this care depends on the systemic and local complications, the severity of the acute pancreatitis, and the trimester of pregnancy. Some diagnostic tools and many drugs are not safe for foetuses, while interventional endoscopy and surgery have limitations and can only be used after an accurate evaluation of benefit/risk ratios. Despite these limitations, maternal mortality due to acute pancreatitis is low during pregnancy, mainly thanks to multidisciplinary approaches for these patients. A careful diet to prevent obesity, alcohol abstinence, routine serum triglyceride control, and breastfeeding for at least three months may prevent acute pancreatitis during and after pregnancy.

Surgical treatment of adrenal tumors during pregnancy

While most adrenal tumors are identified incidentally and are non-functional, hormone-secreting tumors can cause morbidity and mortality. Hemodynamic lability and hypertension in pregnancy are associated with worse maternal and fetal outcomes. Achieving a diagnosis of hormone excess due to adrenal tumors can be clinically more difficult in the gravid patient due to normal physiologic alterations in hormones and symptoms related to pregnancy. This review focuses on some nuances of the diagnostic work-up, perioperative care, and surgical management of adrenally-mediated cortisol excess, primary aldosteronism, and pheochromocytoma and paraganglioma in the pregnant patient.

A 27-Year-Old Primigravida with a Right Renal Cell Carcinoma Removed at 30 Weeks of Gestation by Robot-Assisted Retroperitoneoscopic Partial Nephrectomy

BACKGROUND Large renal tumors during pregnancy are rare findings (0.07-0.1%). Current guidelines recommend surgical removal. This surgery should be carefully planned in an interdisciplinary team and involves special risks for mother and fetus. This report describes a case of a 27-year-old primigravida woman with a right renal cell carcinoma involving the lower pole of the kidney, which was removed at 30 weeks of gestation by robot-assisted retroperitoneoscopic partial nephrectomy (RARPN). CASE REPORT The patient was referred by the treating obstetrician with a newly diagnosed right lower pole renal mass of 6×4 cm in greatest diameter extending deeply into the parenchyma. No metastasis or enlarged lymph nodes were described in subsequent magnetic resonance tomography. Clinical and laboratory examinations documented a healthy mother and fetus. A right-sided RARPN was advised and planned by an interdisciplinary team of treating physicians (gynecologists, oncologists, and urologists). The surgery was conducted under general anesthesia with an obstetrician on stand-by. Surgery was performed without any complications (operation time 95 min, renal-ischemia time 15 min, and negligible blood loss) and histopathology confirmed the diagnosis of a chromophobe renal cell carcinoma. Further follow-up consultations showed regular wound healing and normal progression of pregnancy, and the patient gave birth to a healthy child at term. Follow-up examinations of the patient were uneventful. CONCLUSIONS This case shows that RARPN can be a safe and effective surgical procedure for partial nephrectomy during pregnancy, where surgery is performed in a specialist center and by an interdisciplinary experienced surgical team. It seems to offer advantages and better risk profile over the laparoscopic approach.

Surgical Management of Adnexal Masses in Pregnancy: A Systematic Review and Meta-analysis

OBJECTIVE

The incidence of adnexal masses in pregnancy is 1% to 6%. Although surgery is often indicated, there are no definitive management guidelines. We aimed to investigate the optimal approach to surgical management of adnexal masses in pregnancy on the basis of a meta-analysis of previous studies.

DATA SOURCES

We performed a systematic review using MEDLINE, Embase, Cochrane Library, and Clinicaltrials.gov from inception to July 17, 2020.

METHODS OF STUDY SELECTION

There were no restrictions on study type, language, or publication date. Comparative and noncomparative retrospective studies that reviewed operative techniques used in surgery of adnexal masses in pregnancy were included. Meta-analyses were performed to assess outcomes. This study was registered in the International Prospective Register of Systematic Reviews (CRD42019129709).

TABULATION, INTEGRATION, AND RESULTS

Comparative studies were identified for laparoscopy vs laparotomy and elective vs emergent surgery (11 and 4, respectively). Elective surgery is defined as a scheduled antepartum procedure. For laparoscopy vs laparotomy, the mean maternal ages and gestational ages at time of surgery were similar (27.8 years vs 27.7 years, p = .85; 16.2 weeks in laparoscopy vs 15.4 weeks in laparotomy, p = .59). Mass size was larger in those undergoing laparotomy (mean 8.8 cm vs 7.8 cm, p = .03). The most common pathologic condition was dermoid cyst (36%), and the risk of discovering a malignant tumor was 1%. Laparoscopy was not associated with a statistically increased risk of spontaneous abortion (SAB) or preterm delivery (PTD) (odds ratio [OR] 1.53; 95% confidence interval [CI], 0.67-3.52; p = .31 and OR 0.95; 95% CI, 0.47-1.89; p = .88, respectively). The mean length of hospital stay was 2.5 days after laparoscopy vs 5.3 days after laparotomy (p <.001). The decrease in estimated blood loss in laparoscopy was not statistically significant (94.0 mL in laparotomy vs 54.0 mL in laparoscopy, p = .06). Operative times were similar in laparoscopy and laparotomy (80.0 minutes vs 72.5 minutes, p = .09). Elective surgery was associated with a decreased risk of PTD (OR 0.13; 95% CI, 0.04-0.48; p = .05). Noncomparative studies were identified for laparoscopy and laparotomy. Laparotomy had more SABs and PTDs than laparoscopy (pooled proportion = 0.02 vs 0.07 and pooled proportion = 0.02 vs 0.14, respectively).

CONCLUSION

Laparoscopy for the surgical management of adnexal masses in pregnancy is associated with shorter length of hospital stay and similar risk of SAB or PTD. Elective surgery is associated with a decreased risk of PTD.

Interventional radiological management of hepatobiliary disorders in pregnancy

Hepatobiliary disorders are common in pregnancy and pose a management challenge. Minimally invasive interventional radiological (IR) techniques allow safe and effective management of these disorders. However, the available literature is scarce. Radiological interventions in this group of patients mandate a clear understanding of the risks of radiation to the fetus. The IR physician involved in the care of these patients should be aware of the measures to minimize the exposure to ionizing radiation. Additionally, the risk-benefit ratio should be clearly defined in a multidisciplinary discussion involving IR physicians, obstetricians, and gastroenterologists. This review is an effort to address issues related to the application of IR procedures for hepatobiliary disorders in pregnant patients.

A successful combined laparoscopic cholecystectomy and laparoscopic exploration of common bile duct for acute gangrenous cholecystitis and choledocholithiasis during pregnancy: A case report

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Complicated gallstone disease during pregnancy can be successfully managed by combined laparoscopic cholecystectomy and exploration of common bile duct through trans-cystic duct approach.

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This approach is safe and can cure cholecystitis and choledocholithiasis in one goal.

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This approach avoids ionizing radiation to the developing fetus.

Introduction

Choledocholithiasis during pregnancy is relatively uncommon but it can be life-threatening. Therapeutic endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of ionizing radiation exposure to the developing fetus. Other strategies are thus needed to tackle this problem.

Presentation of case

A 38-year-old 8 weeks’ pregnant lady presented with acute onset of right upper quadrant pain. Ultrasonography showed features of acute cholecystitis and choledocholithiasis, which was later confirmed by magnetic resonance cholangiogram. Emergency combined laparoscopic cholecystectomy (LC) and laparoscopic exploration of common bile duct (Lap ECBD) were performed. Lap ECBD through trans-cystic duct approach was adopted. The patient recovered uneventfully and was discharged on postoperative day 4. A healthy baby boy was delivered at 40 weeks’ gestation without developmental problem.

Conclusion

Lap ECBD avoided ionizing radiation for choledocholithiasis during pregnancy, and can combined with LC as an effective minimally invasive procedure for complicated gallstone disease.

Emergency general surgery in pregnancy

It is often that the acute care surgeon will be called on to evaluate the pregnant patient with abdominal pain. Most of the diagnostic and management decisions regarding pregnant patients will follow the usual tenets of surgery; however, there are important differences in the pregnant patient to be aware of to avoid pitfalls which can lead to complications for both mother and fetus. This review hopes to describe the most common emergencies facing the surgeon caring for the pregnant patient and the latest management options.

Laparoscopic versus open cholecystectomy in pregnancy: a systematic review and meta-analysis

BACKGROUND

The operative management of symptomatic cholelithiasis during pregnancy is either laparoscopic cholecystectomy (LC) or open cholecystectomy (OC). The aim of this systematic review and meta-analysis is to compare the outcomes of the laparoscopic and open approach for cholecystectomy during pregnancy.

METHOD

A literature search was conducted using MEDLINE, PubMed, EMBASE, Cochrane Library, Web of Science, CINAHL and Current Contents Connect using appropriate search terms. All comparative studies reporting maternal, fetal, and/or surgical complications were included.

RESULTS

Eleven comparative studies, with a total of 10,632 patients, were included. The laparoscopic approach was performed at mean 18-week gestation and the open approach at mean 24-week gestation. LC was associated with decreased risks for fetal (OR 0.42; 95 % CI 0.28-0.63; p < 0.001), maternal (OR 0.42; 95 % CI 0.33-0.53; p < 0.001) and surgical (OR 0.45; 95 % CI 0.25-0.82, p = 0.01) complications. The average length of hospital stay (LOS) was: LC 3.2 days and OC 6.0 days (p = 0.02). The conversion rate from LC to OC was 3.8 %.

CONCLUSION

The results of this first meta-analysis suggest that LC is associated with fewer maternal and fetal complications than OC during pregnancy. However, 91 % of included patients were in the first or second trimester at the time of surgery. These findings do not account for gestational age during pregnancy, which may be a significant confounding factor. The results support intervention for symptomatic gallstones in the first and second trimester with a laparoscopic approach.

Estimating the risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery using routinely collected NHS data: an observational study

Background

Previous research suggests that non-obstetric surgery is carried out in 1–2% of all pregnancies. However, there is limited evidence quantifying the associated risks. Furthermore, of the evidence available, none relates directly to outcomes in the UK, and there are no current NHS guidelines regarding non-obstetric surgery in pregnant women.

Objectives

To estimate the risk of adverse birth outcomes of pregnancies in which non-obstetric surgery was or was not carried out. To further analyse common procedure groups.

Data Source

Hospital Episode Statistics (HES) maternity data collected between 2002–3 and 2011–12.

Main outcomes

Spontaneous abortion, preterm delivery, maternal death, caesarean delivery, long inpatient stay, stillbirth and low birthweight.

Methods

We utilised HES, an administrative database that includes records of all patient admissions and day cases in all English NHS hospitals. We analysed HES maternity data collected between 2002–3 and 2011–12, and identified pregnancies in which non-obstetric surgery was carried out. We used logistic regression models to determine the adjusted relative risk and attributable risk of non-obstetric surgical procedures for adverse birth outcomes and the number needed to harm.

Results

We identified 6,486,280 pregnancies, in 47,628 of which non-obstetric surgery was carried out. In comparison with pregnancies in which surgery was not carried out, we found that non-obstetric surgery was associated with a higher risk of adverse birth outcomes, although the attributable risk was generally low. We estimated that for every 287 pregnancies in which a surgical operation was carried out there was one additional stillbirth; for every 31 operations there was one additional preterm delivery; for every 25 operations there was one additional caesarean section; for every 50 operations there was one additional long inpatient stay; and for every 39 operations there was one additional low-birthweight baby.

Limitations

We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Many spontaneous abortions will not be associated with a hospital admission and, therefore, will not be included in our analysis. A spontaneous abortion may be more likely to be reported if it occurs during the same hospital admission as the procedure, and this could account for the associated increased risk with surgery during pregnancy. There are missing values of key data items to determine parity, gestational age, birthweight and stillbirth.

Conclusions

This is the first study to report the risk of adverse birth outcomes following non-obstetric surgery during pregnancy across NHS hospitals in England. We have no means of disentangling the effect of the surgery from the effect of the underlying condition itself. Our observational study can never attribute a causal relationship between surgery and adverse birth outcomes, and we were unable to determine the risk of not undergoing surgery where surgery was clinically indicated. We have some reservations over associations of risk factors with spontaneous abortion because of potential ascertainment bias. However, we believe that our findings and, in particular, the numbers needed to harm improve on previous research, utilise a more recent and larger data set based on UK practices, and are useful reference points for any discussion of risk with prospective patients. The risk of adverse birth outcomes in pregnant women undergoing non-obstetric surgery is relatively low, confirming that surgical procedures during pregnancy are generally safe.

Future work

Further evaluation of the association of non-obstetric surgery and spontaneous abortion. Evaluation of the impact of non-obstetric surgery on the newborn (e.g. neonatal intensive care unit admission, prolonged length of neonatal stay, neonatal death).

Funding

The National Institute for Health Research Health Services and Delivery Research programme.

Efficacy and Safety of Pancreatobiliary Endoscopic Procedures during Pregnancy

Background/Aims

Endoscopic therapy with endoscopic retrograde cholangiopancreatography (ERCP) has been suggested as an effective diagnostic and therapeutic tool for biliary and pancreatic disorders during pregnancy. In this report, we describe our experiences with pancreatobiliary endoscopic procedures during pregnancy.

Methods

We reviewed ERCP and endoscopic ultrasonography (EUS) procedures that were performed at a single tertiary care referral center between January 2002 and October 2013. Medical records were reviewed for the procedure indication, the duration of fluoroscopy, postprocedure complications, etc. Pregnancy outcomes and fetal complications were identified by chart review and phone calls to patients.

Results

A total of 10 ER-CPs and five EUSs were performed in 13 pregnant patients: four of whom underwent the procedure in the first trimester, eight in the second trimester, and one in the third trimester. Indications for endoscopic therapy included gallstone pancreatitis, obstructive jaundice with common bile duct (CBD) stone, asymptomatic CBD stone, pancreatic cyst, choledochal cyst, and acute cholecystitis. Only one patient had a complication, which was postprocedural hyperamylasemia. Two patients underwent an artificial abortion, one according to her own decision and the other due to an adverse drug reaction.

Conclusions

ERCP seems to be effective and safe for pregnant women. Additionally, EUS can be an alternative to ERCP during pregnancy.

Laparoscopic appendectomy and cholecystectomy versus open: a study in 1999 pregnant patients

BACKGROUND

When pregnant patients require surgery, whether to perform an operation open or laparoscopic is often debated. We evaluated the impact of laparoscopy for common general surgical problems in pregnancy to determine safety and trends in operative approach over time.

METHODS

Pregnant patients undergoing appendectomy or cholecystectomy were identified using the National Surgical Quality Improvement Program (NSQIP) database. We analyzed demographics, operative characteristics, and outcomes. Univariate comparison and multivariate regression analysis (MVA) were performed adjusting for confounding factors: age, body mass index (BMI), diabetes, and smoking, and an additional MVA was performed for perforated cases.

RESULTS

A total of 1999 pregnant patients between 2005 and 2012 were evaluated. Of 1335 appendectomies, 894 were performed laparoscopically (LA) and 441 open (OA). For 664 cholecystectomies, 606 were laparoscopic (LC) and 58 open (OC). There were no deaths. For LA versus OA, patient characteristics were not different {age: 27.7 vs. 28.2 years, p = 0.19; diabetes: 1.8 vs. 0.9%, p = 0.24; smoking: 19 vs. 16.1%, p = 0.2} except for BMI (27.9 vs. 28.4 kg/m(2); p = 0.03). LA had shorter operative times (ORT), length of stay (LOS), and fewer postoperative complications compared to OA. In MVA, difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.01), and wound complications (<0.01). MVA was performed for perforated cases alone: LA had equal ORT (p = 0.19) yet shorter LOS (p = <0.001). The majority of LA were performed in the last 4 years versus the first 4 years (61 vs. 39%, p < 0.001). For LC versus OC, patient characteristics were not different: age (28.3 vs. 28.7 years; p = 0.33), BMI (31.4 vs. 33.2 kg/m(2), p = 0.25), diabetes (2.8 vs. 3.5%, p = 0.68), and smoking (21.1 vs. 25.9%, p = 0.4). LC had a shorter ORT, LOS, and fewer postoperative complications than OC. In MVA, the difference between approaches remained statistically significant for ORT (<0.0001), LOS (<0.0001), and minor complications (<0.01). In MVA for cholecystitis with perforation, no difference was seen for LOS, ORT, or postoperative complications (p > 0.05). The percentage of LC cases appeared to increase over time (89 vs. 93%, p = 0.06).

CONCLUSION

While fetal events are unknown, LA and LC in pregnant patients demonstrated shorter ORT, LOS, and reduced complications and were performed more frequently over time. Even in perforated cases, laparoscopy appears safe in pregnant patients.

Abdominal surgery in pregnancy--an interdisciplinary challenge

BACKGROUND

Abdominal operations are performed during ca. 2% of all pregnancies. They represent an unusual situation not only for the patient, but also for the involved surgeons and anesthesiologists. Appendectomy, followed by cholecystectomy are the two most common types of operation performed during pregnancy. Special questions arise with regard to the peri- and intraoperative management and the optimal surgical approach.

METHOD

This review is based on pertinent articles retrieved by a selective search in the PubMed database.

RESULTS

The question of laparoscopy versus laparotomy during pregnancy has been addressed to date only in case series and a few meta-analyses. Two meta-analyses have shown a significantly higher rate of miscarriage after laparoscopic, compared to open, appendectomy (relative risk [RR] 1.91, 95% confidence interval [CI] 1.31-2.77). The risk of preterm birth is also somewhat higher after laparoscopic appendectomy according to one meta-analysis on this subject (RR 1.44, 95% CI 0.78-1.76), but significantly lower according to another meta-analysis (2.1% vs. 8.1%, p<0.0001). For cholecystectomy, laparoscopy was associated with a lower miscarriage rate than laparotomy (1 in 89 cases, versus 2 in 69 cases), but with a somewhat higher preterm birth rate (6 in 89 cases, versus 2 in 69 cases). Delay or non-performance of surgery in a patient with appendicitis or cholecystitis can lead to additional hospitalizations, a higher miscarriage rate, premature rupture of the membranes, and preterm birth.

CONCLUSION

Laparoscopy in experienced hands is safe even during pregnancy, with the recognized advantages of minimally invasive surgery, yet it carries a higher miscarriage rate than laparotomy, with a comparable preterm birth rate. Before surgery, patients should be thoroughly informed about the operation they are about to undergo and the advantages and disadvantages of the available surgical approaches.

Acute pancreatitis during pregnancy: a review

This article aims to draw together recent thinking on pregnancy and acute pancreatitis (AP), with a particular emphasis on pregnancy complications, birth outcomes and management of AP during pregnancy contingent on the etiology. AP during pregnancy is a rare but severe disease with a high maternal-fetal mortality, which has recently decreased thanks to earlier diagnosis and some maternal and neonatal intensive care improvement. AP usually occurs during the third trimester or the early postpartum period. The most common causes of AP are gallstones (65 to 100%), alcohol abuse and hypertriglyceridemia. Although the diagnostic criteria for AP are not specific for pregnant patients, Ranson and Balthazar criteria are used to evaluate the severity and treat AP during pregnancy. The fetal risks from AP during pregnancy are threatened preterm labor, prematurity and in utero fetal death. In cases of acute biliary pancreatitis during pregnancy, a consensual strategy could be adopted according to the gestational age, and taking in consideration the high risk of recurrence of AP (70%) with conservative treatment and the specific risks of each treatment. This could include: conservative treatment in first trimester and laparoscopic cholecystectomy in second trimester. During the third trimester, conservative treatment or endoscopic retrograde cholangiopancreatography with biliary endoscopic sphincterotomy, and laparoscopic cholecystectomy in early postpartum period are recommended. A multidisciplinary approach, including gastroenterologists and obstetricians, seems to be the key in making the best choice for the management of AP during pregnancy.

Delaying cholecystectomy for complicated gallstone disease in pregnancy is associated with recurrent postpartum symptoms

INTRODUCTION

Pregnancy is a risk factor for gallstone disease; in some patients, cholecystectomy may be delayed to the postpartum period. Our aim was to examine the effect of antepartum interventions on postpartum outcomes in complicated gallstone disease (CGD) during pregnancy.

MATERIAL AND METHODS

Retrospective analysis of patients seeking medical care for CGD (cholecystitis, choledocholithiasis, or gallstone pancreatitis) during pregnancy at a single tertiary care institution over a 10-year period (2002-2012). Patients were contacted via standardized telephone survey to account for outside hospitalizations.

RESULTS AND DISCUSSION

We identified 56 patients with CGD during pregnancy, 42.9 % initially presenting during the second trimester. Choledocholithiasis was the most common diagnosis (n = 30). Antepartum cholecystectomy was performed in 17.9 %. Seventeen patients did not follow up postpartum and did not complete telephone survey. Of the remaining 29 patients, 58.6 % had recurrent postpartum symptoms, 35.3 % recurred within 1 month, and 82.4 % within 3 months of delivery. Antepartum ERCP with biliary sphincterotomy decreased postpartum symptom recurrence (38.5 vs. 75.0 %, p = 0.07).

CONCLUSIONS

The majority of patients with CGD who do not undergo antepartum cholecystectomy have recurrent postpartum symptoms often within 3 months postpartum. When appropriate, physicians should advocate for antepartum or early postpartum cholecystectomy to minimize symptom recurrence and unplanned hospitalizations.

Maternal sepsis

Maternal sepsis is relatively common. Most of these infections are the result of tissue damage during labor and delivery and physiologic changes normally occurring during pregnancy. These infections, whether directly pregnancy-related or simply aggravated by normal pregnancy physiology, ultimately have the potential to progress to severe sepsis and septic shock. This article discusses commonly encountered entities and septic shock. The expeditious recognition of common maternal sepsis and meticulous attention to appropriate management to prevent the progression to severe sepsis and septic shock are emphasized. Also discussed are principles and new approaches for the management of septic shock.

Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits

BACKGROUND

Pancreaticobiliary complications of gallstones are common in pregnancy and can result in serious sequelae. Previous studies have shown conflicting results regarding different approaches of treatment.

OBJECTIVE

To compare the outcomes of conservative treatment versus operative and endoscopic interventions in the management of complications related to gallstones during pregnancy.

DESIGN

Retrospective chart review.

SETTING

Tertiary-care referral facility.

PATIENTS

A total of 112 patients who had complications related to gallstones during pregnancy.

INTERVENTION

Patients were classified into 3 groups: conservative treatment, laparoscopic cholecystectomy (LC), and ERCP.

MAIN OUTCOME MEASUREMENTS

We collected demographic data and information regarding treatment complications and pregnancy outcomes.

RESULTS

A total of 112 pregnant patients met the inclusion criteria, with a mean age of 25 years. Main clinical presentations were biliary colic (n = 56), biliary pancreatitis (n = 27), acute cholecystitis (n = 17), and choledocholithiasis (n = 12). A total of 68 patients underwent conservative treatment, 13 patients underwent ERCP, 27 patients had LC, and 4 patients received both ERCP and LC. Recurrent biliary symptoms were significantly more common in patients who received conservative treatment (P = .0005). The number of emergency department visits was significantly higher in the conservative treatment group compared with the active intervention group (P = .0006). The number of hospitalizations also was higher in the conservative treatment group (P = .03). Fetal birth weight was similar in both groups (P = .1). Patients treated conservatively were more likely to undergo cesarean section operations for childbirth (P = .04).

LIMITATIONS

Single-center, retrospective study.

CONCLUSION

Conservative treatment of cholelithiasis and its complications during pregnancy is associated with recurrent biliary symptoms and frequent emergency department visits. ERCP and LC are safe alternative approaches during pregnancy.

Cholecystectomy under segmental thoracic epidural block in a patient with twin gestation

Cholecystectomy represents the second most common surgery during pregnancy. Both general and regional anesthetic techniques have been successfully used for cholecystectomy in pregnant patients. Authors present here a case of a pregnant patient carrying twin gestation who underwent cholecystectomy, which is not frequently encountered by the anesthesiologists. This report enumerates the perioperative issues relating to anesthesia given to a pregnant patient in addition to emphasizing the importance of multidisciplinary approach when such a case is encountered.

Suspicion of acute appendicitis in the third trimester of pregnancy: pros and cons of a laparoscopic procedure

This review suggests that diagnostic laparoscopy during the third trimester of pregnancy is a logical strategy to minimize maternal and fetal risk when acute appendicitis is suspected.

The presentation of acute appendicitis during pregnancy may cause diagnostic and therapeutic difficulty. Delay in diagnosis may lead to increased maternal and fetal risk. Therefore, an aggressive surgical approach is mandatory, even though this may result in an increased number of appendectomies for normal appendices. Diagnostic laparoscopy, followed by laparoscopic appendectomy in case of inflammation, seems a logical strategy. We present the case of a 36-week pregnant woman who presented with suspicion of acute appendicitis. The pro and cons of a laparoscopic approach in the third trimester of pregnancy are discussed as is its safety by reviewing the literature.

Acute pancreatitis during pregnancy

Acute pancreatitis in pregnancy is a rare condition estimated to occur in 1 per 1000 to 1 per 12,000 pregnancies. The most frequent etiology in pregnancy is biliary, followed by hyperlipidemia and/or alcohol abuse. Abdominal ultrasound and endoscopic ultrasound are ideal imaging techniques for diagnosing disease because they have no radiation risk. Computed tomography, magnetic resonance cholangiopancreatography, and endoscopic retrograde cholangiopancreatography should be used with caution. Treatment could be conservative or surgical, and standard algorithms are slightly modified in pregnant women. In the last decades the outcome of acute pancreatitis in pregnancy is much better, and perinatal mortality is less than 5%.

Laparoscopic cholecystectomy in patients with cardiac dysfunction

Laparoscopic cholecystectomy remains the standard treatment for cholelithiasis. Ever increasing number of patients with myriad of medical illness is being treated by this technique. However, significant concern prevails among the surgical community regarding its safety in patients with cardiac co-morbidity. Patients with significant cardiac dysfunction and multiple co-morbidities were prospectively evaluated. Patients were assessed by cardiologists and anesthesiologists and laparoscopic cholecystectomy was performed. Patient demographics, details of peri-operative management and post-operative complications were studied. Between March 2005 and January 2009, 28 patients (M:F = 21:7) with mean age of 60 years (range 26-78) and having significant cardiac dysfunction had undergone laparoscopic cholecystectomy. Of these, 24 patients were in NYHA class-II, while 4 belonged to class-III. Left ventricular ejection fraction, as recorded by transthoracic echocardiography, was 20-30% in 13 (46%) patients and 30-40% in the rest 15 (54%). In addition, 13 (46%) patients had regional wall motion abnormalities, 11 (39%) patients had cardiomyopathy, 2 (7%) patients had valvular heart disease while 12 (43%) patients had prior cardiac interventions. Following laparoscopic cholecystectomy, hypertension (3), tachyarrhythmia (4) and bradycardia (1) were the commonest events encountered. One patient required laparotomy to deal with peritonitis in the immediate postoperative period and succumbed to myocardial infarction, but all other patients made an uneventful recovery. With appropriate cardiological support, laparoscopic cholecystectomy may be safely performed in patients with significant cardiac dysfunction.

BILIARY AND PANCREATIC DISEASE IN PREGNANCY

Pregnancy is a physiological condition that affects all organs. Diseases unrelated to pregnancy may present coincidentally during pregnancy or may be exacerbated by pregnancy, and may increase maternal and/or fetal morbidity or mortality. Compared with many other systems, the changes within the biliary tree and pancreas are relatively minimal. However, pregnancy is associated with an increased likelihood of cholelithiasis, which can have significant implications for the parturient.

Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review

Treatment of surgical disease in the gravid patient requires a unique and careful approach where safety of the mother and fetus are both considered. Approaches to diagnosis and therapy of surgical disease in the gravid patient are increasingly clarified and defined in the literature. Laparoscopy, once described as contraindicated in pregnancy, has been steadily accepted and applied as data supporting its safety and use have accumulated. An extensive review of the literature was performed to define the use of laparoscopy in pregnancy. Diagnoses for independent surgical diseases as well as imaging modalities and techniques during pregnancy are reviewed. Preoperative, intraoperative, and postoperative management of the pregnant patient are described and evaluated with focus on use of laparoscopy. Literature supporting safety and efficacy of laparoscopy in cholecystectomy, appendectomy, solid organ resection, and oophorectomy in the gravid patient is outlined. Based on level of evidence, this review includes recommendations specific to surgical approach, trimester of pregnancy, patient positioning, port placement, insufflation pressure, monitoring, venous thromboembolic prophylaxis, obstetric consultation, and use of tocolytics in the pregnant patient.

[Not Available]

This study was conducted to evaluate the safety of laparoscopic cholecystectomy (LC) during pregnancy. Patients who underwent LC were selected from several hospital databases, only six were performed during pregnancy. In this series, one of the two patients who had LC in the first trimester underwent elective termination of pregnancy while the other one gave birth to a term child normally. Half of the four who had the second trimester LC had normal deliveries at term whereas for the other two cesarean section was performed. None of our patients underwent LC in the third trimester. The findings of the present study suggest LC to be a safe procedure performed during the first and second trimester of pregnancy.

Negative appendectomy in pregnant women is associated with a substantial risk of fetal loss

BACKGROUND

The preoperative diagnosis of acute appendicitis is often inaccurate in pregnant women, and complicated appendicitis is associated with a high rate of fetal loss. The study objective was to evaluate rates of fetal loss and early delivery in pregnant patients undergoing appendectomy, using a large population-based database.

STUDY DESIGN

Using the California Inpatient File, we retrospectively analyzed all women undergoing appendectomy between 1995 and 2002 for pregnancy, diagnosis, operative technique, fetal loss, and early delivery during the same hospitalization as appendectomy.

RESULTS

Of 94,789 women who underwent appendectomy, 3,133 were pregnant. Complicated appendicitis was found in 30% of pregnant women and 29% of nonpregnant women (p=NS). The rate of negative appendectomy was considerably higher in pregnant compared with nonpregnant women (23% versus 18%, p < 0.05). Rates of fetal loss and early delivery were considerably higher in women with complex appendicitis (6% and 11% respectively; p < 0.05) in comparison with negative (4% and 10%) and simple (2% and 4%) appendicitis. Using multivariate logistic regression, complicated and negative appendicitis (odds ratio [OR] 2.69 and 1.88 respectively, compared with simple) remained major positive predictors of fetal loss. Also, laparoscopy was associated with a higher rate of fetal loss compared with open appendectomy (odds ratio=2.31).

CONCLUSIONS

The current approach to possible acute appendicitis in pregnant women puts 23% at risk for fetal loss, even though they have a normal appendix. These data indicate that reducing fetal loss in pregnant women suspected of having acute appendicitis will require more accurate diagnosis to avoid unnecessary operation.

Management of biliary tract disease during pregnancy: a decision analysis

BACKGROUND

The appropriate management of biliary tract disease during pregnancy is uncertain. Although laparoscopic cholecystectomy can be performed safely during pregnancy, the timing and indications for this surgical intervention have not been firmly established.

METHODS

We constructed a Markov decision analytic model that incorporates maternal well-being and fetal outcome into a choice between nonoperative management (NM) and laparoscopic cholecystectomy (LC) for pregnant women with biliary tract disease (BTD). Our model cycles through weeks of pregnancy for a cohort of 200 gravid women presenting with biliary tract disease in both the first and second trimesters. Weekly state probabilities and utilities for fetal outcome were derived from the literature, while weekly utilities for disease and operative states were estimated in consultation with obstetricians. We cycled the model from 6 to 42 weeks and from 19 to 42 weeks to simulate first and second trimester presentations. Outcomes are expressed in quality pregnancy weeks (QPWs). One QPW is the utility of a normal healthy week of pregnancy.

RESULTS

A comprehensive search of the literature yielded a fetal death rate following LC for biliary tract disease of 2.2% and following NM of 7%. Relapse rates were found to be trimester dependent and estimated to be 55%, 55%, and 40% in the first, second, and third trimester, respectively. For a hypothetical cohort of 100 women presenting with biliary tract disease in their first trimester, LC generated 12,800 QPWs compared with 12,400 QPWs for NM, an average gain of 4 QPWs per woman. For the cohort of women entering the model in the second trimester, 11,600 QPWs were accrued by the LC group and 11,400 QPWs by the NM group, an average gain of 2 QPWs per woman. These findings were sensitive only to changes in fetal death rates under the two treatment arms.

CONCLUSIONS

Laparoscopic cholecystectomy is superior to nonoperative management for pregnant women presenting in the first or second trimester with biliary tract disease.

Surgical gastrointestinal disorders during pregnancy

All gastrointestinal (GI) disorders can present during pregnancy, and in fact 0.2% to 1.0% of all pregnant women require non-obstetrical general surgery. All of the clinical decision-making skills of the experienced surgeon must come into play in order to make the correct therapeutic decisions when evaluating the pregnant patient with a GI disorder that potentially requires surgery. While in general the principles of diagnosing and treating a pregnant woman with an acute surgical abdominal problem remain the same as those governing the treatment of the non-pregnant patient, some important differences are present and can pose problems. As a general rule the condition of the mother should always take priority because proper treatment of surgical diseases in the mother will usually benefit the fetus as well as the mother.

Definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis: Tokyo Guidelines

This article discusses the definitions, pathophysiology, and epidemiology of acute cholangitis and cholecystitis. Acute cholangitis and cholecystitis mostly originate from stones in the bile ducts and gallbladder. Acute cholecystitis also has other causes, such as ischemia; chemicals that enter biliary secretions; motility disorders associated with drugs; infections with microorganisms, protozoa, and parasites; collagen disease; and allergic reactions. Acute acalculous cholecystitis is associated with a recent operation, trauma, burns, multisystem organ failure, and parenteral nutrition. Factors associated with the onset of cholelithiasis include obesity, age, and drugs such as oral contraceptives. The reported mortality of less than 10% for acute cholecystitis gives an impression that it is not a fatal disease, except for the elderly and/or patients with acalculous disease. However, there are reports of high mortality for cholangitis, although the mortality differs greatly depending on the year of the report and the severity of the disease. Even reports published in and after the 1980s indicate high mortality, ranging from 10% to 30% in the patients, with multiorgan failure as a major cause of death. Because many of the reports on acute cholecystitis and cholangitis use different standards, comparisons are difficult. Variations in treatment and risk factors influencing the mortality rates indicate the necessity for standardized diagnostic, treatment, and severity assessment criteria.