Gallbladder and pancreatic disease during pregnancy

Surgical trends in the management of acute cholecystitis during pregnancy

BACKGROUND

Since 2007, clinical practice guidelines by the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) recommend early surgical management with laparoscopic cholecystectomy for pregnant women with symptomatic gallbladder disease regardless of trimester. However, little is known about practice patterns in the management of pregnant patients with acute cholecystitis. This study aims to examine nationwide trends in the surgical management of acute cholecystitis, as well as their impact on clinical outcomes during pregnancy.

METHODS

The National Inpatient Sample was queried for all pregnant women diagnosed with acute cholecystitis between January 2003 and September 2015. After applying appropriate weights, multivariate regression analysis adjusted for patient- and hospital-level characteristics and quantified the impact of discharge year (2003-2007 versus 2008-2015) on cholecystectomy rates and timing of surgery. Multivariate regression analysis was also used to examine the impact of same admission cholecystectomy and its timing on maternal and fetal outcomes.

RESULTS

A total of 23,939 pregnant women with acute cholecystitis satisfied our inclusion criteria. The median age was 26 years (interquartile range: 22-30). During the study period, 36.3% were managed non-operatively while 59.6% and 4.1% underwent laparoscopic and open cholecystectomy, respectively. After adjusting for covariates, laparoscopic cholecystectomy was more commonly performed after 2007 (odds ratio [OR] 1.333, p < 0.001). Furthermore, time from admission to surgery was significantly shorter in the latter study period (regression coefficient -0.013, p < 0.001). Compared to non-operative management, laparoscopic cholecystectomy for acute cholecystitis was significantly associated with lower rates of preterm delivery, labor, or abortion (OR 0.410, p < 0.001). Each day that laparoscopic cholecystectomy was delayed significantly associated with an increased risk of fetal complications (OR 1.173, p < 0.001).

CONCLUSIONS

This nationwide study exhibits significant trends favoring surgical management of acute cholecystitis during pregnancy. Although further studies are still warranted, early laparoscopic cholecystectomy should be considered in pregnant patients with acute cholecystitis.

Acute pancreatitis in pregnancy: an overview

Acute pancreatitis is rare in pregnancy but it is associated with increased incidence of maternal and fetal mortality. It should be considered in the differential diagnosis of upper quadrant abdominal pain with or without nausea and vomiting. The commonest identified causes of acute pancreatitis in pregnancy are gallstones, alcohol and hypertriglyceridemia. The main laboratory finding is increased amylase activity. Appropriate investigations include ultrasound of the right upper quadrant and measurement of serum triglycerides and ionized calcium. Management of gallstone pancreatitis is controversial, although laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) are often used and may be associated with lower complication rates. In hypertriglyceridemia-induced acute pancreatitis ω-3 fatty acids and even therapeutic plasma exchange can be used. We also discuss preventive measures.

Nontraumatic abdominal surgical emergencies in the pregnant patient

Although most EPs are aware of the diverse presentations of ectopic pregnancy, this diagnosis remains a formidable challenge in the ED. The diagnosis of abdominal surgical emergencies in pregnant patients continues to challenge EPs, surgeons, and obstetricians alike. Understanding how the gravid state can obscure common conditions such as appendicitis, cholecystitis. bowel obstruction, and adnexal torsion might help the EP identify suspicious cases early, preventing serious consequences to the mother and fetus.