Management of choledocholithiasis during pregnancy by magnetic resonance cholangiography and laparoscopic common bile duct stone extraction. Surg Laparosc Endosc Percutan Tech. 2000;10:323-325. [PMID: 11083218 DOI: 10.1097/00129689-200010000-00013]

Laparoscopic bile duct exploration during pregnancy: a multi-center case series and literature review

BACKGROUND

The physiological changes of pregnancy increase the risk of gallstone formation and choledocholithiasis. Traditionally, endoscopic retrograde cholangiopancreatography (ERCP) has been the main approach for managing choledocholithiasis during pregnancy, but recent progress in laparoscopic bile duct exploration (LBDE) has demonstrated this technique as a safe and effective alternative option.

METHODS

A retrospective multicenter study of all patients who underwent LBDE during pregnancy from five centers with proven experience in LBDE between January 2010 and June 2020 was performed. The primary endpoint was to analyze the role of LBDE during pregnancy and to further characterize its position as a safe and effective alternative for the management of choledocholithiasis. A systematic review of the published literature relating to LBDE during pregnancy until February 2022 was also performed.

RESULTS

Five institutions reported performing LBDE during pregnancy in 8 patients. Median surgical time was 75 min (range: 60-140 min). The bile duct was cleared successfully in all patients, and the median hospital stay was 2 days (range: 1-3 days). The literature review identified a total of 7 patients with a successful CBD clearance rate of 86%. There were no major maternal, fetal, or pregnancy-related complications in any of the total 15 patients included. The symptomatic common bile duct lithiasis with deranged liver function tests was the most frequent indication (n=7).

CONCLUSION

LBDE during pregnancy appears to be safe and effective. More evidence reporting outcomes of LBDE during pregnancy is needed before any strong recommendations can be made.

Choledocholithiasis in Pregnancy: A Case Report

Cholelithiasis during pregnancy and the postpartum period has an incidence of 12%, with pregnancy being an important risk factor for gallstones. Patients with choledocholithiasis can experience complications, such as obstructive jaundice, cholangitis, and pancreatitis, which may be detrimental to both mother and fetus.

A case of cholelithiasis in a second-trimester pregnancy was complicated by choledocholithiasis and obstructive jaundice. Ultrasonography (US), magnetic resonance cholangiopancreatography (MRCP), along with serial blood tests, confirmed the diagnosis. Treatment was safely achieved using endoscopic retrograde cholangiopancreatography (ERCP).

In pregnancy, complicated cholelithiasis is investigated using blood tests, ultrasonography, and cholangiography. Evidence supports the use of intraoperative or endoscopic cholangiography for the management of such complicated gallstone disease in pregnancy.

Non-obstetric surgery in pregnancy (including bowel surgery and gallbladder surgery)

Non-obstetric surgery during pregnancy is required in 0.75-2% of pregnancies. Physiologic changes during pregnancy, both hormonal and anatomic, can have interactions with surgery and anesthesia. Indication, timing as well as risks of anesthesia and surgery should be considered in surgical decision making. The health status of the mother should always be put first. A preoperative multidisciplinary approach, also including an obstetrician and neonatologist, is mandatory. Delay in diagnosis and treatment carry risks of complications in all septic visceral indications. Considerations should be individualized.

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.

Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography

AIM

To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography (ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.

METHODS

Systematic computerized literature search performed using PubMed with the key words “ERCP” and “pregnancy”. Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubMed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.

RESULTS

Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in non-pregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.

CONCLUSION

This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.

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.

Biliary disease in pregnancy with an emphasis on the role of ERCP

The incidence of gallstones during pregnancy is estimated to be between 3% and 12%. About one-third of pregnant patients with cholelithiasis become symptomatic and may require surgical intervention. Choledocholithiasis during pregnancy although infrequent usually requires therapeutic intervention. Abdominal ultrasonography is insensitive for the detection of common bile duct stones. Magnetic resonance imaging is not being associated with known adverse effects and seems to be an excellent diagnostic modality in this context. Paramagnetic contrast agents have been associated with increased spontaneous abortion rates and other abnormalities in animals and should only be used when absolutely necessary. Endoscopic ultrasonography is highly accurate for the detection of common bile duct stones and may be useful before consideration of endoscopic retrograde cholangiopancreatography (ERCP) in select patients. The second trimester seems to be the safest time to perform surgery, as organogenesis is complete and the incidence of spontaneous abortion lower. ERCP followed by sphincterotomy and stone extraction is very effective and can be performed safely during all trimesters of pregnancy with a premature delivery rate less than 5%. All efforts to minimize radiation exposure should be undertaken. These include lead shielding and avoiding hard copy radiographs. When possible, category B (such as meperidine) or C drugs only should be used for sedation during pregnancy. Therapeutic ERCP is now the standard of care for treating choledocholithiasis during pregnancy. Endoscopic sphincterotomy for symptomatic patients with normal cholangiograms is controversial. Consideration of ERCP demands a judicious approach, paying careful attention to risks and benefits of intervention.

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.