Continued evidence for safety of endoscopic retrograde cholangiopancreatography during pregnancy

Laparoscopic cholecystectomy prevents readmissions. A 9-year review of acute pancreatitis in pregnancy in an Australian tertiary center

BACKGROUND

Acute pancreatitis in pregnancy (APIP) is a rare but potentially life-threatening condition, affecting women at any gestation. The aim of this review is to investigate the demographics, etiology, management, and outcomes of pancreatitis in pregnant women in a major tertiary hospital in Queensland.

METHODS

Data was collected from the hospital medical records of all patients diagnosed with APIP from 01/01/2012 until 30/04/2021 at the Mater Hospital, Brisbane. Descriptive statistical measures were employed. Spearman's rank correlation was used to challenge different risk factors for readmission.

RESULTS

26 patients met the inclusion criteria, with 38 admissions during the study period. Biliary pancreatitis was the most common etiology (n = 14, 53.8%). 42.5% of admissions were managed operatively (n = 15). 38.5% of patients had more than one admission (n = 10). Undergoing a laparoscopic cholecystectomy on index admission correlated with a significantly lower chance of repeat admission (rs= -.48, p = .013, CI = - .737 to -.102).

CONCLUSION

This is the first study of this condition in an Australian institution. It demonstrates that in patients with acute biliary pancreatitis, operative management can be safely employed at any trimester and laparoscopic cholecystectomies should be performed in the index admission to reduce the risk of readmission to hospital.

Acute lithiasis cholangitis in pregnant women: About three cases

Acute lithiasis cholangitis is a rare non‐obstetric emergency during pregnancy, which may threaten fetus and mother's life. It requires a codified management in order to avoid complications. In this current study, we aimed to report our center experience in the management of acute lithiasis cholangitis occurring in three pregnant women.

Surgical management of acute cholangitis during pregnancy is still the first line treatment in countries where endoscopic procedures are not widely available. It should be performed promptly to avoid risks for both mother and fetus.

Long-term follow-up after fetal radiation exposure during endoscopic retrograde cholangiopancreatography

Background and study aims  The main concern about endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy is the risk of radiation exposure to the fetus. The potential exists not only in the short-term, but also in the long-term and includes growth and development problems and the possibility of childhood cancer. Little is known about the long-term effects of fetal radiation exposure at the time of ERCP. The aim of the study was to report the long-term outcome of babies born after radiation exposure to mothers who underwent ERCP during pregnancy. Patients and methods  This was a single-center retrospective cohort study. We included 24 consecutive pregnant patients who underwent ERCP due to choledocholithiasis and their children, between June 1997 and June 2015. All patients and their babies were followed up until birth to assess their short-term outcome. To assess long-term outcomes, from September 2014 to September 2015, a comprehensive medical interview was conducted with the mothers and their children. We also evaluated medical records, lab tests, school report cards, and the families completed a questionnaire inquiring about perceived health status of the children. Results  Fifteen patients had full-term pregnancies. One patient had a preterm delivery (32 weeks) due to preeclampsia. There were no cases of miscarriage, stillbirth or fetal malformations. Long-term follow-up was performed at a mean age of 11.08 years (range 1-18) for the children, with no developmental delays, poor school performance, or malignancies found. Conclusions  Long-term outcome in children born after radiation exposure during ERCP was unremarkable.

Safety of endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy: A systematic review and meta-analysis

BACKGROUND/AIMS

Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging procedure rarely associated with severe postprocedure complications. Hormonal changes during pregnancy promote cholelithiasis, but there are limited clinical data available on the outcomes of ERCP in pregnant women. ERCP techniques without irradiation were recently introduced as potential alternative. We performed a systematic review and meta-analysis to assess the safety of ERCP in pregnancy and to compare outcomes of radiation versus nonradiation ERCP.

MATERIALS AND METHODS

A systematic search of PubMed, Medline/Ovid, Web of Science, and Google Scholar through April 18^th, 2018 using PRISMA and MOOSE guidelines identified 27 studies reporting the outcomes of ERCP in pregnancy. Random effects pooled event rate and 95% confidence intervals (CIs) were estimated. Heterogeneity was measured by I², and meta-regression analysis was conducted. Adverse outcomes were divided into fetal, maternal pregnancy-related, and maternal nonpregnancy-related.

RESULTS

In all, 27 studies reporting on 1,307 pregnant patients who underwent ERCP were identified. Median age was 27.1 years. All results were statistically significant (P < 0.01). The pooled event rate for overall adverse outcomes was 15.9% (95% CI = 0.132-0.191) in all studies combined, 17.6% (95% CI = 0.109-0.272) in nonradiation ERCP (NR-ERCP) subgroup and 21.6% (95% CI = 0.154-0.294) in radiation ERCP subgroup. There was no significant difference in the pooled event rate for fetal adverse outcomes in NR-ERCP 6.2% (95% CI = 0.027-0.137) versus 5.2% (95% CI = 0.026-0.101) in radiation ERCP group. There was no significant difference in maternal pregnancy-related adverse outcome event rate between NR-ERCP (8.4%) (95% CI = 0.038-0.173) and radiation ERCP (7.1%) (95% CI = 0.039-0.125). Maternal nonpregnancy-related adverse outcome event rate in NR-ERCP was 7.6% (95% CI = 0.038-0.145), which was half the event rate in radiation ERCP group of 14.9% (95% CI = 0.102-0.211).

CONCLUSIONS

ERCP done by experienced endoscopists is a safe procedure during pregnancy. Radiation-free techniques appear to reduce the rates of nonpregnancy-related complications, but not of fetal and pregnancy-related complications.

Cholelithiasis: Presentation and Management

Cholelithiasis affects approximately 15% of the US population. Rising trends in obesity and metabolic syndrome have contributed to an increase in diagnosis of cholelithiasis. There are several risk factors for cholelithiasis, both modifiable and nonmodifiable. Women are more likely to experience cholelithiasis than are men. Pregnancy, increasing parity, and obesity during pregnancy further increase the risk that a woman will develop cholelithiasis. The classic presentation of persons experiencing cholelithiasis, specifically when gallstones obstruct the common bile duct, is right upper quadrant pain of the abdomen that is often elicited upon palpation during physical examination and documented as a positive Murphy's sign. Referred pain to the right supraclavicular region and/or shoulder, nausea, and vomiting are also frequently reported by persons with cholelithiasis. Cholelithiasis can result in complications, including cholecystitis (inflammation of the gallbladder) and cholangitis (inflammation of the bile duct). Lack of physical examination findings does not rule out a diagnosis of cholelithiasis. Laboratory tests such as white blood cell count, liver enzymes, amylase, and lipase may assist the clinician in diagnosing cholelithiasis; however, ultrasonography is the gold standard for diagnosis. Management is dependent on severity and frequency of symptoms. Lifestyle and dietary modifications combined with medication management, such as use of gallstone dissolution agents, may be recommended for persons who have a single symptomatic episode. If symptoms become severe and/or are recurrent, laparoscopic cholecystectomy is recommended. It is recommended that individuals with an established diagnosis of cholelithiasis be referred to a surgeon and/or gastroenterologist within 2 weeks of initial presentation regardless of severity or frequency of symptoms.

The Pregnant Patient: Assessment and Perioperative Management

Pathologic changes can occur during pregnancy requiring diagnostic tests and procedures. A preoperative assessment and perioperative planning are essential. Normal physiologic changes include increased cardiac output and decreased functional residual capacity. Perioperative care should follow American Congress of Obstetricians and Gynecologists guidelines. Anesthetic concerns include desaturation during periods of apnea, aspiration, difficult intubation, friable nasal tissue, decreased MAC, and hypotension and/or decreased uterine perfusion from the uterus. Anesthesia and medications must be individualized and given only as needed. Limit exposure to multiple drugs and monitor for fetal wellbeing and premature labor per consultation and guidelines.