ORIGINAL ARTICLE
A Multimodal Approach to Acute Biliary Pancreatitis During Pregnancy: A Case Series Andreas Polydorou, PhD,* Konstantinos Karapanos, MD,w Antonios Vezakis, MD,* Aikaterini Melemeni, PhD,* Vasilios Koutoulidis, MD,* Georgios Polymeneas, PhD,* and Georgios Fragulidis, PhD*
Abstract: The treatment of acute biliary pancreatitis during pregnancy remains controversial. We present our experience of treating 7 pregnant women with acute biliary pancreatitis and verified or suspected choledocholithiasis, by using magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and sphincterotomy followed by laparoscopic cholecystectomy. MRCP was performed in all patients to confirm the presence of common bile duct stones, their size and number. ERCP and sphincterotomy were performed without the use of radiation. The procedure was terminated only when all stones (the number clarified at MRCP), were retrieved into the duodenum. All patients underwent laparoscopic cholecystectomy the following day. Neither post-ERCP nor postoperative major complications were noted. All but one patient reached a healthy natural-term labor. One patient had a planned cesarean section on 35th week. The combination of MRCP, nonradiation ERCP, and immediate laparoscopic cholecystectomy provides definite treatment and seems to put both mother and fetus at lower risk than presumed. Key Words: acute pancreatitis, pregnancy, choledocholithiasis, endoscopic sphincterotomy, laparoscopic cholecystectomy, magnetic resonance cholangiopancreatography
(Surg Laparosc Endosc Percutan Tech 2012;22:429–432)
T
he diagnosis and treatment of acute biliary pancreatitis in pregnant women remains one of the most challenging and crucial issues for both obstetricians and surgeons worldwide. The rarity of symptomatic gallstone disease in pregnancy, the lack of any evidence-based conclusions,1 and the high clinical awareness about maternal and fetal outcomes, have led to numerous suggestions for the safest and most effective therapeutic approach. During the last decades,2 many sorts of dogmas such as “conservative management of gallstone pancreatitis during pregnancy should be considered as the gold standard of care and any surgical intervention must be performed only to the life-threatening cases”3,4; “pregnancy is an absolute contraindication for laparoscopic surgery”5; “laparoscopic cholecystectomy should only be carried out, if needed, in the second trimester”6; “endoscopic procedures such as endoscopic retrograde cholangiopancreatography (ERCP), should be avoided in gravid patients, because of the
Received for publication January 13, 2012; accepted May 7, 2012. From the *University of Athens, Aretaieion Hospital, Athens; and wDepartment of Surgery, Metaxa Cancer Memorial Hospital, Piraeus, Greece. The authors declare no conflicts of interest. Reprints: Antonios Vezakis, MD, University of Athens, Second Department of Surgery, Aretaieion Hospital, 76 Vass. Sofias Ave., Athens 11528, Greece (e-mail:
[email protected]). Copyright r 2012 by Lippincott Williams & Wilkins
Surg Laparosc Endosc Percutan Tech
potential teratogenic effects of radiation exposure to the fetus,”7 have been raised and brought down. We present our experience of treating pregnant women with acute biliary pancreatitis by applying the standard multimodal therapy, which is recommended for the nonpregnant patients. This includes a preoperative magnetic resonance cholangiopancreatography (MRCP), ERCP with sphincterotomy, followed by laparoscopic cholecystectomy in all cases. The nonuse of radiation during ERCP stands out as our major modification of this approach.
PATIENTS AND METHODS From July 2005 to October 2010, seven pregnant women with mild acute biliary pancreatitis and verified or highly suspected choledocholithiasis, were referred to our department. Table 1 shows demographic and history data of these patients. The median maternal age was 29 years (range, 24 to 36 y) and the median length of gestation at the time of admission was 24 weeks (range, 13 to 31 wk). Two patients reported prepartum history of symptomatic gallstone disease and one of them (patient No. 4) during her first pregnancy. Despite her physician’s consult and mainly because of the symptom-free interval, this latter patient did not undergo a scheduled laparoscopic cholecystectomy, as recommended. In all cases liver function tests, serum amylase assays, and a transabdominal ultrasound were already conducted, before the admission to our department. All patients had jaundice and gallbladder stones with dilated common bile duct at ultrasonography. After detailed counseling, an informed consent for MRCP, ERCP, and laparoscopic cholecystectomy was obtained. MRCP with both a thick-collimation single-shot technique and a 3-dimensional thin-collimation technique was performed in all patients. MRCP imaging facilitated the subsequent nonradiation ERCP as a valuable anatomic guide. ERCP was performed with the patient placed in a left lateral to prone position. Moderate conscious sedation was achieved and maintained with intravenous propofol. Bile duct cannulation was attempted using a double lumen sphincterotome with a guidewire. When deep cannulation was achieved the guidewire was withdrawn and the position of the sphincterotome in the bile duct was confirmed by bile aspiration. Endoscopic sphincterotomy was performed and stones were retrieved using a balloon catheter. The length of sphincterotomy was dependent on the diameter of the bile duct and the size of stones depicted at MRCP. The exact number of stones was clarified from the MRCP and the endoscopic procedure was terminated only when all stones were retrieved into the duodenum after numerous passages of the balloon (Fig. 1). The confirmation of the
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TABLE 1. Demographic and History Data of the Patients 1 2 3 4 5 6 7
Maternal Age (y)
Gestational Age (wk)
No. Fetuses
Prepartum Symptomatic Gallstone Disease
No. Prior Births
29 26 36 29 31 24 27
13 24 19 27 17 31 26
Single Single Twins Single Single Single Single
Yes No No Yes No No No
1 2 1 1 2 0 0
successful ERCP was made by the equal number of stones retrieved and stones revealed in the MRCP. All patients underwent a laparoscopic cholecystectomy the following day. A standard 4-trocar laparoscopy was used in all patients and a left lateral recumbent position was utilized. Initial trocar insertion was done exclusively under direct vision (Hassan technique), to avoid uterine injury. Positioning of the initial and subsequent trocars were altered according to gestational age and size of the uterus. Standard inhalation anesthesia was maintained with sevoflurane. Rocuronium was used for muscle relaxation and all patients received fentanyl intraoperatively. Endtidal CO2 was kept between 32 and 36 mm Hg. Pneumoperitoneum pressures were limited within 8 to 10 mm Hg. No intraoperative cholangiography was performed. Perioperative monitoring of fetal heart tone and uterine contractions was done by the gynecologist and tocolytic agents were given routinely in all cases. All the endoscopic interventions and laparoscopic procedures were performed by the same and highly experienced operator (A.P.). Maternal and fetal outcomes were analyzed, with particular attention to post-ERCP and postoperative courses, trimester of pregnancy at the time of treatment, rate of preterm labor, and mode of delivery.
RESULTS Initially, all patients had been treated conservatively for a short period of time (median, 3 d; range, 2 to 5 d) and after stabilization they were referred to our department. In 4 patients, choledocholithiasis at the distal portion of the common bile duct was confirmed on ultrasonography. MRCP confirmed choledocholithiasis in 3 additional pa-
tients. In 2 patients, sonographic evidence of concomitant acute cholecystitis (gallbladder wall thickening, mild pericholecystic oedema) was also identified. The median diameter of the common bile duct was 11 mm (range, 9 to 14 mm). Table 2 summarizes the ultrasonographic and MRCP findings of the series. ERCP, sphincterotomy, and common bile duct clearance were successful in all patients. In 2 patients a precut needle knife sphincterotomy was required to cannulate the common bile duct. The median duration of ERCP was 15 min (range, 9 to 25 min). The median operating time for laparoscopic cholecystectomy was 55 min (range, 40 to 80 min). Neither post-ERCP nor postoperative major complications were noted. Infection of the umbilical trauma was developed in 1 patient, despite standard endobag retrieval of the gallbladder, and was successfully treated by subcutaneous drainage. All but 1 patient reached a healthy natural-term labor. One patient had a cesarean section on 35th week, because of history of insulin-dependent diabetes mellitus and twin carriage. The median length of postoperative stay was 3 days (range, 2 to 5 d).
DISCUSSION Symptomatic gallstone disease is considered as the second most common abdominal emergency in pregnant women with an incidence of 0.05% to 0.8%8,9 and poses a severe clinical problem, as it can put in danger simultaneously more than one human lives. The traditional approach of symptomatic cholelithiasis during pregnancy consisted of nonoperative treatment and postdelivery cholecystectomy.10 This approach has been abandoned early because of the high relapse rates after nonoperative
FIGURE 1. A, Magnetic resonance cholangiopancreatography showing 3 stones at the distal portion of the common bile duct (white arrow). B, After sphincterotomy, 2 stones were removed with a balloon catheter at the first attempt. C, Additional attempts were required for the extraction of the third stone.
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Biliary Pancreatitis and Pregnancy
TABLE 2. Ultrasonographic and MRCP Findings of the Series
1 2 3 4 5 6 7
GB Stones
Acute Cholecystitis
CBD Diameter (mm)
US
US
US
+ + + + + + +
+ +
9 12 10 12 14 10 11
CBD Stones US + + + +
No. Stones
Size of Stones (mm)
MRCP
MRCP
MRCP
+ + + + + + +
1 2 1 3 1 1 2
