A Review Of The Management.pdf

The American Journal of Surgery (2008) 196, 599 – 608

Review

A review of the management of gallstone disease and its complications in pregnancy R.S. Date, M.D., F.R.C.S.a,*, M. Kaushal, F.R.C.S.b, A. Ramesh, F.R.C.S.c a

Department of Gastrointestinal Surgery, Lancashire Teaching Hospital NHS Foundation Trust; bDepartment of Gastrointestinal Surgery, Royal Blackburn Hospital; cDepartment of Gastrointestinal Surgery, South Manchester University Hospital KEYWORDS: Cholecystectomy; Cholecystitis; Endoscopic retrograde cholangiopancreatography; Gall bladder; Pregnancy; Pancreatitis

Abstract BACKGROUND: Symptomatic gallstone disease is the second most common abdominal emergency in pregnant women. There have been significant developments in the management of gallstone disease, but risk to the fetus has prevented their routine application in pregnant women. We reviewed the literature to find the current best evidence for the management of gallstones and its complications in pregnancy. DATA SOURCES: MEDLINE and PubMed literature searches were performed to identify original studies. RESULTS AND CONCLUSIONS: Six studies comparing conservative with surgical management of cholecystitis showed no significant difference in incidence of preterm delivery (3.5% vs 6.0%, P ⫽ .33) or fetal mortality (2.2% vs 1.2%, P ⫽ .57). There was no maternal or fetal mortality in 20 reports of laparoscopic cholecystectomy and 9 reports of endoscopic retrograde cholangiopancreatography, thus indicating their safety when performed with necessary precautions. Laparoscopic cholecystectomy is a safe procedure in all trimesters. In 12 reports of gallstone pancreatitis, fetal mortality was 8.0% versus 2.6% (P ⫽ .28) in conservative and surgical groups, respectively, suggesting the need for earlier surgical intervention. © 2008 Elsevier Inc. All rights reserved.

The most common abdominal emergencies during pregnancy are cholecystitis, acute appendicitis, and intestinal obstruction.1,2 The incidence of gallstone-related diseases complicating pregnancy is .05 to .8%3– 6, and management of these diseases has always been a difficult diagnostic and therapeutic challenge to surgeons. The current literature recommends surgical rather than conservative treatment of acute cholecystitis, within 72 hours of presentation in nonpregnant patients.7,8 The British Society of Gastroenterology guidelines recommend cholecystectomy within 2 weeks of index admission for gallstone * Corresponding author. Tel.: ⫹011-01257 245 267; fax: ⫹011-01257 245 495. E-mail address: [email protected] Manuscript received December 19, 2007; revised manuscript January 19, 2008

0002-9610/$ - see front matter © 2008 Elsevier Inc. All rights reserved. doi:10.1016/j.amjsurg.2008.01.015

pancreatitis.9 However, the potential risk of fetal death from both disease and cholecystectomy make these decisions difficult in pregnant patients. Other perceived anxieties during pregnancy are risk of radiation to the fetus during endoscopic retrograde cholangiopancreatography (ERCP), mechanical and physiologic effects of laparoscopic cholecystectomy (LC) and the risk of anaesthesia, and the effects of magnetic fields on the fetus during magnetic resonance cholangiopancreatography (MRCP). Most literature on this subject is in the form of anecdotal reports. Reviews supporting the feasibility and safety of LC were published toward the end of the 20th century,10,11 but they did not provide any firm guidance on the management of gall bladder disease in general. There have been sporadic reports of MRCP in pregnancy.12,13 There have not been any reviews on ERCP or the management of gallstone pancreatitis.

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Absence of reliable guidelines on this subject prompted us to review the literature to find the current best evidence for the comprehensive management of biliary disease in pregnant women.

Methods Literature search A computerized search was made of the PubMed and MEDLINE databases for the period from January 1966 through October 2007. The Ovid search engine (version 9; Ovid Technologies, New York, New York) was employed. The MESH headings “cholecystitis,” “cholecystectomy,” “obstructive jaundice,” “choledocholithiasis,” “endoscopic retrograde cholangiopancreatography,” “magnetic resonance cholangiopancreatography,” and “pancreatitis” were searched. These searches were combined using the term “OR.” Then Medline Subject Heading “pregnancy” was searched. The 2 searches were then combined using the term “and” (Fig. 1). Abstracts of the articles found were scrutinized to identify the original human studies and also to exclude editorials, review articles, and letters. The full text of each of the human studies was obtained and studied. Manual crossreferencing was then carried out, based on the bibliography of articles identified in the original searches, to ensure

Figure 1

inclusion of all possible studies. Articles were excluded if they were duplicate studies on the same patient group. The literature was considered under the following headings (some overlap is inevitable because of the wide spectrum of presentation of gallstones): 1. Management of symptomatic cholelithiasis: surgical versus conservative management 2. Management of choledocholithiasis: MRCP, ERCP, intraoperative cholangiogram (IOC), and common bile duct (CBD) exploration 3. Management of acute pancreatitis (AP) 4. Surgery for gallstone disease (comparison of open versus laparoscopic cholecystectomy, LC)

Statistical analyses Throughout the report, “n” refers to the number of patients. Statistical analyses were carried out using the SPSS software package (version 11.5; SPSS, Chicago IL). Pearson’s chisquare test was used to compare proportions in the 2 groups.

Results Management of symptomatic cholelithiasis The literature on cholelithiasis and pregnancy is broadly divided into the prelaparoscopic cholecystectomy era and

Summary of literature search.

601

0 1 2 5/2/2* 3/14/1 4/3/2 4/5/? NA NA AC ⫽ acute cholecystitis; BC ⫽ biliary colic; GSP ⫽ gallstone pancreatitis. *Ten patients were postpartum.

19ⴱ 18 9 0 5/1/0 NA 0 2 NA 26 44 30

7 26 21

Indication BC/AC/GSP Patients (n)

Hiatt et al.15 Dixon et al.14 Landers et al.16

Conservative management

Patients (n) Patients (total n)

Table 1

There were 6 reports of 310 patients comparing conservative with surgical management.2,11,17–20(Table 2) All of the patients were initially treated conservatively. No maternal mortality was reported in either group. In patients treated conservatively, readmission rate was 38% to 70%.19,20 Swisher et al20 reported an average of 2 to 6 relapses during pregnancy; Elamin et al17 reported an average of 4 ⫾ 1.3 admissions for relapse; and Lu et al17 reported 1 to 3 additional admissions, each lasting 5 to 8 days.19 Each subsequent relapse was more severe than the previous one.19 Eighty-three (27%) patients had to undergo surgery due to the failure of conservative treatment (Table 2). Glasgow et al reported an increasing trend toward surgical management after the introduction of LC.18 In this series, 2 of 15 (13%) patients were offered surgery from 1980 through 1990, compared with 15 of 32 (47%) patients from 1991 through 1996, because conservative treatment failed. The incidence of preterm deliveries with conservative management was 8 of 227 (3.5%) patients compared with 5 of 83 (6.0%) patients receiving surgical treatment (P ⫽ .33). Similar figures for fetal mortality were 5 of 227 (2.2%) and 1 of 83 (1.2%), respectively (P ⫽ .57).

Gallstone disease and pregnancy in the prelaparoscopic era

Conservative versus surgical treatment

Premature deliveries (n)

Fetal mortality (trimester 1/2/3)

Surgical management

Time of surgery (trimesters 1 through 3)

Premature deliveries (n)

Fetal mortality (trimester 1/2/3)

the post-LC era. The 3 original reports published just before the laparoscopic era can be considered representative of practice at the time14 –16 (Table 1). Two of these case studies, published from Los Angeles, held different views. In a review of 44 patients, Dixon et al14 recommended surgical treatment for patients presenting with biliary symptoms during the second trimester of pregnancy, or even before the planned pregnancy, if symptomatic gallstones were diagnosed in young women. They also recommended a conservative approach during the first and third trimesters of pregnancy. In contrast, continuation of medical management until delivery was recommended in a review of 26 patients by Hiatt et al15 because there was high fetal mortality in the surgical group. The investigators stated, however, that should surgery become necessary, it should be done during the second trimester. Another study of 9 patients published at approximately the same time reported high fetal loss (5 of 9 pregnancies).16 These articles highlight some interesting facts regarding medical practice in that era. Five of 46 (11%) patients in these 3 studies were found to have unsuspected pregnancy after undergoing cholecystectomy. Three of 7 patients presenting with biliary symptoms during the first trimester requested therapeutic abortion because they had been exposed to radiation during the investigation.16 Because there were significant changes in medical practice when these studies were performed and reports written, the prelaparoscopic literature should be viewed with caution. The safety of surgical intervention during the second trimester, however, is reflected even in the prelaparoscopic literature.

5/1/0 3/0/0 3/0/1

Review of gallstone disease management

Investigators

R.S. Date et al.

The American Journal of Surgery, Vol 196, No 4, October 2008 The study by Elamin et al17 stands out from the others because of the high frequency (.33%) of acute cholecystitis during pregnancy. This was thought to be caused by the high prevalence of gallstones, early marriage, and repeat pregnancies in the community. The investigators also reported a high incidence of preterm delivery (n ⫽ 9), abortion (n ⫽ 5), and fetal deaths (n ⫽ 2) in their study of 49 patients. Apart from this report, there were 2 preterm deliveries each in the surgical and conservative groups. Both preterm deliveries in the surgical group appeared to be unrelated to surgery. One patient had twins who were delivered in week 30 (20 weeks after LC),20 and the other patient delivered in week 35 (25 weeks after LC).18 The only fetal death apart from that in Elamin’s study was reported by Lu et al,19 and this was not related to gallstone disease.

0 0/0/1 0 0 0 0 1 b

Laparoscopic ⫽ 3/11/0; open ⫽ 0/2/1. no data available for indication in 5 patients. c indications for surgery were refractory pain, deteriorating clinical status, or presentation during the second trimester. d twin pregnancy; death from unknown etiology.

Management of choledocholithiasis

a

1 3 0 1 0 0 5 3/13/1a NA 2/10/4 5/11/0 0/8/1 0/8/2 10/50/8 47 49 42 72 37 63 310 Glasgow18 Elamin17 Daradkeh2 Swisher20 Sungler11 Lu19 Total

30 34 26 56 28 53 227

0 6 0 0 0 2 8

0 0/0/4 0 0 0 0/1/0d 5

17 15 16 16 9 10 83

10/6/1 0/15/0 13/3/0 3/4/4b 5/2/2 NA/NA/2c 31/38/9

Premature deliveries (n) Time of surgery (trimester 1/2/3) Indication BC/AC/GSP No. of patients Premature deliveries (n)

Conservative management

Patients (n) Patients (total n) Investigators

Table 2

Trial of conservative versus surgical treatment

Fetal mortality (trimester 1/2/3)

Surgical management

Fetal mortality (trimester 1/2/3)

602

Ductal stones may pose a risk to both fetus and mother by causing obstructive jaundice, cholangitis, or pancreatitis. There is also the risk of exposure to ionizing radiation and to magnetic fields during ERCP, IOC, and MRCP. Until recently, ERCP was contraindicated in pregnancy. It was thought that ionizing radiation would cause birth defects or even loss of the fetus. Since the early 1990s, there have been 9 reports on ERCP in pregnancy, all of which showed that there is no serious harm to mother or fetus (Table 3). The amount of radiation used during ERCP was 18 to 310 mrad,21–23 which is lower than the harmful dose of 5 to 10 rad, which is the dose at which fetal damage is known to occur. Radiation risk is greatest during the first trimester. Some endoscopists have reported undertaking ERCP without fluoroscopy in pregnant women to minimize radiation risk.24,25 The other main risk during ERCP is maternal pancreatitis. The cumulative incidence of pancreatitis in these studies was 5 of 104 (4.8%).22,23,26 –28 All cases of pancreatitis were mild and self-limiting. Other complications noted were bleeding (n ⫽ 2) and pre-eclampsia (n ⫽ 2). There were 4 published case reports of MRCP in pregnant women for stones and cancer.12,13,29,30 No maternal or fetal morbidity or mortality was noted in these reports. IOC with LC was described in 8 reports.6,19,31–36 IOC was used frequently, along with cholecystectomy, until the early 1990s. However, recent literature recommends the use of IOC only in the presence of choledocholithiasis and during exploration of CBD.33 Morrell et al and Cosenza et al recommended use of a shield to cover the fetus.31,34 Glasgow et al18 did not use IOC but described the use of laparoscopic ultrasound (US) scan in 6 patients to exclude retained CBD stones.18 From these reports, it is clear that there was no maternal morbidity or mortality. However, 1 spontaneous abortion was reported.32 Six cases of laparoscopic13,18,37–39 and 20 cases of open6,19,20,31,40 CBD exploration were described in the

R.S. Date et al. Table 3

Review of gallstone disease management

603

ERCP during pregnancy

Investigators 28

Patients (n)

ERCP (n)

ECRP timing (trimester 1/2/3)

Indication C/GSP/OJ/other

EBS

Jamidar Farca21 Barthel26 Sungler11 Howden63 Tham23 Simmons25 Kahaleh22

23 10 3 5 21 15 6 17

29 11 3 5 22 15 6 17

15/8/6 3/5/2 NA 0/4/1 5/11/6 1/5/9 3/1/2 4/9/4

0/2/3/0 0/7/6/8 0/6/2/7 5/1/0/0 2/10/0/5

15# 1 3 5 17 6# 6 17

Gupta27

18

18

4/6/8

3/1/0/14

17

118

126

35/49/38

10/30/29/46

87

Total

0/1/18/4 0/2/0/8

Average radiation dose (mrad)

Maternal morbidity (n)

Fetal morbidity (n)

Fetal mortality

1 pancreatitis 0 1 pancreatitis 0 N/A 1 pancreatitis 0 1 bleeding 1 pancreatitis 2 pre-eclampsia 1 pancreatitis 1 bleeding

1^ 0 0 0 1^ 0 1 2^

2† 0 0 0 0 0 1 0

NA 18 NA

1^

0

NA

6

3

205 310 0 40

C ⫽ cholangitis; EBS ⫽ endoscopic biliary sphincterotomy; OJ ⫽ obstructive jaundice. #Biliary stent inserted in 1 patient. ^preterm delivery. †one infant death, 1 abortion, and 2 additional elective abortions.

literature. There was no maternal or fetal morbidity or mortality.

Management of gallstone pancreatitis during pregnancy AP in pregnancy has attracted attention since the early part of the 20th century, suggesting a specific association between the 2 conditions.41 In 1973, Wilkinson42 reviewed 98 cases of AP during pregnancy and reported a further 8 new cases. In these 98 cases, maternal outcome was recorded in 81 women, of whom 30 (37%) died. This mortality rate is much higher than that associated with pancreatitis in the modern era (10%).9 A total of 12 case studies has been published since then (including this report) reporting a total of 212 patients. Forty-one patients had AP during the postpartum period. Of the remaining 171 patients, 113 had confirmed gallstone-induced AP (Table 4). For the purpose of this review, we analyzed this group of 113 cases. Seventy five (66.3%) patients were managed conservatively, and 38 (33.7%) underwent surgery (Table 5). Two patients underwent drainage of pancreatic abscess, and the remainder underwent cholecystectomy. The indication for cholecystectomy was failure to respond to conservative management or recurrent disease in 21 (55.2%) patients, and 15 (39.5%) patients underwent planned surgery to prevent recurrence. One patient underwent cholecystectomy and CBD exploration for a presentation of gallstone pancreatitis (GSP) and obstructive jaundice.19 There was no maternal mortality in either the surgical group or the conservatively treated group. Morbidity in surgical group included prolonged parenteral nutrition in 1 patient because of intolerance to oral fluids after LC19 and splenic hematoma in 1 patient, who

was treated conservatively.43 There were 6 premature deliveries in these studies, including 3 low birth–weight babies. Overall fetal mortality was 8 (7.07%): 6 in the conservatively managed group and 2 in the surgical group (P ⫽ .28). Two patients lost fetuses: 1 after LC and the other after drainage of pancreatic abscess.44

Surgery for gallstone disease LC. In the early days, pregnancy was considered to be an absolute contraindication for LC. Subsequently, many case reports were published testifying to the feasibility and safety of the procedure during pregnancy. These reports were reviewed independently by Ghumman et al, Nezhat et al, and Sungler et al, in the late 1990s.10,11,45 The investigators concluded that LC was a safe and effective option for

Table 4

GSP during pregnancy

Investigators 64

Corlett Wilkinson42 Jouppila65 McKay62 Block66 Ramin67 Swisher68 Chen43 Legro69 Cosenza31 Lu19 Robertson44 Total

AP (total n)

AP during pregnancy (n)

GSP (n)

52 8 8 20 21 43 18 8 9 9 12 4 212

43 3 8 7 11 42 18 8 9 9 12 1 171

12 1 5 6 11 28 18 5 5 9 12 1 113

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Table 5

GSP: conservative versus surgical treatment

Cumulative data

Conservative

Operative

Patients (total n) Maternal mortality (n) Maternal morbidity (n) Preterm labor (n) Fetal morbidity (n) Fetal mortality (n)

75 0 1a 18 3c 6

38 0 1b 2 0 1

P

.01 .28

a

Splenic hematoma. b prolonged total parenteral nutrition. c low birth weight.

complicated and nonresolving biliary disease during pregnancy. In our review, case studies reporting ⬍5 LCs in pregnancy were excluded to minimize publication bias. Twenty reports were identified that included a total of 197 patients (Table 6). Two patients requested termination of pregnancy at the time of surgery,46 and there was one fetal death unrelated to surgery.47 No maternal deaths attributable to LC. Most investigators used the open technique for insertion of the first port. The Verres needle was used in the

Table 6

left upper quadrant by Upadhyay et al and by Geisler et al in 10 and 6 patients, respectively.33,48 Buser49 reported perforation of the uterus during the third trimester, which was caused by manipulation of a blunt 10-mm canula while attempting to insert a telescope. LC was completed, and the patient subsequently underwent uneventful Cesarean section. Open cholecystectomy versus LC. Four retrospective reports comparing open cholecystectomy (OC) versus LC were identified (Table 7). These studies did not show any significant difference in maternal and fetal outcome. There were 6 of 89 (6.74%) preterm deliveries in the LC group compared with 2 of 69 (2.90%) in the open-surgery group (P ⫽ .27). One fetal death occurred in the LC group compared with 2 in the open-surgery group (P ⫽ .41). The fetal death reported by Cosenza et al occurred on postsurgical day 6. This woman underwent LC converted to OC for gallstone-induced pancreatitis in the 14th week of gestation. In a report by Barone et al, a 27-year-old woman died from postsurgical hemorrhage after undergoing LC in the 20th week of gestation. The source of bleeding was not identified. The other fetal death in this series occurred 4 weeks

LC case series

Investigators

Patients (n)

IOC

Morrell34 McKellar6 Soper70 Elerding35 Lanzafame71 Steinbrook72 Reyes-Tineo36 Abuabara73 Graham46 Geisler48 Gouldman74 Muench75 Patel32 Buser49 Rizzo76 Rollins47 Daradkeh77 Halkic78 Palanivelu79 Upadhyay33 Total

5 9 5 5 5 10 5 22 6 6 8 16 10 (2 open) 10 5 31 20 5 9 5 195

5 3 5

Time of surgery (trimester 1/2/3) 0/3/2 2/4/3 0/5/0 1/3/1 0/3/2 3/6/1

1

2

1 17

2/16/4 2/4/0 0/4/2 1/7/0 3/11/2 3/6/1 2/4/4 2/2/1 3/19/9 4/11/5 NA 0/9/0 0/0/5 28/117/42

PTD ⫽ preterm delivery. a Three patients were lost to follow-up. b two patients had choledocholithiasis. c includes 2 transcystic CBD explorations. d unrelated to gallstones. e voluntary termination. f one patient had empyema. g one patient failed to gain weight.

Indication BC/AC/CC/GSP

Mean surgical time (min)

Abdominal pressure

0/5/0/0 NA 5/0/0/0 0/3/2/0 3/1/0/1 0/8/2/0 0/1/0/4 0/17/3//0b 3/3/0/0 NA 0/2/4/2 7/3/0/6 0/0/10/0 0/10/0/0 2/3/0/0 NA

NA NA 51 NA 69 NA

NA NA ⬍12 15 ⬍15 12–15

59c NA 59 67 NA NA NA 61.2

10–14 15 15 12 12–15 NA NA 10 13

75 45.2 NA 60.8

NA NA 12 10–15

0/5/0/0 0/8/0/0f 1/3/0/0g 21/72/21/13

PTD

Fetal mortality (trimester 1/2/3)

Maternal mortality (n)

0 0 0 0 0 0 0 1d 0 0 0 0 0 1 0 2 0 0 0 0 4

0 0 0 0 0 0a 0 0 2e 0 0 0 0 0 0 1d 0 0 0 0 3

0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0 0

R.S. Date et al. Table 7

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605

LC versus OC LC

Investigators

Patients (n)

Curet40 Barone60 Cosenza31 Affleck55 Total

12 20 12 45 89

OC EGA at surgery (wk) ⬍28 18.4 20.5 21 ⫾ 6.9

PTD

Fetal death (n)

Conversion from laparotomy (n)

EGA at surgery (wk)

0 1 0 5 6

0 1 0 0 1

10 26 20 (2) 13 (2) 69

⬍28 24.8 21 NA

PTD

Fetal death (n)

0 0 1 1 2

0 1 1 0 2

EGA ⫽ estimated gestational age; NA ⫽ not available; PTD ⫽ preterm delivery.

after surgery after the mother underwent OC in the 16th week of gestation. Laparoscopic surgery was compared with open surgery in pregnancy in 3 other studies. LC and OC formed the part of respective cohort, but they were not discussed separately in these articles. A large population study based on the Swedish Health Registry evaluated laparoscopic cases (including cholecystectomies) from 2 million deliveries in Sweden during a 2-decade time frame (1973 to 1993).50 They compared 5 fetal outcome parameters in pregnant patients undergoing laparotomy (n ⫽ 2,491) with those in pregnant patients undergoing laparoscopy (n ⫽ 2,233). They also compared the same outcome parameters in pregnant women undergoing surgery with the total population. There was no difference in fetal outcome parameters between the laparoscopy and laparotomy groups in singleton pregnancies between 4 and 20 weeks of gestation. The study suggested the following increased risks, relative to the total population, for infants in both the laparoscopy and laparotomy groups: weight ⬍2,500 g, delivery at ⬍37 weeks, and having increased incidence of growth restriction. It is not clear whether this increased risk is related to the disease process itself or to the surgery. The results of this large study are limited by the absence of disease-specific subgroup analysis. Two further case studies were reported by Amos et al (n ⫽ 7 vs 5) and Conron et al (n ⫽ 2 vs 9) comparing laparoscopic surgery (cholecystectomy, appendectomy, and diagnostic laparoscopy) with open surgery.51,52 Data on individual sugeries are lacking in the report by Conron. In this study, laparoscopic surgery was performed earlier during pregnancy compared with open surgery (12 weeks vs 29 weeks, P ⫽ .001). There was 1 miscarriage 7 days after LC. The investigators concluded that laparoscopic surgery does not show higher fetal loss compared with open surgery. Contrary to this, Amos et al51 reported 4 fetal deaths occurring after laparoscopic surgery. Four patients in the laparoscopic group in this study were at increased risk of fetal loss from their diseases (three GSP and 1 perforated appendix). Three of these resulted in fetal death. It is difficult to say whether the fetal deaths were caused by the disease process or the surgery.

Comments The spectrum of gallstone disease ranges from biliary colic to life-threatening pancreatitis; therefore, management must be tailored to the patient according to her presentation. The first available large study on pregnancy-related gall bladder disease was published in 1963, and in this series of 17 patients, Greene et al53 noted fetal loss of 24% (4 of 17). Although a number of reports have been published since then, the dilemma still remains whether or not to treat these patients conservatively. Risks of conservative treatment of cholecystitis include risk to the fetus due to recurrent episodes, other complications of gallstones, and risk of malnutrition caused by lack of oral intake. In contrast, surgical treatment carries risk to the fetus from surgery and anaesthesia and risks specific to laparoscopic surgery. In our review, it was evident that 27% of the patients failed to respond to conservative management. Although this group of patients should have been expected to have more severe disease than those who responded to conservative management, there was no difference in morbidity and mortality in the 2 groups. Surgical intervention, if necessary, is best deferred until the second trimester when fetal risk is at its lowest.54 The historic reasons for carrying out a surgery at this time include the fact that organogenesis is complete and the uterus is not big enough to obliterate the surgical view. However, equally good results have been noted during other trimesters as well.55–59 On the basis of 4 retrospective studies comparing LC with OC, it is difficult to recommend any particular treatment because these studies did not specifically look at the physiologic effects of pneumoperitoneum or CO2- induced acidosis on the fetus during LC or the effects of uterine manipulation during OC.31,40,55,60 LC in pregnant women provides all of the advantages of laparoscopic surgery–such as significantly reduced hospitalization, decreased narcotic use, and quick return to a regular diet– compared with open laparotomy in pregnant women.40 Other advantages of LC include less manipulation of the uterus and detection of other pathology that may be present.55 It also decreases the possibility of postoperative

606 deep vein thrombosis because improved early mobility can be promoted in such patients. Bile duct stones pose diagnostic as well as therapeutic dilemmas during pregnancy. Diagnostic modalities, such as ERCP and MRCP, are not without risk. The data showed that ERCP in pregnancy is reasonably safe if the radiation dose is kept to a minimum. The incidence of maternal pancreatitis and other complications occurring after ERCP is low. The literature also suggested that the procedure should only be performed by an experienced endoscopist, and the fetus should be shielded at all times. Even though there is paucity of data on the safety of MRCP, an inference can be extrapolated from the experience of MRI during pregnancy. The American College of Radiologists’ guidelines recommend cautious use of MRI during pregnancy when the benefits outweigh the risks.61 With the advent of ERCP and MRCP, the need for IOC is minimal, although specialized units use it routinely for demonstrating the anatomy of the biliary tree. There have been no reports investigating the safety of IOC during pregnancy. In the absence of clear evidence, potential risks should be discussed with the patient. Laparoscopic US scan appears to be an attractive alternative to IOC to detect retained CBD stones, but experience of this technique is limited to specialized units.18 There have been few reported cases of CBD exploration during pregnancy. There was no significant morbidity or mortality during such, although there could have been publication bias in reporting. It appears from the available literature that the management of CBD stones in pregnancy is similar to that in the nonpregnant population. Pancreatitis during pregnancy was thought to be idiopathic in origin, and hyperlipidemia has been widely reported as a cause of AP.41 However, the advent of the US scanning has confirmed that the majority of cases are caused by gallstones.62 The initial management of AP during pregnancy during pregnancy is similar to management in the general population. The subsequent management of severe AP is somewhat less controversial because maternal safety is of paramount importance, and fetal outcome becomes a secondary concern. However, controversy exists about the treatment of mild to moderate pancreatitis during pregnancy regarding early elective cholecystectomy after index admission (British Society of Gastroenterology guidelines).9 When cholecystectomy is deferred until after delivery, nearly 60% of patients develop recurrence during the same pregnancy, which significantly increases morbidity, frequency, and length of hospitalization.20 There is also an increased risk of fetal loss, although this is not statistically significant. GSP also increases the risk of prematurity and babies born with low birth weight. To summarize: 1. A quarter of pregnant patients with cholecystitis fail to respond to conservative treatment.

The American Journal of Surgery, Vol 196, No 4, October 2008 2. The results of conservative and surgical management of cholecystitis are similar in terms of maternal and fetal morbidity and mortality. 3. Although there is no difference between laparoscopic cholecystectomy and OC, LC might be the preferred option because of its inherent advantages. 4. LC appears to be a safe procedure during all trimesters but is best carried out during the second trimester. 5. It may be advisable for women with symptomatic gallstones to undergo cholecystectomy before planning pregnancy. 6. Although generally considered safe, there are no clear guidelines for the use of MRCP during pregnancy. 7. ERCP is a safe intervention in patients with symptomatic choledocholithiasis if necessary precautions are taken. 8. LC should be offered to the patients with mild to moderate GSP according to guidelines for nonpregnant patients. The following precautions should be exercised during LC: 1. Use open technique for insertion of the umbilical port. 2. Avoid high intraperitoneal pressures. 3. Use the left lateral position to minimize aortocaval compression. 4. Avoid rapid changes in the position of the patient. 5. Take care to use electrocautery cautiously and away from uterus. It must be realized that there are no randomised controlled trials to support the recommendations in this review. It is unlikely that such trials could be performed in the near future because of the ethical issues involved. It is also difficult to accumulate a sufficient number of cases from a single institution. Under the circumstances, the recommendations must be based on the currently available literature, and their limitations should be appreciated. It is worth noting that overall morbidity and mortality is minimal in the published literature; however, this may be due to publication bias. We recommend the development of a central database at the regional or national level to improve the reporting of cases and to avoid publication bias.

References 1. Kammerer WS. Nonobstetric surgery during pregnancy. Med Clin North Am 1979;63:1157– 64. 2. Daradkeh S, Sumrein I, Daoud F, et al. Management of gallbladder stones during pregnancy: conservative treatment or laparoscopic cholecystectomy? Hepatogastroenterology 1999;46:3074 – 6. 3. Gurbuz AT, Peetz ME. The acute abdomen in the pregnant patient. Is there a role for laparoscopy? Surg Endosc 1997;11:98 –102. 4. Jamal A, Gorski TF, Nguyen HQ, et al. Laparoscopic cholecystectomy during pregnancy. Surg Rounds 1997;20:408 –15. 5. Ko CW. Risk factors for gallstone-related hospitalization during pregnancy and the postpartum. Am J Gastroenterol 2006;101:2263– 8.

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