Acute cholecystitis with calculous biliary duct obstruction in the gravid patient. Management by ERCP, papillotomy, stone extraction, and laparoscopic cholecystectomy

Pancreatitis in pregnancy

OBJECTIVE

To estimate the incidence, cause, and complications of pancreatitis in pregnancy and to identify factors associated with adverse outcomes.

METHODS

This study was a chart review of all pregnant patients diagnosed with pancreatitis from 1992-2001 at 15 participating hospitals. Information was collected on presentation, management, and outcome, along with the number of deliveries at each hospital.

RESULTS

During the 10 years of the study, 101 cases of pancreatitis occurred among 305,101 deliveries, yielding an incidence of one in 3,021 (.03%). There were no maternal deaths; perinatal mortality was 3.6%. Eighty-nine women had acute pancreatitis, and 12 women had chronic pancreatitis. The majority (66%) of cases of acute pancreatitis were biliary in origin, and they were associated with better outcomes than nonbiliary causes. Cases of gallstone pancreatitis that received surgical or endoscopic intervention during pregnancy had lower rates of preterm delivery and recurrence than those that were conservatively managed, but this difference was not significant (P=.2). Alcohol was responsible for 12.3% of acute pancreatitis cases and 58% of chronic pancreatitis cases and was associated with increased rates of recurrence and preterm delivery. A calcium level, triglycerides, or both was not obtained in half of cases identified as idiopathic.

CONCLUSION

Pancreatitis is a rare event in pregnancy, occurring in approximately 3 in 10,000 pregnancies. Although it is most often acute and related to gallstones, nonbiliary causes should be sought because they are associated with worse outcomes.

LEVEL OF EVIDENCE

III.

Management of biliary tract disease during pregnancy: a decision analysis

BACKGROUND

The appropriate management of biliary tract disease during pregnancy is uncertain. Although laparoscopic cholecystectomy can be performed safely during pregnancy, the timing and indications for this surgical intervention have not been firmly established.

METHODS

We constructed a Markov decision analytic model that incorporates maternal well-being and fetal outcome into a choice between nonoperative management (NM) and laparoscopic cholecystectomy (LC) for pregnant women with biliary tract disease (BTD). Our model cycles through weeks of pregnancy for a cohort of 200 gravid women presenting with biliary tract disease in both the first and second trimesters. Weekly state probabilities and utilities for fetal outcome were derived from the literature, while weekly utilities for disease and operative states were estimated in consultation with obstetricians. We cycled the model from 6 to 42 weeks and from 19 to 42 weeks to simulate first and second trimester presentations. Outcomes are expressed in quality pregnancy weeks (QPWs). One QPW is the utility of a normal healthy week of pregnancy.

RESULTS

A comprehensive search of the literature yielded a fetal death rate following LC for biliary tract disease of 2.2% and following NM of 7%. Relapse rates were found to be trimester dependent and estimated to be 55%, 55%, and 40% in the first, second, and third trimester, respectively. For a hypothetical cohort of 100 women presenting with biliary tract disease in their first trimester, LC generated 12,800 QPWs compared with 12,400 QPWs for NM, an average gain of 4 QPWs per woman. For the cohort of women entering the model in the second trimester, 11,600 QPWs were accrued by the LC group and 11,400 QPWs by the NM group, an average gain of 2 QPWs per woman. These findings were sensitive only to changes in fetal death rates under the two treatment arms.

CONCLUSIONS

Laparoscopic cholecystectomy is superior to nonoperative management for pregnant women presenting in the first or second trimester with biliary tract disease.

Laparoscopic management of appendicitis and symptomatic cholelithiasis during pregnancy

BACKGROUND

Laparoscopic surgery during pregnancy is a challenging procedure that most surgeons are reluctant to perform. The objective of this study was to evaluate whether laparoscopic appendectomy and cholecystectomy is safe in pregnant women. The management of these situations remains controversial. We report a single center study describing the successful management of 16 patients during pregnancy.

METHODS

More than 3,356 laparoscopic procedures were performed in our institutions between May 1990 and June 2005. Sixteen of these patients were operated on in the second and third trimester between 22 and 32 weeks of estimated gestational age. We performed 11 laparoscopic appendectomies and 5 laparoscopic cholecystectomies. We also reviewed the management and operative technique used in these patients.

RESULTS

In this study, the laparoscopic appendectomy or cholecystectomy was performed successfully in all patients. Three patients were in their second trimester, weeks 22, 23, and 25, and 13 were in the third trimester, weeks 27 (three patients), 28 (five patients), 31 (three patients), and 32 (two patients). No maternal or fetal morbidity occurred. Open laparoscopy was performed safely in all patients and all patients delivered healthy babies.

CONCLUSION

From our experience laparoscopic management of appendicitis and biliary colic during pregnancy is safe, however the second trimester is preferable for laparoscopic cholecystectomy. Pregnancy is not a contraindication to the laparoscopic approach to appendicitis or symptomatic cholelithiasis. We believe that laparoscopic operations, when performed by experienced surgeons, are safe and even preferable for the mother and the fetus.

Laparoscopic cholecystectomy in the new millennium

BACKGROUND

Laparoscopic cholecystectomy has become the gold standard for the treatment of symptomatic cholelithiasis. Many authors-including investigators at our institution, who reported one of the initial experiences with laparoscopic cholecystectomy in July 1992-have documented a definite learning curve associated with this procedure. We present a follow-up study of our experience with laparoscopic cholecystectomy and compare these data to an earlier study of the initial experience with laparoscopic cholecystectomy at the Beth Israel Medical Center.

METHODS

We retrospectively reviewed 300 consecutive patients from March 1998 through March 1999. The patient population was epidemiologically similar to that of the original study with regard to age, sex, and American Society of Anesthesia (ASA) classification. However, whereas the initial population included only patients with chronic disease, in our study 13.7% of the patients had been admitted through the emergency room with acute stone disease of the biliary tract.

RESULTS

We found a 5.7% conversion rate, a 1% rate of major complication, and a 5.7% rate of minor complication rates, as compared to the initial study's rates of 12%, 4%, and 10%, respectively. Whereas none of the patients in the original study left the hospital on the day of surgery and only 49% were discharged within 1 day, in our group, 29 patients (10%) underwent ambulatory procedures and an additional 186 patients (62%) were discharged on the 1st post-operative day. The average duration of the operation was 90 min, which did not represent a statistical improvement over the time of 93 min reported in the earlier study.

CONCLUSIONS

Since 1992, both the conversion rate and length of stay have declined at our hospital, but operative time has remained essentially the same. These findings probably reflect a bimodal learning curve, the increase in the number of cholangiograms and additional intraoperative procedures now performed, the greater severity of gallbladder disease currently treated with laparoscopic cholecystectomy, and increases in the number of attending physicians as well as the level of residents who perform this procedure.