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Kumar SS, Collings AT, Wunker C, Athanasiadis DI, DeLong CG, Hong JS, Ansari MT, Abou-Setta A, Oliver E, Berghella V, Alli V, Hassan I, Hollands C, Sylla P, Slater BJ, Palazzo F. SAGES guidelines for the use of laparoscopy during pregnancy. Surg Endosc 2024; 38:2947-2963. [PMID: 38700549 PMCID: PMC11133165 DOI: 10.1007/s00464-024-10810-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 03/21/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND When pregnant patients present with nonobstetric pathology, the physicians caring for them may be uncertain about the optimal management strategy. The aim of this guideline is to develop evidence-based recommendations for pregnant patients presenting with common surgical pathologies including appendicitis, biliary disease, and inflammatory bowel disease (IBD). METHODS The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Guidelines Committee convened a working group to address these issues. The group generated five key questions and completed a systematic review and meta-analysis of the literature. An expert panel then met to form evidence-based recommendations according to the Grading of Recommendations Assessment, Development, and Evaluation approach. Expert opinion was utilized when the available evidence was deemed insufficient. RESULTS The expert panel agreed on ten recommendations addressing the management of appendicitis, biliary disease, and IBD during pregnancy. CONCLUSIONS Conditional recommendations were made in favor of appendectomy over nonoperative treatment of appendicitis, laparoscopic appendectomy over open appendectomy, and laparoscopic cholecystectomy over nonoperative treatment of biliary disease and acute cholecystitis specifically. Based on expert opinion, the panel also suggested either operative or nonoperative treatment of biliary diseases other than acute cholecystitis in the third trimester, endoscopic retrograde cholangiopancreatography rather than common bile duct exploration for symptomatic choledocholithiasis, applying the same criteria for emergent surgical intervention in pregnant and non-pregnant IBD patients, utilizing an open rather than minimally invasive approach for pregnant patients requiring emergent surgical treatment of IBD, and managing pregnant patients with active IBD flares in a multidisciplinary fashion at centers with IBD expertise.
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Affiliation(s)
- Sunjay S Kumar
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amelia T Collings
- Hiram C. Polk, Jr Department of Surgery, University of Louisville, Louisville, KY, USA
| | - Claire Wunker
- Department of Surgery, Saint Louis University, Saint Louis, MO, USA
| | | | - Colin G DeLong
- Department of Surgery, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Julie S Hong
- Department of Surgery, NewYork-Presbyterian Queens, New York, NY, USA
| | - Mohammed T Ansari
- School of Epidemiology and Public Health, Faculty of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Ahmed Abou-Setta
- Centre for Healthcare Innovation, University of Manitoba, Winnipeg, MB, Canada
| | - Emily Oliver
- Department of Obstetrics, Gynecology and Reproductive Sciences, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Vincenzo Berghella
- Department of Obstetrics & Gynecology, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Vamsi Alli
- Department of Surgery, Pennsylvania State University College of Medicine, Hershey, PA, USA
| | - Imran Hassan
- Department of Surgery, Mercy Medical Center Cedar Rapids, Cedar Rapids, IA, USA
| | - Celeste Hollands
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Patricia Sylla
- Division of Colon and Rectal Surgery, Mount Sinai Health System, New York, NY, USA
| | - Bethany J Slater
- Department of Surgery, University of Chicago Medicine, Chicago, IL, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
- Thomas Jefferson University, 1100 Walnut Street, Suite 500, Philadelphia, PA, 19107, USA.
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Ridtitid W, Rerknimitr R, Ramchandani M, Lakhtakia S, Shah RJ, Shah JN, Thosani N, Goenka MK, Costamagna G, Wagh MS, Perri V, Peetermans J, Goswamy PG, Liu Z, Yin S, Banerjee S. Endoscopic clearance of non-complex biliary stones using fluoroscopy-free direct solitary cholangioscopy: Initial multicenter experience. DEN OPEN 2024; 4:e241. [PMID: 37273518 PMCID: PMC10235796 DOI: 10.1002/deo2.241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 06/06/2023]
Abstract
Background and Aims Fluoroscopy-free endoscopic retrograde cholangiopancreatography for common bile duct stone (CBDS) clearance is usually offered only to pregnant patients. We initiated a multicenter, randomized controlled trial comparing clearance of non-complex CBDSs using fluoroscopy-free direct solitary cholangioscopy (DSC) to standard endoscopic retrograde cholangiography (ERC) to evaluate the wider applicability of the DSC-based approach. Here we report the initial results of stone clearance and safety in roll-in cases for the randomized controlled trial. Methods Twelve expert endoscopists at tertiary care centers in four countries prospectively enrolled 47 patients with non-complex CBDSs for DSC-assisted CBDS removal in an index procedure including fluoroscopy-free cannulation. Successful CBDS clearance was first determined by DSC and subsequently validated by final occlusion cholangiogram as the ERC gold standard. Results Fully fluoroscopy-free cannulation was successful in 42/47 (89.4%) patients. Brief fluoroscopy with minimal contrast injection was used in 4/47 (8.5%) patients during cannulation. Cannulation failed in 1/47 (2.1%) patients. Fluoroscopy-free complete stone clearance was reached in 38/46 (82.6%) cases. Residual stones were detected in the validation ERC occlusion cholangiogram in three cases. Overall serious adverse event rate was 2.1% (95% confidence interval 0.1-11.3): postprocedural pancreatitis in one patient. Conclusions In patients with non-complex CBDS, the fluoroscopy-free technique is easily transferred to endoscopic retrograde cholangiopancreatography experts with acceptable rates of cannulation and stone clearance and few serious adverse events. (ClinicalTrials.gov number, NCT03421340).
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Affiliation(s)
- Wiriyaporn Ridtitid
- Department of Medicine, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial HospitalThai Red Cross SocietyBangkokThailand
| | - Rungsun Rerknimitr
- Department of Medicine, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial HospitalThai Red Cross SocietyBangkokThailand
| | | | | | - Raj J Shah
- Division of Gastroenterology and HepatologyUniversity of Colorado HospitalAuroraUSA
| | - Janak N Shah
- Division of GastroenterologyOchsner Clinic FoundationNew OrleansUSA
| | - Nirav Thosani
- Ertan Digestive Disease Center‐Texas Medical CenterHoustonUSA
| | - Mahesh K Goenka
- Institute of Gastrosciences and LiverApollo Multispeciality HospitalsKolkataIndia
| | - Guido Costamagna
- Digestive Endoscopy UnitDepartment of Translational Medicine and SurgeryFondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | - Mihir S Wagh
- Division of Gastroenterology and HepatologyUniversity of Colorado HospitalAuroraUSA
| | - Vincenzo Perri
- Digestive Endoscopy UnitDepartment of Translational Medicine and SurgeryFondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | | | | | - Zoe Liu
- Boston Scientific CorporationMarlboroughUSA
| | - Srey Yin
- Boston Scientific CorporationMarlboroughUSA
| | - Subhas Banerjee
- Division of Gastroenterology and HepatologyStanford UniversityStanfordUSA
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Pal P, Reddy DN, Tandan M. Endoscopy in Pregnancy: A Systematic Review. JOURNAL OF DIGESTIVE ENDOSCOPY 2021. [DOI: 10.1055/s-0041-1739567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
Abstract
Abstract
Background Fetomaternal outcomes are of primary concern for gastrointestinal (GI) endoscopy in pregnancy. We aimed to systematically review the safety and utility of endoscopic procedures in pregnancy.
Methods A systematic literature search was performed using PubMed. All original research articles with sample size > 10 involving endoscopy in pregnancy were included for the review along with case report/series describing novel/rare techniques from 1948 to July 2021.
Results After screening 12,197 references, 216 citations were found and finally 66 references were included. Esophagogastroduodenoscopy had favorable fetal outcome (>95%) based on two large retrospective studies and a review of case reports. Sclerotherapy and band ligation of varices were safe according to case series. A large nationwide cohort study established safety of endotherapy for nonvariceal bleed. Botulinum toxin and pneumatic dilation in achalasia are only supported by case reports. Percutaneous endoscopic gastrostomy can be useful to support nutrition based on case reports. A retrospective case–control and cohort study with systemic review justified flexible sigmoidoscopy if strongly indicated. Low birth weight was more common when sigmoidoscopy was done in inflammatory bowel disease based on a prospective study. Colonoscopy was considered safe in second trimester based on a case–control study whereas it can be performed otherwise only in presence of strong indication like malignancy. Capsule endoscopy is promising and can be useful in acute small bowel bleeding although risk of capsule retention is unknown. There are no reports of enteroscopy in pregnancy. Twelve retrospective studies and one prospective study showed high success rate of therapeutic endoscopic retrograde cholangiopancreatography (ERCP) (> 90%) in all trimesters and can be performed if strongly indicated. Pregnancy was an independent risk factor for post-ERCP pancreatitis in a large nationwide case–control study. Radiation-free ERCP with wire-guided bile observation, stent-guided or precut sphincterotomy, endoscopic ultrasound (EUS) guidance, and spyscopy have been described. Safety of EUS is limited to case series and can be used in intermediate probability of choledocholithiasis to guide ERCP and endoscopic cystogastrostomy.
Conclusion This review concludes that GI endoscopy during pregnancy can be done effectively if strongly indicated with good fetomaternal outcomes. Precautions are advocated during procedures where radiation exposure is expected.
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Affiliation(s)
- Partha Pal
- Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - D. Nageshwar Reddy
- Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Manu Tandan
- Medical Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
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Zeng W, Hu J, Pan Y, Zhang M, Xu L. Nonradiation-to-endoscopist ERCP is non-inferior to standard ERCP. Surg Endosc 2021; 36:4795-4801. [PMID: 34698935 PMCID: PMC9160145 DOI: 10.1007/s00464-021-08822-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 10/17/2021] [Indexed: 12/04/2022]
Abstract
Background Radiation exposure is inherently involved in endoscopic retrograde cholangiopancreatography (ERCP), which could cause radiation-induced injury to endoscopists with long-term exposure. Nonradiation ERCP has been applied to pregnant patients. Conceivably, the same techniques could be used to benefit endoscopists. This study was designed to evaluate the effectiveness and safety of nonradiation-to-endoscopist (NRE) ERCP, compared with standard ERCP. Methods A retrospective, single-center study was conducted from August 2010 to December 2015. Patients aged 18–90 years and with choledocholithiasis (< 15 mm) or distal biliary stricture were eligible. Pre-ERCP evaluation with magnetic resonance cholangiopancreatography was mandatory. To overcome selection bias, we performed 1:2 match using propensity score matching (PSM) between NRE and standard groups. The primary endpoint was overall ERCP success rate. Secondary endpoints were cannulation success rate, stone clearance rate, complication rate, and duration of hospitalization. Results A total of 329 patients met inclusion criteria. After PSM, 73 patients were included in the NRE group and 146 in the standard group. The ERCP overall success rate for NRE and standard groups was equivalent (94.5% vs. 93.2%, P = 0.70). There was no difference in cannulation success rates between the two groups (95.6% vs. 97.8%, P = 0.39). A total of 88.3% of patients in the NRE group and 93.9% of patients in the standard group had stones cleared at initial ERCP (P = 0.57). No difference in overall stone clearance rate between the two groups (95.0% vs. 93.9%, P = 0.77) was found after second ERCP. The complication rate (1.4% vs. 1.4%, P = 1.00) and hospital duration (8.3 ± 5.1 vs. 10.2 ± 8.8 days, P = 0.07) were not different between the two groups. Conclusion Although technically demanding, NRE-ERCP is both safe and feasible in selected patients compared with standard ERCP.
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Affiliation(s)
- Wei Zeng
- Department of Gastroenterology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 2000 Xiang'an East Road, Xiamen, 361102, Fujian, China
| | - Jie Hu
- Department of Medical Engineering, The 305 Hospital of PLA, Beijing, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Mingqing Zhang
- Department of Gastroenterology, 909 Hospital of PLA, Affiliated Southeast Hospital of Xiamen University, 269 zhanghua middle road, Zhangzhou, 363000, Fujian, China.
| | - Li Xu
- Department of Gastroenterology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 2000 Xiang'an East Road, Xiamen, 361102, Fujian, China.
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Endoscopic retrograde cholangiopancreatography results for the treatment of symptomatic choledocholithiasis in pregnant patients: A recent experience at a secondary care hospital in Mexico City. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2021. [DOI: 10.1016/j.rgmxen.2019.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Bedside Biliary Drainage without Fluoroscopy for Critically Ill Patients. BIOMED RESEARCH INTERNATIONAL 2020; 2020:2850540. [PMID: 32626738 PMCID: PMC7315268 DOI: 10.1155/2020/2850540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Revised: 05/21/2020] [Accepted: 05/25/2020] [Indexed: 12/24/2022]
Abstract
Background Bedside biliary drainage by endoscopic retrograde cholangiopancreatography (ERCP) without fluoroscopy for critically ill patients in the intensive care unit (ICU) remains challenging for endoscopists. The present study was to evaluate the efficacy and safety of radiation-free ERCP for these patients. Methods Consecutive ICU patients with severe pancreaticobiliary disorders who underwent bedside radiation-free ERCP were retrospectively analyzed. Results Radiation-free ERCP was performed in 80 patients with acute physiology and chronic health evaluation (APACHE II) score of 24.1 ± 6.2. Cannulation was achieved in 75 (93.75%) patients. Biliary drainage was successfully conducted in 74 (92.5%) patients, including 54 (67.5%) and 20 (25.0%) cases of endoscopic retrograde biliary drainage (ERBD) and endoscopic nasobiliary drainage (ENBD), respectively. Adverse event (mild post-ERCP pancreatitis (PEP)) occurred only in 1 case. The 30-day mortality rate of these patients was 36.25% (29/80) and was much more higher in patients with ERBD in contrast to that of patients with ENBD, 40.7% (22/54) vs. 20% (4/20), OR = 2.750, 95%CI = 0.810 − 9.3405, P = 0.110. The APACHE II score in nonsurvivors was significantly higher than survivors, 27.6 ± 4.3 versus 22.2 ± 6.3, P = 0.009. The APACHE II score > 22 was an independent risk factor for mortality, 50% versus 10.7%, 95%CI = 2.148 − 31.569, P = 0.002. Conclusions Radiation-free ERCP guided bedside biliary drainage is effective and safe for critically ill patients, and ENBD may be an optimal procedure due to a low mortality in these patients.
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Endoscopic retrograde cholangiopancreatography results for the treatment of symptomatic choledocholithiasis in pregnant patients: A recent experience at a secondary care hospital in Mexico City. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO 2020; 86:21-27. [PMID: 32197919 DOI: 10.1016/j.rgmx.2019.12.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 11/26/2019] [Accepted: 12/10/2019] [Indexed: 01/27/2023]
Abstract
INTRODUCTION Endoscopic retrograde cholangiopancreatography (ERCP) is the treatment of choice for symptomatic choledocholithiasis during pregnancy. In pregnant patients, aside from the risks inherent in the procedure and sedation, there is the added concern of the potentially damaging effects of ionizing radiation on the fetus. AIM To describe the maternal and fetal results of ERCP performed to resolve symptomatic choledocholithiasis in pregnant patients. MATERIALS AND METHODS A retrospective, descriptive, observational, and cross-sectional study was conducted. It included pregnant patients with choledocholithiasis that underwent ERCP within the time frame of June 2017 and June 2018. RESULTS The study included 9 pregnant patients, with a mean gestational age of 24.1 weeks, that underwent ERCP. There were no maternal or fetal complications associated with sedation, mean fluoroscopy time was 26.7seconds, and one patient (11.1%) presented with mild post-ERCP pancreatitis that was resolved through medical management. Pregnancy progression was normal in 100% of the cases, resulting in the birth of neonates with a normal Apgar score, a mean weight of 3,120g, a mean length of 49.94cm, and a mean gestational age of 38.37 weeks. At follow-up at 6 months, the infants had a mean weight of 7.1kg and a mean length of 66.94cm. CONCLUSIONS The results from our hospital center were similar to those described in the international literature, showing that ERCP in our medical environment is a feasible, safe, and efficacious method for both the mother and fetus. When performed by an experienced endoscopist, it should be considered the treatment of choice for choledocholithiasis in pregnant patients.
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Azab M, Bharadwaj S, Jayaraj M, Hong AS, Solaimani P, Mubder M, Yeom H, Yoo JW, Volk ML. Safety of endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy: A systematic review and meta-analysis. Saudi J Gastroenterol 2019; 25:341-354. [PMID: 31744939 PMCID: PMC6941455 DOI: 10.4103/sjg.sjg_92_19] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
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 18th, 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.
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Affiliation(s)
- Mohamed Azab
- Department of Gastroenterology and Hepatology, Loma Linda University Medical Center, California, USA,Address for correspondence: Dr. Mohamed Azab, Department of Gastroenterology, Loma Linda University School of Medicine, 11234 Anderson Street, MC 1503A, Loma Linda, California - 92354, USA. E-mail:
| | - Shishira Bharadwaj
- Department of Gastroenterology and Hepatology, Loma Linda University Medical Center, California, USA
| | - Mahendran Jayaraj
- Department of Gastroenterology, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Annie S. Hong
- Department of Internal Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Pejman Solaimani
- Department of Gastroenterology and Hepatology, Loma Linda University Medical Center, California, USA
| | - Mohamad Mubder
- Department of Internal Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Hyeyoung Yeom
- Department of School of Community Health Sciences, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Michael L. Volk
- Department of Gastroenterology and Hepatology, Loma Linda University Medical Center, California, USA
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Challenges encountered in the management of gall stones induced pancreatitis in pregnancy. Int J Surg 2019; 71:72-78. [DOI: 10.1016/j.ijsu.2019.09.016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2019] [Revised: 09/10/2019] [Accepted: 09/16/2019] [Indexed: 12/27/2022]
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Cappell MS, Stavropoulos SN, Friedel D. Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography. World J Gastrointest Endosc 2018; 10:308-321. [PMID: 30364767 PMCID: PMC6198312 DOI: 10.4253/wjge.v10.i10.308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/13/2018] [Accepted: 08/27/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
- Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, United States
| | | | - David Friedel
- Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY 11501, United States
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Ofori E, Ramai D, John F, Reddy M, Ghevariya V. Occupation-associated health hazards for the gastroenterologist/endoscopist. Ann Gastroenterol 2018; 31:448-455. [PMID: 29991889 PMCID: PMC6033760 DOI: 10.20524/aog.2018.0265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/11/2018] [Indexed: 12/13/2022] Open
Abstract
Advances in the field of endoscopy have allowed gastroenterologists to obtain detailed imaging of anatomical structures and to treat gastrointestinal diseases with endoscopic therapies. However, these technological developments have exposed endoscopists and staff to hazards such as musculoskeletal injuries, exposure to infectious agents, and ionizing radiation. We aimed to review the occupational hazards for the gastroenterologist and endoscopist. Using PubMed, Medline, Medscape, and Google Scholar, we identified peer-reviewed articles with the keywords “occupational hazards,” “health hazards,” “occupational health hazards,” “endoscopy,” “gastroenterologist,” “infectious agents,” “musculoskeletal injuries,” and “radiation.” Strategies for reducing exposure to infectious agents, radiation, and the risk of musculoskeletal injuries related to gastroenterology include compliance with established standard measures, the use of thyroid shields and radioprotective eyewear, and ergonomic practices. We conclude that educating endoscopic personnel and trainees in these practices, in addition to further research in these areas, will likely lead to the development of more efficient and user-friendly workspaces that are safer for patients and personnel.
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Affiliation(s)
- Emmanuel Ofori
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy)
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy).,St George's University School of Medicine, True Blue, Grenada, W.I. (Daryl Ramai)
| | - Febin John
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy)
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy)
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Feng Q, Cheng XY, Liu Z. Safety of endoscopic retrograde cholangiopancreatography during pregnancy for disease diagnosis and treatment. Shijie Huaren Xiaohua Zazhi 2018; 26:250-255. [DOI: 10.11569/wcjd.v26.i4.250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
At present, endoscopic retrograde cholangiopancreatography (ERCP) is one of the most commonly used methods for diagnosis and treatment of biliopancreatic diseases. However, over the years, ERCP has been avoided in pregnancy given the concerns regarding the adverse effects, such as the safety of sedative drugs, the impact of radiation on the developing fetus, and the complications of ERCP. However, years of research has shown that it is safe and effective to perform ERCP during pregnancy, and the postponement or rejection of ERCP in pregnant women may lead to a higher risk for mother and fetus, especially when the indication is unequivocal (e.g., cholangitis, biliary pancreatitis, and symptomatic choledocholithiasis). This article gives an overview of the safety of ERCP during pregnancy for disease diagnosis and treatment.
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Uncomplicated common bile duct stone removal guided by cholangioscopy versus conventional endoscopic retrograde cholangiopancreatography. Surg Endosc 2017; 32:2704-2712. [DOI: 10.1007/s00464-017-5966-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2017] [Accepted: 10/23/2017] [Indexed: 01/15/2023]
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Magno-Pereira V, Moutinho-Ribeiro P, Macedo G. Demystifying endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy. Eur J Obstet Gynecol Reprod Biol 2017; 219:35-39. [PMID: 29040894 DOI: 10.1016/j.ejogrb.2017.10.008] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2017] [Revised: 09/30/2017] [Accepted: 10/04/2017] [Indexed: 12/13/2022]
Abstract
BACKGROUND For many years, ERCP was avoided in pregnancy given the concerns regarding the adverse effects that, with special focus on radiation, could occur in the developing fetus. However, the postponement or rejection of ERCP in pregnant women, may lead to a higher risk for mother and fetus, especially when the indication is unequivocal, namely cholangitis, biliary pancreatitis and symptomatic choledocholithiasis. SUMMARY AND KEY MESSAGES This review aims to summarize the scarce literature on the subject in order to plan ERCP in pregnancy with the highest safety. The use of techniques that reduce radiation and increase the protection of pregnant women allow radiation levels far below the safety limits. We also discuss the various alternatives of ERCP without radiation. EUS can eliminate the need for ERCP with doubtful choledocholithiasis and plan the best approach in those with previous evidence. The possibility of performing "ERCP" with a linear echoendoscope uniquely under ultrasound control has been described. Conversely, the two-step strategy (initial sphincterotomy with stent placement without fluoroscopy and after delivery, ERCP with lithiasis extraction) proved to be safe obviating fluoroscopy. In conclusion, ERCP can be performed in pregnancy safely and effectively with minimal radiation or even no-radiation at all.
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Affiliation(s)
| | - Pedro Moutinho-Ribeiro
- Gastrenterology Department, Centro Hospitalar de São João, Faculty of Medicine of Porto University, Porto, Portugal.
| | - Guilherme Macedo
- Gastrenterology Department, Centro Hospitalar de São João, Faculty of Medicine of Porto University, Porto, Portugal.
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Shah JN, Bhat YM, Hamerski CM, Kane SD, Binmoeller KF. Feasibility of nonradiation EUS-based ERCP in patients with uncomplicated choledocholithiasis (with video). Gastrointest Endosc 2016; 84:764-769. [PMID: 27040099 DOI: 10.1016/j.gie.2016.03.1485] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Accepted: 03/23/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIMS ERCP inherently involves radiation exposure. Nonradiation ERCP has been described in pregnancy. Theoretically, the same techniques could be applied to the general population. We prospectively assessed the feasibility of nonradiation, EUS-based ERCP in nonpregnant patients with choledocholithiasis. METHODS Consecutive patients referred for ERCP for choledocholithiasis were recruited over a 1-year period. Patients providing study consent underwent the following procedural protocol. First, EUS was performed to verify the presence, size, and number of stones. Second, biliary cannulation was attempted without fluoroscopy for a maximum of 10 minutes. Selective cannulation was based on deep insertion with visible bile in the catheter on aspiration. Third, for stone removal, sphincterotomy was performed and stones were removed using a basket or balloon. The number of stones exiting the papilla was matched to the number seen on EUS. Finally, once the duct was deemed clear by the endoscopist, a final occlusion cholangiogram and ductal sweep served as the reference standard for confirmation of stone clearance. RESULTS Nonradiation ERCP was attempted in 31 patients. Cannulation without fluoroscopy was successful in 26 patients (84%). Complete stone removal without fluoroscopy was achieved in all 26 of these cases. The 5 patients with failed nonfluoroscopic cannulation required double guidewire (n = 2) or precut papillotomy (n = 3) for deep biliary access and subsequent stone clearance. One patient who required precut papillotomy for access developed moderate post-ERCP pancreatitis (3%). CONCLUSIONS Nonradiation, EUS-based ERCP for uncomplicated choledocholithiasis appears to be successful and safe. (Clinical trial registration number: NCT01678391.).
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Affiliation(s)
- Janak N Shah
- Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA
| | - Yasser M Bhat
- Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA
| | - Chris M Hamerski
- Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA
| | - Steve D Kane
- Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA
| | - Kenneth F Binmoeller
- Interventional Endoscopic Services, California Pacific Medical Center, San Francisco, California, USA
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