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

Investigating gastrointestinal disorders in pregnancy

This article reviews anatomical and physiological changes and alterations in reference intervals for laboratory tests in healthy pregnancy, pertinent to investigation of the gastrointestinal system. The safety of procedures and radiological investigations relevant to the investigation of gastrointestinal disorders in pregnancy are also reviewed.

Cholecystectomy and ERCP in pregnancy: a nationwide register-based study

OBJECTIVE

The objective was to examine the outcomes of cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy and compare these outcomes with those in nonpregnant women of fertile age.

SUMMARY BACKGROUND DATA

Although both laparoscopic cholecystectomy and ERCP are considered safe and feasible in pregnant patients, there is still concern and uncertainty regarding gallstone intervention during pregnancy. This study aimed to investigate outcomes in pregnant patients compared to outcomes in nonpregnant patients.

METHODS

Data on all female patients aged 18-45 years were retrieved from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography. The patients were divided into groups according to intervention: cholecystectomy, ERCP, or a combination thereof. Differences between pregnant and nonpregnant patients were analyzed.

RESULTS

A total of 21 328 patients were included, with 291 cholecystectomy and 63 ERCP procedures performed in pregnant patients. At the 30-day follow-up, more complications after cholecystectomy were registered for pregnant patients. However, pregnancy was not a significant risk factor for adverse events when adjusting for previous complicated gallstone disease, intraoperative complications, emergency surgery, and common bile duct stones. There were no differences in outcomes when comparing cholecystectomy among the different trimesters. ERCP had no significant effect on outcomes at the 30-day follow-up.

CONCLUSION

Cholecystectomy, ERCP, and combinations thereof are safe during pregnancy.

Remimazolam versus propofol in combination with esketamine for surgical abortion: A double-blind randomized controlled trial

Remimazolam is a new benzodiazepine with a short half-life, good efficacy, and safety profiles in general anesthesia. Combining esketamine with propofol (P + E) could reduce propofol consumption and injection pain. It is, however, unclear if a low dose of remimazolam co-administrated with esketamine (R + E) is comparable to the increasingly used P + E for surgical abortion with general anesthetic. We conducted a double-blind randomized controlled trial to compare the efficacy and safety of R + E and P + E. Two hundred patients scheduled for a surgical abortion were randomized to receive remimazolam 0.3 mg/kg plus esketamine 0.3 mg/kg (R + E), and propofol 2 mg/kg plus esketamine 0.3 mg/kg (P + E). Sedative effectiveness was evaluated by measuring the time to lose consciousness (LOC), recovery time, and successful sedation rate. Safety was assessed by hemodynamics and adverse events during and postoperation. The time to LOC and recovery time in R + E was 5 s shorter and 1 min longer than that in P + E, respectively (both p < 0.001). Success sedation rate did not differ between groups (p = 0.73). Bradycardia incidence and injection site pain were less frequent in the R + E group than that in the P + E group. More rash was observed in the R + E group compared with the P + E group (32% vs. 5%, p < 0.001), but all were mild (only chest rash) and resolved subsequently. Low dose of remimazolam when combined with esketamine has favorable profiles with rapid onset and recovery, but mild hemodynamic side effects and adverse events. It can be used as an alternative for surgical abortion with general anesthetic.

Clinical advances: pregnancy in gastroenterologic and hepatic conditions

The fields of gastroenterology and hepatology, along with endoscopic practice, have seen significant changes and innovations to practice in just the past few years. These practice changes are not limited to gastroenterology, but maternal fetal medicine and the care of the pregnant person have become increasingly more sophisticated as well. Gastroenterologists are frequently called on to provide consultative input and/or perform endoscopy during pregnancy. To be able to provide the best possible care to these patients, gastroenterologists need to be aware of (and familiar with) the various nuances and caveats related to the care of pregnant patients who either have underlying gastrointestinal (GI) conditions or present with GI and liver disorders. Here, we offer a clinical update with references more recent than 2018, along with a few words about SARS-CoV-2 infection and its relevance to pregnancy.

Laparoscopic bile duct exploration during pregnancy: a multi-center case series and literature review

BACKGROUND

The physiological changes of pregnancy increase the risk of gallstone formation and choledocholithiasis. Traditionally, endoscopic retrograde cholangiopancreatography (ERCP) has been the main approach for managing choledocholithiasis during pregnancy, but recent progress in laparoscopic bile duct exploration (LBDE) has demonstrated this technique as a safe and effective alternative option.

METHODS

A retrospective multicenter study of all patients who underwent LBDE during pregnancy from five centers with proven experience in LBDE between January 2010 and June 2020 was performed. The primary endpoint was to analyze the role of LBDE during pregnancy and to further characterize its position as a safe and effective alternative for the management of choledocholithiasis. A systematic review of the published literature relating to LBDE during pregnancy until February 2022 was also performed.

RESULTS

Five institutions reported performing LBDE during pregnancy in 8 patients. Median surgical time was 75 min (range: 60-140 min). The bile duct was cleared successfully in all patients, and the median hospital stay was 2 days (range: 1-3 days). The literature review identified a total of 7 patients with a successful CBD clearance rate of 86%. There were no major maternal, fetal, or pregnancy-related complications in any of the total 15 patients included. The symptomatic common bile duct lithiasis with deranged liver function tests was the most frequent indication (n=7).

CONCLUSION

LBDE during pregnancy appears to be safe and effective. More evidence reporting outcomes of LBDE during pregnancy is needed before any strong recommendations can be made.

Gastrointestinal malignancies in pregnancy

Gastrointestinal malignancies, though uncommon in pregnancy, present several unique challenges with regards to diagnosis, staging, and treatment. Imaging the pregnant patient with a suspected or confirmed GI malignancy requires modifications to the radiologic modality of choice and protocol in order to minimize harm to the fetus, ensure accuracy in diagnosis and staging and guide treatment decisions. In this review article, we discuss the imaging approach to the pregnant patient with GI cancer, including safe radiologic modalities and modifications to imaging protocols. We also review the most common GI cancers encountered in pregnancy, including colorectal, pancreatic, gastric, and small bowel tumors, with emphasis to imaging findings, staging, and treatment considerations.

Surgery A survey of patients' perceptions and experiences of intervention for gallstone disease during pregnancy

Background

Gallstones intervention during pregnancy might be a stressful event for both mother and fetus and stress might affect outcome. The aim of this study was to identify factors that might improve the care of pregnant patients in need of intervention for gallstone disease.

Methods

By crossmatching the Swedish Registry of Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks) and the Swedish Medical Birth Registry, we identified patients with gallstone intervention during pregnancy. A questionnaire covering patient experience before, during and after surgery and the Beck Depression Inventory II (BDI-II) were distributed.

Results

In total, 275 patients subjected to cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) or both were identified, and 146 (54%) patients responded. Surgery was in median performed in pregnancy week 16 (12–20), and 62 (42%) patients had symptoms of gallstone disease before pregnancy, with 17 of these patients scheduled for surgery before pregnancy. Thirty-four (24%) patients felt that the information regarding the upcoming surgery was inadequate, with differences comparing patients with overall favorable versus overall non-favorable experiences (103 (89%) vs. 8 (27%) p < 0.001) and similar differences regarding information on disease/symptoms (95 (84%) vs. 12 (43%), p < 0.001). A majority (57%) were very worried about their expected child, and 51% thought that no measures were taken to relieve their worries. Recurring as suggested improvements was more information about the disease and the surgical procedure.

Conclusion

Intervention due to gallstone disease during pregnancy is a stressful event that impacts many patients negatively, both before and after surgery. Patient education might positively affect patient experience.

The Clinical Application of Remimazolam Benzenesulfonate Combined with Esketamine Intravenous Anesthesia in Endoscopic Retrograde Cholangiopancreatography

In this project, algorithm-based image processing methods in 3D endoscopic image processing endoscopic retrograde cholangiopancreatography (ERCP) were analyzed. To enhance local information of images, an adaptive histogram equalization method with limited contrast is introduced. The influences of the algorithm on 3D endoscopic image peak signal-to-noise ratio (PSNR), image discrete information entropy (DE), and average mean brightness error (AMBE) of images before and after the optimization before were compared. A total of 92 patients receiving ERCP at Yuhuangding Hospital between December 2019 and December 2021 were selected and divided into the control group (fentanyl+propofol) and the observation group (remimazolam benzenesulfonate+esketamine). Mean arterial pressure heart rate (HR), oxygen saturation (SpO2), and respiratory rate (RR) of the patients at each time point including the entry into the operation room (T0), 2 minutes after the beginning of medication (T1), after endoscopy (T2), endoscopy withdrawal (T3), and postoperative awakening (T4) were recorded. The comparison of MAP between T1, T2, T3, and T4 and T0 among patients in the observation group and the control group showed statistical differences (P < 0.05). Besides, HR and RR at T4 in the observation group were obviously higher than those in the control group (P < 0.05). The comparison of SpO2 at T3 and T4 and that at T0 both showed statistical differences (P < 0.05). Awakening time and VAS scores in the observation group were obviously lower than those in the control group (P < 0.05). The incidence of bradycardia, nausea, vomiting, and chill in the observation group was all lower than that in the control group (P < 0.05). The results indicated that an effective endoscopic image processing method was established based on an image enhancement algorithm, and the combination of remimazolam benzenesulfonate and esketamine showed high safety and efficacy in ERCP.

Effect of Programmed Nursing Plan Based on Thinking Map Guidance Mode on Hemodynamics and Intestinal Function Recovery of Patients Undergoing Endoscopic Retrograde Cholangiopancreatography

ERCP is an effective method for the diagnosis and treatment of pancreatic and biliary diseases. With the improvement of endoscopes by researchers and the intubation and angiography technologies of medical workers, the role of ERCP in the diagnosis and treatment of pancreatic and biliary diseases has become increasingly important. Although ERCP is a minimally invasive diagnostic technique, it still falls into the category of surgery, and thus the physical and psychological dysfunction of patients undergoing ERCP caused by various factors such as surgery cannot be ignored. This study explored the effects of the procedural nursing plan based on the thinking map guidance mode on hemodynamics and intestinal function recovery of ERCP patients. The results showed that this plan could reduce the effects of ERCP on hemodynamics of patients, promote intestinal function recovery, relieve their bad psychology, reduce postoperative complications, and help to improve patients’ satisfaction with the nursing work, and it was worthy of promotion.

Management of Difficult Choledocholithiasis

Over 30% of all endoscopic retrograde cholangiography procedures in the US are associated with biliary stone extraction, and over 10-15% of these cases are noted to be complex or difficult. The aim of this review is to define the characteristics of difficult common bile duct stones and provide an algorithmic therapeutic approach to these difficult cases. We describe additional special clinical circumstances in which difficult biliary stones are identified and provide additional management strategies to aid endoscopic stone extraction efforts.

Management of common bile duct stones in a pregnant woman by percutaneous biliary drainage followed by elective endoscopic stone removal after delivery

A woman in her 30s who was 12 weeks pregnant with her third child presented with jaundice. Blood tests showed elevated hepatobiliary enzymes and direct bilirubin. Abdominal ultrasonography showed dilatation of the common bile duct and strong echo with a 9 mm acoustic shadow in the distal bile duct. She was diagnosed with common bile duct stone disease and biliary drainage was considered necessary. Percutaneous transhepatic biliary drainage (PTBD) was performed considering the effect on both the fetus and the mother, and the procedure was successful without any complications. The PTBD tube was left in place until delivery at 36 weeks 6 days of gestation and endoscopic stone removal was performed 14 days after delivery. The patient was discharged 18 days after delivery without any complications. In pregnant women with common bile duct stones, palliative PTBD followed by elective endoscopic stone removal after delivery can be considered a treatment strategy.

Choledocholithiasis in Pregnancy: A Case Report

Cholelithiasis during pregnancy and the postpartum period has an incidence of 12%, with pregnancy being an important risk factor for gallstones. Patients with choledocholithiasis can experience complications, such as obstructive jaundice, cholangitis, and pancreatitis, which may be detrimental to both mother and fetus.

A case of cholelithiasis in a second-trimester pregnancy was complicated by choledocholithiasis and obstructive jaundice. Ultrasonography (US), magnetic resonance cholangiopancreatography (MRCP), along with serial blood tests, confirmed the diagnosis. Treatment was safely achieved using endoscopic retrograde cholangiopancreatography (ERCP).

In pregnancy, complicated cholelithiasis is investigated using blood tests, ultrasonography, and cholangiography. Evidence supports the use of intraoperative or endoscopic cholangiography for the management of such complicated gallstone disease in pregnancy.

Differences in Outcome and Comparison of Stress and Immune Status in Patients with Recurrent Common Bile Duct Stones after Biliary Tract Surgery Choosing Three Procedures (ERCP, OCBDE, and LCBDE) for Treatment

OBJECTIVE

To compare the effect of choosing ERCP, OCBDE, and LCBDE for the treatment of patients with recurrent common bile duct stones after biliary tract surgery.

METHOD

115 patients with recurrent common bile duct stones after biliary surgery in our hospital were retrospectively analyzed and divided into three groups according to the procedure, 36 patients in the ERCP group, 38 patients in the OCBDE group, and 41 patients in the LCBDE group, and compared the efficacy, stress status, and immune status of the three groups.

RESULT

The stone removal rates were 91.67%, 97.37%, and 97.56% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). There were statistical differences between the ERCP, OCBDE, and LCBDE groups in terms of operative time, postoperative recovery time of exhaustion, recovery time of defecation, recovery time of feeding, and hospitalization time (P < 0.05). The postoperative complication rates were 8.33%, 10.53%, and 7.32% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05). The recurrence rates within 1 year after surgery were 2.78%, 7.89%, and 2.44% in the ERCP, OCBDE, and LCBDE groups, respectively (P > 0.05).

CONCLUSION

ERCP has short operative time, short hospital stay, and rapid postoperative recovery. LCBDE has mild trauma, and OCBDE has a wide range of application. Each of the three procedures has its own advantages and shortcomings, and the most appropriate procedure should be selected on the basis of comprehensive evaluation.

Nonradiation-to-endoscopist ERCP is non-inferior to standard ERCP

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.

Effectiveness of supraglottic ventilation by transtracheal catheter for painless ERCP

PURPOSE

This study aimed to investigate the effect of supraglottic ventilation via transtracheal catheter in painless endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

Sixty patients with painless ERCP who were treated in our hospital were enrolled as the study subjects and divided into a study group (n=30) and a control group (n=30) according to the method of ventilation during the operation. The control group received ventilation via modified laryngeal mask, while the study group received supraglottic ventilation through a transtracheal tube. The mean arterial pressure (MAP), heart rate (HR), oxygen saturation (SpO₂), and End-tidal CO₂ (EtCO₂) at multiple time points after admission (T0), after induction of anesthesia (T1), immediately after catheter placement (T2), immediately after operation (T3), and at the time of resuscitation (T4) were compared between the two groups. The incidence of various adverse events in the perioperative period was also compared.

RESULTS

The two groups showed significant fluctuations in intraoperative hemodynamic parameters. However, the changes in MAP, SpO₂ and ETCO₂ of the study group were more stable, and better than those of the control group at the T2 and T3 (P<0.05). The intubation time, operation time and recovery time of patients in the study group were significantly lower than those in the control group (P<0.05). The total incidence of adverse events in the study group was significantly lower than that in the control group (P<0.05).

CONCLUSION

It is highly feasible to apply supraglottic ventilation with transvalvular catheter in painless ERCP, which can significantly stabilize the perioperative hemodynamic parameters, accelerate recovery and also help decrease the rate of postoperative complications.

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.