Elsevier

Gastrointestinal Endoscopy

Volume 67, Issue 2, February 2008, Pages 364-368
Gastrointestinal Endoscopy

Case study
Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos)

https://doi.org/10.1016/j.gie.2007.09.036Get rights and content

Background

Symptomatic choledocholithiasis during pregnancy can be treated with ERCP, but fluoroscopy may pose a risk to the fetus. Nonradiation ERCP may be a safer form of treatment, but its performance has not been optimized.

Objectives

The purpose of this study was to evaluate new methods of nonradiation ERCP during pregnancy, including wire-guided cannulation techniques to achieve bile-duct access without the use of fluoroscopy, and the use of peroral choledochoscopy to confirm ductal clearance.

Study Design

A retrospective review of consecutive ERCPs performed on pregnant women.

Setting

Urban referral hospital.

Patients

Pregnant women with symptomatic choledocholithiasis.

Interventions

All patients underwent therapeutic ERCP without any use of fluoroscopy. Endoscopist-controlled wire-guided cannulation was performed to achieve biliary access.

Main Outcome Measurements

The rate of successful biliary cannulation and short-term outcomes.

Limitations

ERCP procedures were performed by a single endoscopist.

Results

Successful bile-duct cannulation with sphincterotomy and the removal of biliary stones or sludge was performed without fluoroscopy in 21 pregnant women. There was one case of mild post-ERCP pancreatitis. Choledochoscopy confirmed ductal clearance in 5 cases.

Conclusions

Nonradiation ERCP is a safe and effective treatment for symptomatic choledocholithiasis during pregnancy. Wire-guided biliary cannulation and choledochoscopy may enhance the performance of ERCP in this setting.

Section snippets

Patients and methods

Since November 2000, we have performed a therapeutic ERCP on 21 consecutive pregnant women without the use of fluoroscopy. During the study period, no pregnant patients underwent an ERCP with fluoroscopy, and no other pregnant women underwent a diagnostic ERCP. This study was approved by the Methodist Dallas Medical Center Institutional Review Board during July 2007.

A history and physical examination, laboratory studies, and imaging were used to determine the need for a therapeutic ERCP.

Results

An ERCP with sphincterotomy and removal of biliary stones (14 patients) or sludge (7 patients) was successfully performed without fluoroscopy in all 21 pregnant women. Of the 6 patients who underwent an EUS before an ERCP, 2 patients had bile-duct stones, and 4 patients had bile-duct sludge found on an EUS. Patient clinical data, method of biliary access, and complication outcomes are summarized in Table 1. The mean age of the patients was 27 years, and the mean gestation age was 19 weeks. All

Discussion

Symptomatic choledocholithiasis is a relatively common disorder during pregnancy and may have serious consequences if not treated. An ERCP can be therapeutic in this setting, and nonradiation ERCP may be preferable, because fluoroscopy carries a potential risk for the fetus. Nonradiation ERCP during pregnancy was first described by Binmoeller and Katon7 in 1990: a needle-knife papillotomy was performed to free an impacted ampullary stone. We previously reported the largest series at that time

References (23)

  • V. Valdivieso et al.

    Pregnancy and cholelithiasis: pathogenesis and natural course of gallstones diagnosed in early puerperium

    Hepatology

    (2007)
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      In addition, the radiation effect of fluoroscopy used during ERCP might be associated with teratogenicity. Therefore, alternative methods aiming to visualize the biliary tree by using radiation free ERCP techniques have been described in literature, like cholangioscopy, bile aspiration and endosocopic sonography [29,42–45]. Although these reports were generally based on single centre experiences that involved small number of patients, they could perhaps pave the way for larger future studies.

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