|Year : 2017 | Volume
| Issue : 1 | Page : 13-18
Individualized endoscopic treatment for pregnant patients with acute pancreaticobiliary diseases
Ping Huang1, Hao Zhang2, Xiao-Feng Zhang1, Xiao Zhang1, Wen Lv1
1 Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, China
2 Department of Gastroenterology, Hangzhou Xixi Hospital, Zhejiang, China
|Date of Submission||28-Mar-2016|
|Date of Acceptance||01-Dec-2016|
|Date of Web Publication||1-Feb-2017|
Department of Gastroenterology, Hangzhou First People's Hospital, Nanjing Medical University, Hangzhou, Zhejiang, 310006
Source of Support: None, Conflict of Interest: None
Background: Acute pancreaticobiliary diseases are more prevalent and can often lead to severe maternal and fetal morbidity and mortality during pregnancy period. It is very important that early relieving biliary obstruction. Aims: To evaluate the safety and efficacy of individualized endoscopic treatment in managing acute pancreaticobiliary diseases in pregnant patients. Settings and Design: It is a single-center, retrospective study. Materials and Methods: Clinical data of 86 pregnant women with acute pancreaticobiliary diseases treated using individualized endoscopic treatment from January 2012 to January 2016 were analyzed retrospectively. The primary observed indicators included the operation success rate, recovery of laboratory indicators 1 week after the first endoscopic treatment, complications, prognosis, hospital stay, and different effect of individualized endoscopic therapy during different pregnancy period. Statistical Analysis Used: Data were analyzed using Statistical Package for the Social Sciences (SPSS) version 13.0 statistical software. Descriptive statistics was used. Results: The operation success rate was 97.67% (84/86) in all patients. Postoperative abdominal pain, fever, and other clinical symptoms were improved rapidly in patients. The laboratory indicators 1 week after the first endoscopic treatment were improved significantly (P < 0.05). The complications included biliary bleeding, acute cholangitis, postendoscopic retrograde cholangiopancreatography pancreatitis, and hyperamylasemia in 2, 1, 2, and 2 cases, respectively. The complication rate was 8.14% (7/86). The mean hospital stay of patients was 16.02 ± 4.32 days. Moreover, there was not statistically significant difference in the effect of endoscopic therapy during different pregnancy period (P > 0.05). Conclusions: Due to the good safety, marked effect, and little complications, individualized endoscopic treatment should be preferred therapy for patients with acute pancreaticobiliary diseases during pregnancy when performed by experienced hands.
Keywords: Acute obstructive and suppurative cholangitis, acute pancreaticobiliary diseases, acute pancreatitis, choledocholithiasis, individualized endoscopic treatment, pregnancy
|How to cite this article:|
Huang P, Zhang H, Zhang XF, Zhang X, Lv W. Individualized endoscopic treatment for pregnant patients with acute pancreaticobiliary diseases
. J Health Res Rev 2017;4:13-8
|How to cite this URL:|
Huang P, Zhang H, Zhang XF, Zhang X, Lv W. Individualized endoscopic treatment for pregnant patients with acute pancreaticobiliary diseases
. J Health Res Rev [serial online] 2017 [cited 2020 Feb 25];4:13-8. Available from: http://www.jhrr.org/text.asp?2017/4/1/13/199326
| Introduction|| |
Acute pancreaticobiliary diseases are more prevalent and can often lead to severe maternal and fetal morbidity and mortality during pregnancy period. It is estimated that about 3%–12% pregnancies complicated symptomatic biliary disease by gallstone disease.,, Choledocholithiasis can often lead to life-threatening complications such as acute obstructive suppurative cholangitis (AOSC) or acute biliary pancreatitis (ABP). Owing to sudden onset, dangerous conditions, multitudinous complications, acute pancreaticobiliary diseases may lead to the higher mortality of pregnant women and more fetal abortion, premature delivery rate if not handled properly. At the same time, they can lead to biliary obstruction, it is very important that early relieving biliary obstruction and recovering biliary drainage.
Traditional surgical operation has been considered better than the conservative therapy, but it has been associated with an increasing risk of fetal compromise. Because of the operation time being restricted by pregnancy period, surgical operation is difficult to carry out widely during pregnancy. In contrast, endoscopic retrograde cholangiopancreatography (ERCP) can make up for the inadequacy of surgery that has been affirmed by more and more scholars. In the past,, ERCP was performed in a condition with radiation exposure, and now its potential negative impact on the fetus has been receiving adequate attention, because the “gold standard” of the fetal safety is no X-ray exposure. Nowadays, it is the focus to us that ERCP without radiation exposure in treating biliary and pancreatic disease during pregnancy. Some studies ,, have reported their availability and safety in treating acute pancreaticobiliary diseases during pregnancy. However, due to the daedal clinical conditions, the endoscopist can not follow a single pattern during endoscopic treatments. Selecting the best way and time of endoscopic therapy is critical to pregnancies with acute pancreaticobiliary diseases. Individualized endoscopic treatment may make it materialize.
| Materials and Methods|| |
The present study was approved by the Ethical Committee. From a total of 86 pregnancies with acute pancreaticobiliary diseases were performed individualized endoscopic treatment January 2012 to January 2016. Abdominal ultrasound or magnetic resonance cholangiopancreatography (MRCP) was used to find out the specific situation of bile duct in all patients before ERCP, and the laboratory data and clinical course of the patients were analyzed. Majority of patients suffered from biliary colic, fever, or jaundice and had elevated serum total bilirubin, direct bilirubin, alanine aminotransferase, aspartate aminotransferase, and alkaline phosphatase. Intrahepatic bile duct dilatation in all patients was 0.3 cm or more, and 1.2 cm or more in the extrahepatic bile duct.
All patients or their spouses signed informed consents for the procedures after receiving an explanation on the risks, benefits, and alternatives of ERCP and associated therapeutic procedures.
The following equipment and accessories were used: TJF240/260 duodenoscopy (Olympus, Japan), guidewire, catheter, basket, balloon, needle knife, APC300/ICC200EA (ERBE, Germany), papillotome, nasobiliary drainage tube, plastic stent.
On preoperation, pethidine and midazolam were used for analgesia and sedation and intravenous hyoscine hyobromide for duodenal relaxation to every patient which monitored saturation and pulse. All patients were positioned in either left lateral or semi-prone posture to avoid any compromise.
Individualized endoscopic treatment mean selecting specifically endoscopic way and appropriate treatment time under ERCP according to the clinical conditions of the pregnancy women. First, the common bile duct (CBD) was cannulated with a guidewire through the papilla without fluoroscopy or spot radiography, then a catheter was slid over the guidewire. When bile was aspirated and/or bile oozed, correct cannulation was confirmed. For those with AOSC or severe ABP (SABP), the following process was adopted [Figure 1]. The management process of mild acute cholangitis, mild ABP (MABP), and CBD stones (CBDSs) is presented in [Figure 2]. For those with non-biliary severe acute pancreatitis (NBSAP), the process is presented in [Figure 3]. And emergent needle-knife sphincterotomy was performed for those with impacted papilla. When the cannulation or placing stent was very hard and impossiblely successful, short-time fluoroscopy was used to provide the guidance using lead shields cover the pregnant uterus. Stent replacement was performed for those placed stents 3 months after the procedure. Two weeks after delivery, all patients which placed stents were subjected to systemic ERCP for stones or benign biliary stricture. All patients were regularly followed up for 12 months by telephone after the last procedure.
|Figure 1: Methods for severe acute biliary pancreatitis and acute obstructive suppurative cholangitis. SABP: Severe acute biliary pancreatitis, AOSC: Acute obstructive suppurative cholangitis, EST: Endoscopic sphincterotomy, ENBD: Endoscopic retrograde nasobiliary drainage, ERBD: Endoscopic retrograde biliary drainage, NBSAP: Nonbiliary severe acute pancreatitis, ERCP: Endoscopic retrograde cholangiopancreatography|
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|Figure 2: Methods for mild acute biliary pancreatitis and mild acute cholangitis. MABP: Mild acute biliary pancreatitis, CBDS: Common bile duct stone, EST: Endoscopic sphincterotomy, ENBD: Endoscopic retrograde nasobiliary drainage, ERBD: Endoscopic retrograde biliary drainage, ERCP: Endoscopic retrograde cholangiopancreatography|
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|Figure 3: Methods for nonbiliary acute pancreatitis. EST: Endoscopic sphincterotomy; ENBD: Endoscopic retrograde nasobiliary drainage, ERBD: Endoscopic retrograde biliary drainage|
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The operation success meant the successful cannulation and nasobiliary drainage tube or plastic stent placement. Definition of post-ERCP pancreatitis (PEP) was consisted of epigastric pain and serum amylase elevation to >3 times normal values at 24 h after ERCP. Asymptomatic hyperamylasemia was defined as a 3-fold in serum amylase without epigastric pain at 24 h after ERCP. Moreover, acute cholangitis was a clinical syndrome characterized by abdominal pain, fever, and jaundice that developed as a result of infection in the biliary tract. Biliary bleeding implied that bleeding derived from bile duct injury or sphincterotomy during endoscopic treatment or postoperative 1 week.
The primary outcome measures of the present study included the operation success rate, the recovery of laboratory indicators 1 week after the first endoscopic treatment, complications, prognosis, hospital stay and the different effect of individualized endoscopic therapy during different pregnancy period.
Categorical variables were summarized by frequencies and percentages which were compared using Fisher's exact tests or Pearson's Chi-square test; continuous variables were summarized by mean ± standard deviation, which were compared using a two-sample independent t-test or F-test. A statistical software package (SPSS, version 13.0; SPSS Inc., Chicago, Illinois, USA) was used for data management and analysis, and two-tailed P < 0.05 was considered statistically significant.
| Results|| |
Eight-six patients were included in the present study. The median age of the patients was 27 years (range, 21–36 years). The mean duration of gestation was 22.5 weeks (range, 15–35 weeks). Majority of the patients had experienced biliary colic, fever or jaundice, consisting of 23 cases with acute cholangitis (choledocholithiasis, benign biliary stricture and others in 15, 5, and 3 cases, respectively), 32 cases with ABP (choledocholithiasis and benign biliary stricture in 20.12 cases, respectively), 20 cases with CBDSs only and 11 cases with NBSAP. There was not statistically significant in different diseases during different pregnancy periods (χ2 = 0.88, P > 0.05). The characteristics and indications for ERCP were shown in [Table 1].
Twenty-nine cases (AOSC in 10, SABP in 8 and NBSAP in 11) were performed firstly endoscopic sphincterotomy (EST) + endoscopic retrograde nasobiliary drainage (ENBD) without exposure to radiation, then endoscopic retrograde biliary drainage (ERBD) 3–5 days after the first therapic procedure when the patients' conditions were steady. Twenty cases with choledocholithiasis, 24 cases with MABP and 13 cases with mild acute cholangitis were performed EST + ERBD within 72 h after admission to hospital. During pregnancy, 51 cases needed stents replacement for avoiding stents obstruction after they were placed for 3 months. Needle-knife sphincterotomy was performed for those with impacted papilla in 5 cases (1 AOSC, 2 SABP, 1 MABP and 1 CBDS). Five cases needed short-time fluoroscopy guidance because of the difficult cannulation derived from the benign biliary stricture or obstruction, and three acquired success, two failed and transferred for surgery. Eleven cases with NBSAP were removed stents during pregnancy when they recovered from the diseases, and others were performed stent removal or systemic ERCP when stones or benign biliary stricture indicated 2 weeks after delivery [Table 2]. The operation success rate was 97.67% (84/86).
Postoperative abdominal pain, fever, and other clinical symptoms were improved rapidly in all patients. The laboratory indicators 1 week after the first endoscopic treatment were improved significantly (P < 0.05) [Table 3].
|Table 3: The recovery of laboratory indicators 1 week after the first endoscopic treatment (̄±s)|
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Biliary bleeding occurred in two cases whose duodenal ampulla occluded by stones and asked for precutting with needle knife, and bleeding stopped after local hemostasia. One case complicated by acute cholangitis because of the retrograde bacterial infection. PEP occurred in two cases due to frequent cannulations or guidewire inserted into the pancreatic duct, and cured after conservative treatment. Hyperamylasemia occurred in two cases which needed no special therapy. There were no others program-related-complications such as duodenal perforation, mechanical asphyxia. The complication rate was 8.14% (7/86). The mean hospital stay of patients was 16.02 ± 4.32 days. All babies' birth weights were normal (>3 kg) and with a mean Apgar score of 9 at 5 min. Followed up for 12 months, pregnant women and babies were healthy even those suffered from short-time fluoroscopy exposure.
The operation success rate, the complication rate, and hospital stay of all patients between different pregnancy period are listed in [Table 4]. Moreover, there was not statistically significant in the effect of endoscopic therapy during different pregnancy period (P > 0.05).
|Table 4: The different effect of endoscopic therapy during different pregnancy period|
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| Discussion|| |
Since Baillie et al. reported firstly therapeutic ERCP on pregnancies in 1990, the literature about therapeutic ERCP on pregnancies are more and more. According to the literature,,, the effect of therapeutic ERCP during pregnancy was very obvious. Many problems were easily solved after using therapeutic ERCP. It was embodied in the following: (1) therapeutic ERCP relieved the biliary obstruction and the complications such as jaundice, AOSC, and ABP can be cured through the minimally invasive method; (2) it was not restricted by the pregnant period and safe in the full pregnant period. However, the radiation exposure may have the potential danger for pregnant women and fetuses. Although during a short-term follow-up, X-ray had little effect on the newborn and the mother, the long-term negative effects on newborns are still unknown which should be paid sufficient attention to.
The side effects of X-ray to the fetus include stillbirth, miscarriage, premature delivery, intrauterine growth retardation, malformations, and childhood cancer. Exposure time and dose of radiation threaten directly the health of the fetus. In experimental animals, it did not increase the incidence of fetal congenital malformations or microcephaly when they are irradiated within 10–20 cGy dose X-ray during pregnancy period. To human, it was thought by the International Radiation Protection Association that the teratogenic risk of X-ray <5 cGy dose can be ignored when compared with the other risk factors during pregnancy. According to the clinical doctors' views, X-ray <5 cGy dose should not be the basis for the fetus to terminating the pregnancy, even within 5–10 cGy it may be safe. Hence, we need to take some measures to prevent the direct exposure of X-ray to the fetus.
In some series,, the following attempts were made to minimize the radiation exposure to the fetuses: (1) Use of lead shields cover the pregnant uterus; (2) short duration of radiation exposure; (3) coned-down fluoroscopical screening views; (4) no spot radiographs taken unless essential. Using the above-mentioned protective measures, the pregnant women and fetuses were safe. However, we still lack long-term random-clinical-controlled study up to now.
In recent years, many scholars have been trying to use nonradiation ERCP for those with biliary and pancreatic disease during pregnancy and achieved good results.,, However, there are three main problems in using this method: The first problem is that sometimes cannulations are very hard on some patients with benign biliary stricture or large stones obstructing the bile duct without X-ray guidance; the second is that catheter, guidewire or stent is likely placed into the gallbladder or pancreatic duct; the third is that it can hardly have good drainage effect when the stent is not placed across the obstructive CBD.
In the present study, individualized endoscopic treatment was applied for pregnant patients with acute pancreaticobiliary diseases which selected most reasonable endoscopic way and most appropriate therapy time according to the clinical conditions. Moreover, the aim was to relieve or cure the patients as soon as possible, decrease the maternal and fetal complications and shorten the average hospital stay and reduce iatrogenic risks.
For patients with SABP or AOSC, early relieving biliary obstruction and recovering biliary drainage using a minimally invasive therapy is most important due to the severe clinical conditions. Moreover, EST followed by ENBD within 24 h after admission to hospital had demonstrated the unsurpassed effect in many clinical studies as validated in the present study. However, long-time drainage by ENBD may lose too much bile and even has effect on the internal environment. Hence, ERBD was performed 3–5 days after the ENBD for recovering biliary physiology. Stent removal was asked 2 weeks after delivery and even systemic ERCP when indicated. Moreover, for those with MABP, mild acute cholangitis or CBDS, EST followed by ERBD may avoid patients' conditions developing into SABP and AOSC which made the following therapy complicated.
So far, the role of endoscopic therapy in the treatment of nonbiliary acute pancreatitis is a problem of clinical controversy. The focus of this controversy is how much benefit the endoscopic treatment can bring to those patients, because the nonbiliary acute pancreatitis is not caused by biliary obstruction. In fact, in clinical practice, we also found the following phenomena: (1) extremely edematous duodenal papilla often blocked bile and pancreatic juice drainage; (2) pancreatic head edema constricted the distal CBD and led to jaundice and hypohepatia and further aggravated the patient's condition; (3) unobstructed biliary drainage may help the recovery of severe acute pancreatitis. Moreover, just for this reason, individualized endoscopic treatment was applied to treat those pregnant women with NBSAP in the present study and played a very good effect.
Athrough O'mahony  had ever reported that pregnant women may have the highest risk in the first trimester due to the lower rate of term pregnancy (73.3%), the higher rate of preterm delivery (20%) and low birth weight rate (21.4%) when interventions were required for complications, and patients were most safe in the second trimester of pregnancy. However, in fact, a large number of studies ,,, have shown that ERCP is sufficient safe because of the meager program-related complications in the full period of pregnancy and it will not lead fatal effects to pregnant women and fetuses so long as the feasible preventing measures adopted. It was also proved in the present study at the same time.
By the present study, the following experience can be used for reference: (1) to make a comprehensive analysis and judgment to the specific circumstances of pancreaticobiliary duct through preoperative ultrasound and MRCP that is extremely important because it relates to the global treatment and determines the best location of cannulation or stent placement; (2) unless it is necessary, try not to use the needle knife, because it will greatly increase the risk of bleeding or perforation; (3) only to those with very hard cannulation, using short time fluoroscopy for providing the guidance using lead shields cover the pregnant uterus; (4) EST for a small incision before placing a stent has four advantages:First, it can ensure placing the stent into CBD successfully; second, it is conducive to the discharge of small stones; third, it may prevent stent obstruction after the procedure and decrease the incidence or relapse of acute cholangitis; finally, it may prevent the PEP, because the ampulla edema resulted from frequent cannulations and placing stents may affect the outflow of pancreatic juice. On the contrary, a large incision may lead to bleeding or perforation which will bring about adverse effects on the fetus; (5) to reduce the possibility of stent migration, using the “Christmas tree” type plastic stent as far as possible.
This study has the limitations inherent in any retrospective study of two centers' experience. On the other hand, the number of patients in the present study is small and no control group in design.
| Conclusion|| |
Individualized endoscopic treatment adopted special endoscopic way and appropriate therapy time for relieving the etiologies of pregnant patients with acute pancreaticobiliary diseases. Due to the good safety, marked effect and little complications, individualized endoscopic treatment should be preferred therapy for patients with acute pancreaticobiliary diseases during pregnancy when performed by experienced hands.
The authors gratefully acknowledge the help of Bing Cheng for statistical analyses.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2], [Table 3], [Table 4]