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Clinical case
Cir Cir 2014;82:158-163.
Choledocholithiasis and pregnancy.
Hybrid laparo-endoscopic
treatment in one step
David Valadez-Caballero
Roberto González-Santamaría
Héctor Soto-Mendoza
Jorge Alberto Blanco-Figueroa
Juan Manuel Flores-Pantoja
Servicio de Cirugía de Invasión Mínima y Cirugía
Bariátrica
Hospital Regional de Alta Especialidad Zumpango
Estado de México, México.
ABSTRACT
Background: Complications associated with choledocholithiasis
are uncommon during pregnancy. However, when it occurs, related
morbidity and mortality for the product and the mother increases;
therefore, timely and appropriate treatment is imperative in these
patients.
Clinical case: We present the case of a 25-year-old patient in her second
trimester of pregnancy. Her current condition began 4 days prior to
hospital admission with abdominal pain in the right upper quadrant
with nausea and vomiting. Twenty-four hours later, jaundice and dark
urine were observed. Physical examination showed scleral jaundice
and right upper quadrant abdominal pain without peritoneal irritation
and uterus at umbilicus level without uterine activity. Laboratory tests
showed elevated bilirubin and transaminases without leukocytosis.
Ultrasound reported unique live intrauterine product with a heart rate
128 beats/min. Gallbladder demonstrated multiple images that cast
acoustic shadowing and a 10-mm common bile duct with dilatation of
intrahepatic bile ducts. Laparoscopic cholecystectomy was performed
with intraoperative cholangiography and placement of a transcystic
jaguar guide for selective cannulation of the common bile duct.
Intraoperative endoscopic retrograde cholangiopancreatography
was performed with endoscopic stone extraction. The outcome was
satisfactory with hospital discharge at 48 h.
Conclusion: Current evidence has shown that the combined use of
laparoscopy and therapeutic endoscopic cholangiography in one step
is effective for the treatment of choledocholithiasis, decreasing the risk
of complications associated with cannulation of the bile duct.
Key words: Choledocholithiasis, pregnancy, endoscopic retrograde
cholangiopancreatography, laparoendoscopic surgery.
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Received: 2-13-2013
Accepted: 6-18-2013
Correspondence:
Dr. David Valadez Caballero
Carretera Zumpango-Jilotzingo 400
55600 Zumpango de Ocampo
Estado de México, México.
Tel: (55) 46113902
E-mail: [email protected]
www.amc.org.mx
Valadez-Caballero D, et al. Choledocholithiasis and pregnancy
BACKGROUND
Acute appendicitis and symptomatic cholelithiasis represent common nonobstetric medical
emergencies during pregnancy and are the cause
of abdominal surgery in 1/500-635 pregnant
females.1 The incidence of gallstones during
pregnancy is ~4%,2,3 and choledocholithiasis
is associated with cholangitis and pancreatitis.
Although pancreatitis during pregnancy is not
common (1/1,000-12,000 pregnancies),4 66.3%
of the cases are of biliary origin and are associated
with premature labor, fetal death and admission to
intensive care in 18.6, 4.7 and 2.3%, respectively,5
for which timely treatment is important.
Treatment of choledocholithiasis with preoperative
retrograde cholangiography followed by laparoscopic cholecystectomy is safe and effective
during pregnancy; 6-8 however, the risks and
complications associated with endoscopic
cholangiography remain latent and there are no
clinical trials in pregnant patients.9-11
In past years the combination of laparoscopy and
endoscopy at one time has proven to be efficient
for treating patients with choledocholithiasis.12
This technique (laparoendoscopy) is a hybrid
procedure that combines gallbladder resection
with laparoscopy and stone extraction by means
of endoscopy with selective cannulation of the
biliary duct during the same surgical procedure,
without need for additional equipment other than
what is normally used for these procedures,13
decreasing the risk and complications associated
with traditional cannulation of the bile duct
with endoscopic retrograde cholangiography.14
We report the case of a pregnant patient with
diagnosis of choledocholithiasis subjected to
laparoendoscopic hybrid surgery.
Clinical Case
We present the case of a 25-year-old female
patient with a normal pregnancy at 18.5 weeks
gestation. The patient reported adequate prenatal control prior to her admission. The actual
ailment began 4 days prior to her admission with
a clinical picture characterized by abdominal
pain in the right lower quadrant radiating to the
back, accompanied by nausea and vomiting,
which was partially relieved with fasting and
ingestion of “over the counter” nonsteroidal antiinflammatory medications. Twenty four hours
after intensity of the pain, icterus and choluria
appeared. For this reason, she presented for medical evaluation and was referred to this department.
On physical examination the patient was in good
general condition with adequate hydration. She
had icteric sclerae without cardiopulmonary
complaints. Abdomen was soft and depressible
with pain on deep palpation of the right lower
quadrant and positive Murphy’s sign, without
peritoneal irritation. The uterus was palpated at
the level of the umbilical scar, without uterine
activity but with positive peristalsis. Genitalia
were without discharge. Lower extremities did
not show edema and there were normal deep
tendon reflexes. Laboratory tests showed leukocytes 5590 cells/mm3, hemoglobin 10.4 g/dL,
hematocrit 31.1%, platelets 235,000 cells/mm3,
glucose 119 g/dL, urea nitrogen 7 g/dL, creatinine
0.6 g/dL, total bilirubin 4.2 IU/L, direct bilirubin
3.7 IU/L, AST 103 IU/L, ALT 102 IU/L, alkaline
phosphatase 281 IU/L, amylase 145 IU/L, PT
11.4 sec, and PTT 26.4 sec. Obstetric ultrasound
reported the existence of a live intrauterine fetus
with fetal heart rate of 128 beats/min. Ultrasound
of the liver and bile ducts showed the gallbladder with multiple ovoid images that projected a
posterior acoustic shadow and mobilized with
changes in position. Gallbladder wall was 7 mm,
choledocho 10 mm, and there was dilatation of
the intrahepatic bile duct.
The patient was transferred to the operating room
and general anesthesia was given. Laparoscopy
was done and showed the pregnant uterus
at the level of the umbilical scar (Figure 1).
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Volume 82, No. 2, March-April 2014
Figure 1. Intrauterine pregnancy. Laparoscopic view
with trocar showing the uterus at the level of the
umbilical scar.
Dissection of the gallbladder was begun from
the visceroperitoneum up to the structures at the
level of the triangle of Calot. Direct view of the
elements, stapling and cutting the cystic artery
was accomplished. With partial dissection of the
cystic duct, intraoperative cholangiography and
fluoroscopy was done after ensuring protection
of the pregnant uterus. Dilation of the intra- and
extrahepatic bile duct was done and a stone at
the level of the choledochal duct was observed
(Figure 2). A transcystic Jaguar endoscopic guide
was placed towards the duodenum to selectively
cannulate the bile duct (Figure 3) and to perform
an endoscopic retrograde cholangiography
whereby the stones were satisfactorily extracted
with a Dormia basket (Figures 4 and 5). The
gallbladder was excised in the usual manner. The
postoperative course was adequate and without
fever. Oral tolerance was achieved at 12 h, and
pancreatic enzymes were normal at 4 and 8 h.
The patient was discharged from the hospital at
48 h following evaluation of the fetal well-being.
Discussion
Treatment of abdominal pain in a pregnant patient is a dilemma for which the surgeon should
take the risks and benefits of the diagnostic and
therapeutic modalities into account, both for the
mother and the fetus. A fundamental principle
for the differential diagnosis of abdominal pain
160
Figure 2. Fluoroscopy. Intraoperative cholangiography
where important dilation of the bile duct is seen with
filling defect at the level of the distal choledochus
compatible with a stone.
Figure 3. Transcystic cannulation. Laparoscopic view
where the introduction of the transcystic Jaguar guide
is observed.
establishes that “early diagnosis means a better
prognosis.” In pregnant females with abdominal
pain, fetal well-being depends on the mother’s
well-being.15
Valadez-Caballero D, et al. Choledocholithiasis and pregnancy
surgical treatment was not recommended for
symptomatic cholelithiasis during pregnancy.16
Today, early surgical treatment is the choice
based on the data that demonstrated recurrent
symptoms in 92, 64 and 44% of the patients
treated nonsurgically during the first, second
and third trimester, respectively.17 This delay in
surgical treatment translates into greater rates
of hospitalizations, spontaneous abortions and
premature labor compared with patients who
undergo cholecystectomy.18,19
Figure 4. Selective cannulation of the ampulla of Vater.
Endoscopic view where selective cannulation of the
ampulla is seen via the transcystic Jaguar guide.
In general, nonsurgical treatment of symptomatic
biliary stones in pregnant patients translates into
recurrent symptoms in > 50%, and 23% of these
patients will have acute cholecystitis or biliary
pancreatitis, the latter associated with fetal loss
in 10-60% of cases.20
In the gravid female, morbidity and mortality
associated with gallbladder disease favors surgical treatment. Laparoscopic cholecystectomy is
the treatment of choice because of its advantages in relation to the low complications and
secondary effects.21 There have been no reports of
fetal death due to laparoscopic cholecystectomy
performed during the first and second trimesters of pregnancy. In addition, a decrease in
spontaneous abortions and premature labor have
been reported in laparoscopic cholecystectomy
compared with open surgery.22
Figure 5. Stone extraction. Endoscopic view where
extraction of the stone with a Dormia basket is seen.
During its inception, some authors argued that
there was contraindication for laparoscopic surgery during pregnancy due to the risk of uterine
injury and decrease in fetal perfusion. Currently,
with the acquired experience, laparoscopy has
become the first-line treatment for many surgical diseases in pregnant patients. In the past,
Although it has been shown that treatment of
choledocholithiasis in pregnancy with endoscopic
retrograde cholangiography followed by laparoscopic cholecystectomy is safe and effective,6-8
there are no other studies comparing it with
other approaches. Currently, the combination of
laparoscopy and intraoperative endoscopy in one
surgical procedure has emerged as a viable option for the treatment of choledocholithiasis and
it has been demonstrated to be safe and effective. 23-25 The laparoendoscopic hybrid technique
(Figure 6) combines resection of the gallbladder
laparoscopically and stone extraction with intra-
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2. Maringhini A, Ciambra M, Baccelliere P, Raimondo M,
Orlando A, Tine F, et al. Biliary sludge and gallstones in
pregnancy: incidence, risk factors, and natural history. Ann
Intern Med 1993;119:116-120.
3. Basso L, McCollum PT, Darling MRN, Tocchi A, Tanner WA.
A descriptive study of pregnant women with gallstones.
Relation to dietary and social habits, education, physical
activity, height, and weight. Eur J Epidemiol 1992;8:629-633.
4. Ramin KD, Ramin SM, Richey SD, Cunningham FG.
Acute pancreatitis in pregnancy. Am J Obstet Gynecol
1995;173:187-191.
5. Eddy JJ, Gideonsen MD, Song JY, Grobman WA, O’Halloran P.
Pancreatitis in pregnancy. Obstet Gynecol 2008;112:10751081.
6. Baillie J, Cairns SR, Putman WS, Cotton PB. Endoscopic
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Surg Gynecol Obstet 1990;171:1-4.
Figure 6. Laparoendoscopic hybrid surgery where
disposition of the laparoendoscopic equipment is
observed.
operative endoscopy selectively cannulating the
bile duct, whereby the risks of pancreatitis are
expected to be decreased12,14 as well as having
a shorter hospital stay.26,27
In conclusion, the treatment of choice for
choledocholithiasis associated with pregnancy
is difficult to define due to the lack of controlled clinical trials in this group of patients.
The current recommendation points to a preoperative endoscopic retrograde cholangiography
and laparoscopic cholecystectomy as the first
line treatment. However, the hybrid laparoendoscopic approaches could offer a therapeutic
advantage by selectively cannulating the bile
duct and with it decrease the risk of complications that could be catastrophic for the mother
and the fetus. Also, treatment-related costs would
be reduced. Studies in this group of patients
are required that would validate these potential
advantages.
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