Management of Choledocholithiasis with Laparoscopic Surgery and Endoscopic Retrograde Cholangiopancreatography in Pregnancy: A Case Series

Christopher F McNicoll, MD, MPH, MS¹, Cory G Richardson, MD¹, Lindsay M Wenger, MD¹, Matthew S Johnson, MD², Charles R St. Hill, MD, MSc, FACS¹, Nathan I Ozobia, MD, FACS³. ¹Department of Surgery, University of Nevada School of Medicine, ²Desert Surgical Associates, Las Vegas, Nevada, ³University Medical Center of Southern Nevada

The prevalence of gallstones during pregnancy can be as high as 12%, and biliary disease is the second most common cause of abdominal surgery in pregnancy.  Laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) have previously been shown to be safe and effective treatments for complicated biliary disease during pregnancy, as supported by SAGES Guidelines.  The authors have experience performing one-step laparoscopic cholecystectomies with intraoperative ERCP, and we present the management of choledocholithiasis in two pregnant patients.

CASE 1:

A 20 year old female, gravida 1, para 0, 8 weeks 1 day pregnant, presented to the emergency department for the third time with right upper quadrant abdominal pain and tenderness, nausea, and vomiting for 1 day.  An abdominal ultrasound revealed cholelithiasis, choledocholithiasis, and a 9.8 millimeter common bile duct.  She had elevated liver enzymes and lipase, no leukocytosis, and total bilirubin 1.2 mg/dL.  Her total bilirubin continued to rise to 3.6 mg/dL, and a one-step diagnostic laparoscopy and ERCP was performed on hospital day 3.  Intra-operatively, no gallbladder was found, though the patient had very dilated common hepatic and common bile ducts.  An intra-operative ERCP confirmed the diagnosis of congenital gallbladder agenesis, and multiple stones were removed from the common bile duct following sphincterotomy.  The patient was discharged on hospital day 5 after an uneventful post-operative course, and her healthy child was delivered at 34 weeks 0 days.

CASE 2:

A 27 year old female, gravida 4, para 3, 34 weeks 2 days pregnant, presented to the emergency department for the seventh time with right upper quadrant abdominal pain and tenderness, nausea, and vomiting.  Her liver enzymes, lipase, and white blood cell count were normal.  Abdominal ultrasound revealed a 12 millimeter common bile duct, and MRCP revealed a 7 millimeter stone in the distal common bile duct.  After discussion with the patient, an ERCP with sphincterotomy and stent placement was performed on hospital day 4, and she was discharged home. She delivered a healthy infant at 39 weeks 1 day.  Two days following delivery, she underwent a one-step laparoscopic cholecystectomy and ERCP for stent removal.  Her post-operative course was uneventful.

Total fluoroscopy times were 6 and 3 seconds, respectively. The surgeon who performs both laparoscopy and ERCP can potentially reduce both complications and the number of separate procedures that a patient will undergo for diagnoses such as choledocholithiasis.  This is advantageous for all patients, but is especially beneficial for pregnant patients.