A B S T R A C T

Innovative Technique for Cholecystectomyin Twin Pregnancy Complicated with

Biliary Pancreatitis

Key words Bilio-pancreatic disorders, Laparoscopic clip applicator, Twin pregnancy, Cholecystectomy.

Shalin Lyall, Jacob Jayakar, Guru Prasath

INTRODUCTION:While 2-4% of pregnant women will be found to havegallstones during obstetric ultrasound, symptomaticbilio-pancreatic gallstone disease during pregnancyoccurs in only 5 to 10 females in 10,000 gestations(0.05-0.1%).1 Open or laparoscopic cholecystectomyis recommended as a safe procedure duringpregnancy.2 Biliary pancreatic disease is one of therare and serious complications of gall stonesespecially if it is associated with pregnancy. Earlysurgery is recommended for such cases. We presenta new surgical approach in such si tuat ion.

CASE REPORT:A patient presented to emergency room with severeabdominal pain during 21-22 weeks of gestation withtwin pregnancy. Pain was aggravated on sitting upand bending forward. This was her second episodeof pain in the same pregnancy. She was alreadydiagnosed to have cholelithiasis at 17 weeks andwas managed conservatively for her biliary colic.Routine investigations revealed a leukocyte countof 12100/mm3. Liver function tests were within normallimits. Serum lipase was 421 u/l(normal-less than38 u/l). Patient also became febrile during the courseof her hospital stay. Ultrasound showed bulky

Correspondence:Dr. Shalin LyallDepartment of General surgeryPondicherry Institute of Medical SciencesGanapathychettykulam, KalapetPondicherry-605014. IndiaEmail- shalin93@gmail.com

pancreas with dichorionic, diamniotic twins withapproximate gestation of 21-22 weeks. It also showedbilateral pleural effusion. A diagnosis of biliarypancreatitis was made. She underwent ERCP andsphincterotomy preoperatively. Due to recurrent painin the same pregnancy, worsening clinical condition,an open cho lecys tec tomy was p l anned .

Open cholecystectomy with the use of laparoscopicclip applicator, was done to save time and to avoidundue re t ract ion as in convent iona l opencholecystectomy, which could have compromisedthe fetus (FIg I). Epidural anesthesia was used dueto respiratory complications of acute pancreatitis.Pre-operative, intra-operative and post-operativefetal monitoring was performed. Prophylactic tocolysiswere not given. Patient had an uneventful recoverywhich was confirmed by post operative ultrasoundfor fetal well being (Fig II). She was discharged onthe fourth post operative day.

DISCUSSION:Pregnancy predisposes women to gallbladder diseasedue to hormonal changes causing an increase ingallbladder volume during fasting, an increasedresidual volume after emptying, an increasedsaturation of bile with cholesterol, and a decreasein the circulating bile salt pool. These factors resultin asymptomatic cholelithiasis in 4.5% of pregnantwomen, symptomatic cholelithiasis in 0.05%; almost40% of whom require surgery. Gallstone pancreatitiscomplicating cholelithiasis has been linked to a 15%maternal mortality rate and a 60% rate of fetal demise.

Bilio-pancreatic disorders manifesting during pregnancy are relatively rare and themanagement of these conditions remains controversial. Although perioperative problemswith fetal loss have been reported, recent publications have advocated an early surgicalapproach. We present a case of twin pregnancy with biliary pancreatitis associated withbilateral pleural effusion. Epidural anesthesia was given. A laparoscopic clip applicatorwas used to clip the cystic artery and cystic duct instead of conventional suture ligationthus reducing the operative time, retraction of uterus and the associated stress. Thistechnique is recommended as an alternate means, of duct and artery ligation when theoperative time has to be reduced with narrow field of vision.

CASE REPORT

43 Journal of Surgery Pakistan (International) 17 (1) January - March 2012

Symptomatic biliary disease which responds initiallyto medical management carries a relapse rate of92% for patients presenting in the first trimester,64% in patients who present in the second trimester,and 44% in patients who present in the third trimester.The high incidence of recurrence of biliary diseasein patients managed conservatively and the potentialcomplications of prolonged medical managementhas strengthened the recommendation of surgeryas initial treatment of hepatobiliary disease in thesecond trimester. Early cholecystectomy is beneficialcompared to delaying surgery beyond 2 weeks.3

However, patients who have had sphincterotomyare still at risk of developing biliary complications.4

The risk of gallstone pancreatitis recurrence aftersphincterotomy is 0–2%.5

Decreasing the risks of surgery to mother and fetusare critical if surgery during pregnancy is chosenas the method of definitive treatment. Schedulingsurgery during the second trimester may lead to a

preferred surgical outcome, and has reported toresult in a significantly lower abortion and pretermbirth rate than surgery in the first or third trimesters.Studies have shown that patients with sphincterotomywithin 30 days of the index admission requiredcholecystectomy, likely from cholecystitis, butpossibly from recurrent gallstone pancreatitis.6

Cholecystectomy is required in 41% of pregnantpatients who fail on initial medical management.7

Our pa t ien t was thus p lanned fo r opencholecystectomy due to recurrent pain, worseningclinical condition, high leucocyte count, high amylaseand lipase.

Physiologically, the uterus during the secondtrimester in singleton pregnancy is of adequate sizeas not to obscure the operative field, as would occurwith a third trimester fetus. Our case presented hereadded challenge due to patient’s twin pregnancyand the uterine size, which was of term size. Thesecond trimester miscarriage rate is only 5.6%compared to 12% in the first trimester, while pretermdelivery rates during the third trimester are as highas 40%.8 There is no evidence to support the useof prophylactic tocolysis.9 We emphasize the useof this innovative technique especially in a resourcepoor setting where sophisticated instruments likeharmonic scalpel or Ligasure are not available.

REFERENCES:

1. Scott LD. Gallstone disease and pancreatitisin pregnancy. Gastroenterol Clin North Am1992;21:803-15.

2. Mckellar DP, Anderson CT, Boynton CJ,Peoples JB. Cholecystectomy duringpregnancy without fetal loss. Surg GynecolObstet 1992;174:465-8.

3. Hernandez V, Pascual I, Almela P, Anon R,Herreros B, Sanchiz V, et al. Recurrence ofacute gallstone pancreatitis and relationshipwith cholecystectomy or endoscopicsphincterotomy. Am J Gastroenterol2004;99:2417-23.

4. I to K, I to H, Whang EE. Timing ofcholecystectomy for biliary pancreatitis: dothe data support current guidelines? JGastro in test Surg 2008;12:2164-70.

5. Lee JK, Ryu JK, Park JK, Yoon WJ,Lee SH, Hwang JH, et al. Roles ofe n d o s c o p i c s p h i n c t e r o t o m y a n dcholecystectomy in acute biliary pancreatitis.

44Journal of Surgery Pakistan (International) 17 (1) January - March 2012

Shalin Lyall, Jacob Jayakar, Guru Prasath

Fig I: Open cholecystectomy in twin pregnancy beingperformed.

Fig II: Completed cholecystectomy in almost termsize uterus.

Hepatogastroenterol 2008;55:1981-5.

6. Shanley DJ, Gagliardi JA, Daum-KowalskiR. Choledochal cyst complicating pregnancy:antepartum diagnosis with MRI. AbdomImaging 1994;19:61-3.

7. Haitt JR, Haitt CG, Williams RA. Biliarydisease in pregnancy: strategy for surgical

management. Am J Surg 1988;151:23-6.

8. Goodman S. Anesthesia for nonobstetricsurgery in the pregnant patient. SeminarPerinatol 2002;26:136-45.

9. Katz VL, Farmer RM. Controversies intocolytic therapy. Clin Obstet Gynecol1999;42:802-19.

45 Journal of Surgery Pakistan (International) 17 (1) January - March 2012

Innovative Technique for Cholecystectomy in Twin Pregnancy Complicated with Biliary Pancreatitis