Endoscopic Common Bile Duct Stones Clearance During Pregnancy: Challenges and solutions. A retrospective Cohort Study

AbstractBackground Pregnancy is associated with a higher risk of common bile duct stones. Currently Endoscopic Retrograde Cholangiopancreatography (ERCP) is the treatment of choice for symptomatic choledocholithiasis. However, ERCP during pregnancy is associated with hazards of radiation exposure, as well as challenging patient positioning and anesthesia. Aim of the study: It aimed to present our trial to overcome challenges in endoscopic clearance of symptomatic common bile duct stones during pregnancy. Patients and methods: This is a retrospective analysis of endoscopic CBD clearance in 27 pregnant patients with symptomatic choledocholithiasis between February 2019 and February 2023. Sedation and anesthesia was done by safe medications by senior anesthetist, and the endoscopic procedure was performed in left lateral decubitus instead of prone position. The gravid uterus was kept away from the monopolar electrocautery current pathway. Radiocontrast injection and fluoroscopy was deleted and replaced by trans-abdominal US and endoscopic bile aspiration. Data were collected, tabulated and analyzed by SPSS ver. 26. Result The patient’s age ranged from 18 to 36 years (Mean: 25 years). The mean duration of gestation ranged from 7–32 (Mean 15 weeks) and 17 patients were in the first trimester, 8 patients in the second trimester, and two patients in the third trimester). Therapeutic ERCP was successfully performed in all patients. The time of the procedure ranged from 19 to 45 minutes (Mean: 27 ± 13 min). As regards post-ERCP complications, one patient (3.7%) developed pancreatitis post-ERCP and was treated successfully with conservative treatment, and one patient (3.7%) with minor bleeding. All procedures were performed without any material adverse events immediately or on follow-up. There were no signs of fetal distress during any of these cases, and there were no fetal complications noted upon delivery or at 30-day follow-up. Conclusion Endoscopic clearance of symptomatic common bile duct stones during pregnancy can be obtained safely without fluoroscopy. Adjunct US and endoscopic bile aspiration can overcome the absence of fluoroscopy. Careful positioning of the patient, proper positioning of monopolar cautery pad, and judicious anesthetic modification are all crucial for patient and fetal safety.