|
|
SpyGlass cholangioscopy for management of choledocholithiasis during pregnancy |
Lance Uradomo, Frank Pandolfe, George Aragon and Marie L. Borum |
Department of Gastroenterology and Liver Diseases,the George Washington University,Washington, DC, USA (Email: luradomo@mfa.gwu.edu) |
|
|
Abstract To the Editor:
We read with great interest the article by Chong and Jalihal[1] regarding endoscopic management of biliary disorders during pregnancy which reaffirms that endoscopic retrograde cholangiopancreatography (ERCP) is safe and effective in managing choledocholithiasis during pregnancy. The authors use ERCP under fluoroscopic guidance with lead apron shielding as well as non-fluoroscopic cannulation using bile flow and bile aspiration as indicators of successful bile duct cannulation. We discuss an emerging technology for direct cholangioscopy which aids in confirmation of duct clearance and eliminates the need for fluoroscopy.
A 26-year-old G3P2 female in her first trimester of pregnancy presented to hospital with post-prandial epigastric pain and vomiting. She had obstructive jaundice and pancreatitis by laboratory evaluation. Transabdominal ultrasound showed choledocholithiasis and common bile duct dilation.
Urgent ERCP was performed with sphincterotomy and stone extraction facilitated by the SpyGlass Direct Visualization System (Boston Scientific, Natick, MA, USA). A 4.4 Fr sphinctertome was angled in the biliary orientation and a hydrophilic 0.35" guidewire was gently advanced into the major papilla resulting in bile flow around the guidewire. The sphincterotome was advanced over the wire and aspiration of 10 ml of clear yellow bile confirmed the location within the bile duct. A biliary sphincterotomy was performed. Sweep with a 9-mm extraction balloon easily removed a single 8-mm stone from the bile duct. The SpyGlass SpyScope was exchanged over the guidewire and cholangioscopy directly visualized the common bile duct, common hepatic duct and left and right intrahepatic ducts. Saline lavage through the cholangioscope flushed debris and two 2-mm residual stones from the bile duct into the duodenum. No fluoroscope was used during the entire procedure. The patient tolerated the procedure well with clinical and laboratory resolution.
Multiple non-radiating techniques for ERCP in the pregnant patient have been described in the literature.[2-5] To date, 7 pregnant patients undergoing (including the current report) SpyGlass cholangioscopy–assisted ERCP have been reported.[5, 6] The technique allows for the limitation or elimination of ionizing radiation through direct intraductal visualization and stone clearance confirmation. The diagnostic and therapeutic capability of ERCP is increased in a manner that contributes to patient safety and hopefully better maternal and fetal outcomes. The availability of this equipment remains limited, but in institutions where the equipment and expertise is available, the use of direct intraductal visualization should play a role in the management for this common complication of pregnancy.
|
|
|
|
|
|
|
|