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SpyGlass cholangioscopy for management of choledocholithiasis during pregnancy

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.

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

1 Chong VH, Jalihal A. Endoscopic management of biliary disorders during pregnancy. Hepatobiliary Pancreat Dis Int 2010;9:180-185.

2 Simmons DC, Tarnasky PR, Rivera-Alsina ME, Lopez JF, Edman CD. Endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy without the use of radiation. Am J Obstet Gynecol 2004;190:1467-1469.

3 Akcakaya A, Ozkan OV, Okan I, Kocaman O, Sahin M. Endoscopic retrograde cholangiopancreatography during pregnancy without radiation. World J Gastroenterol 2009;15: 3649-3652.

4 Pasquale L, Caserta L, Rispo A, Biondi V, Rossi M, Ciccarelli A, et al. Endoscopic management of symptomatic choledocholithiasis in pregnancy without the use of radiations. Eur Rev Med Pharmacol Sci 2007;11:343-346.

5 Shelton J, Linder JD, Rivera-Alsina ME, Tarnasky PR. Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos). Gastrointest Endosc 2008;67:364-368.

6 Girotra M, Jani N. Role of endoscopic ultrasound/SpyScope in diagnosis and treatment of choledocholithiasis in pregnancy. World J Gastroenterol 2010;16:3601-3602.

The Author Reply:

We thank Dr. Uradomo et al for their interest in our recent publication on biliary interventions during pregnancy and value their views on one of the latestinnovation for biliary interventions without radiation exposure.[1]We fully agree with their comments that such technologies should be evaluated and adopted into clinical practice. However, in any interventions including those carried out during pregnancy, several principles should be adhered to.

First, the indication for interventions should be appropriate and procedures should be carefully planned out. Second, once interventions have been decided, the modality best suited for the situation and one that the endoscopist is most comfortable with should be used. This is taking into account that in the more equipped centers, multiple modalities may be available. Obviously in centers where the latest equipments such as the SpyGlass Direct Visualization System (Boston Scienti fic, Natick, MA, USA) are available, this should be considered especially if the expertise is also available. In carrying out biliary interventions, achieving the desired outcomes, namely biliary decompression and stones clearance in the shortest time possible, is very important. This can be done with (traditional intervention with proper precautions i.e. lead shielding and minimal fluoroscopy time) or without the use of fluoroscopy (SpyGlass, intraductal ultrasound, endoscopic ultrasound, wire guided cannulation and stone extraction); some has yet to be reported in pregnancy.[2-5]It is important to note that use of nonfluoroscopy interventions may actually prolong the overall duration of the procedure due to learning curves and technical experiences of endoscopists and hence increase the risk, especially in dif ficult cases. Furthermore, in our daily practice, non- fluoroscopy modalities are not often used. Therefore, we should not hesitate to use fluoroscopy if required with the knowledge that limited radiation exposure is safe during pregnancy.[6]Despite this, we fully agree that newer modalities that can negate fluoroscopy should be included into our armamentarium.

Vui Heng Chong and Anand Jalihal,

Division of Gastroenterology and Hepatology,

Department of Medicine,

RIPAS Hospital,

Bandar Seri Begawan BA 1710,

Brunei Darussalam

Email: chongvuih@yahoo.co.uk

References

1 Chong VH, Jalihal A. Endoscopic management of biliary disorders during pregnancy. Hepatobiliary Pancreat Dis Int 2010;9:180-185.

2 Girotra M, Jani N. Role of endoscopic ultrasound/SpyScope in diagnosis and treatment of choledocholithiasis in pregnancy. World J Gastroenterol 2010;16:3601-3602.

3 Levy MJ. Therapeutic endoscopic ultrasound for biliary and pancreatic disorders. Curr Gastroenterol Rep 2010;12:141-149.

4 Ang TL, Teo EK, Fock KM, Lyn Tan JY. Are there roles for intraductal US and saline solution irrigation in ensuring complete clearance of common bile duct stones? Gastrointest Endosc 2009;69:1276-1281.

5 Shelton J, Linder JD, Rivera-Alsina ME, Tarnasky PR. Commitment, confirmation, and clearance: new techniques for nonradiation ERCP during pregnancy (with videos). Gastrointest Endosc 2008;67:364-368.

6 Tham TC, Vandervoort J, Wong RC, Montes H, Roston AD, Slivka A, et al. Safety of ERCP during pregnancy. Am J Gastroenterol 2003;98:308-311.