Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography

Table 4 Literature review of case series of radiation-free endoscopic retrograde cholangiopancreatography during pregnancy

First author, yr, reference	Number reported	Indications	Technique of radiation-free ERCP	Outcomes
Shah 2016[75]	Non-radiation ERCP attempted-31 non-pregnant subjects. 26 successfully underwent ERCP without fluoroscopy. 5 required fluoroscopy during ERCP	Adult patients with suspected biliary stones based on abnormal serum liver tests, abdominal imaging, and/or abdominal pain. Underwent EUS per protocol. Patients with suspected large stone burden, complicated stone disease, or difficult anatomy were excluded	Antecedent EUS used as a guide before ERCP. Selective cannulation confirmed by aspirating visible bile in 26 patients. 5 patients required radiation for double wire or precut papillotomy. All patients had EUS. 4 others had ERCP obviated by EUS	No adverse events among patients who underwent bile cannulation, sphincterotomy, and stone removal without fluoroscopy. One patient undergoing ERCP with fluoroscopy had moderated post-ERCP pancreatitis
Ersoz 2016[74]	22 patients: first trimester-2, second trimester-3, third trimester-17	Abdominal ultrasound demonstrates stone/sludge in gallbladder-22 (100%), choledocholithiasis-12, mean total bilirubin = 5.49 ± 1.66 mg/dL, acute cholangitis-2, acute cholecystitis-2	Selective biliary cannulation attempted with sphincterotome and confirmed by bile aspiration. Biliary sphincterotomy and balloon dilation-18/22 had visible gallstones, 3 required transpancreatic papillary septotomy	5 complications after ERCP: epigastric pain without elevated lipase elevation-2, mild pancreatitis treated conservatively-2, minor post-sphincterotomy bleeding successfully treated with epinephrine injection without blood transfusions. All delivered healthy infants at term
Sethi S, 2015[73]	3 patients: 14, 7, or 28 wk pregnant	1 and 2-Dilated CBD and total bilirubin > 5.0 mg/dL after laparoscopic cholecystectomy, 3-Dilated CBD, multiple gallstones and increased total bilirubin level	All cases: EUS-guided ERCP with selective biliary cannulation confirmed by bile aspiration. Biliary sphincterotomy and stone extraction(s) using balloon sweeps or Spyglass technology	Uncomplicated. All mothers did well-rapidly discharged from hospital. Fetal outcomes not reported
Agcaoglu O, 2013[72]	5 patients: mean gestational age = 20 wk, range 12-32 wk	Gallstone pancreatitis and obstructive jaundice-3, cholangitis and obstructive jaundice-2	Selective cannulation confirmed by aspiration or direct visualization of bile. After CBD cannulated guide-wire passed, sphincterotomy completed, and stones extracted by basket or balloon sweep	No maternal or fetal adverse events or short term complications. No long-term follow-up available
Yang J, 2013[71]	24 patients: first or second trimester-9, third trimester-15	All patients had severe biliary pancreatitis. Leukocyte count 15000-29000 × 106/L, serum amylase: 500-2000 units/L, increased bilirubin in 20	All patients underwent emergency ERCP without fluoroscopy and endoscopic biliary drainage. 15 patients in third trimester had pregnancy terminated: induced delivery-7, cesarean section-6, full-term normal delivery-2. Then underwent second ERCP with fluoroscopy to remove gallstones. 9 patients in early pregnancy underwent endoscopic retrograde biliary drainage in second ERCP without fluoroscopy. Had biliary stent for average of 3.8 mo	100% technical success rate: CBD stones removed in all 24 patients. Only 2 maternal complications: mild hemorrhage during second ERCP. All infants born healthy. At term births-20, premature births-4 with cesarean section (for severe intrauterine distress)
Huang P, 2017[70]	86 patients (largest series): no fluoroscopy-81 ultra-short duration of fluoroscopy-5. Mean gestational age = 22.5 wk, Range: 15-35 wk	Acute biliary pancreatitis-32, acute cholangitis-23, dilated CBD-20, severe nonbiliary acute pancreatitis-11	Underwent antecedent abdominal ultrasound or MRCP. CBD cannulated using a guide-wire and then catheter over guide-wire. CBD cannulation confirmed by aspiration or oozing of bile. Then endoscopic biliary sphincterotomy and endoscopic nasobiliary drainage or retrograde biliary drainage. 51 had biliary stents	Technical success: 81 without fluoroscopy.Complications in 8.1%:Biliary bleeding-2, acute cholecystitis-1, post-ERCP pancreatitis-2. All babies were healthy at up to 12 mo. follow-up. All babies had normal birth weights (> 3 kg). Mean Apgar score at 5 min = 9
Akcakaya A, 2009[69]	6 patients: mean gestational age = 23 wk, range: 14-34 wk	Choledocholithiasis-4, Cholangitis-1, Persistent biliary fistula after hydatid disease surgery-1 (undergoing 2 ERCPs)	All patients had biliary sphincterotomy and balloon sweeps. Precut sphincterotomy performed with needle-knife for 1 patient with impacted stone	Complete stone extraction confirmed by abdominal ultrasound. No post-ERCP complications, premature birth, abortion or intrauterine growth retardation were observed
Shelton J, 2008[68]	21 patients: first trimester-7, second trimester-9, third trimester-5	Jaundice and biliary colic-11, biliary pancreatitis-8, cholecystitis-1, abnormal intraoperative cholangiogram-1	Guide-wire inserted into CBD followed by sphincterotome over guide-wire. CBD cannulation then confirmed by suction of yellow bile via catheter in first 10 cases. In next 11 cases CBD cannulation confirmed by leakage of yellow bile around guide-wire. Then wire-guided biliary sphincterotomy performed followed by balloon sweeps to extract stones. Choledochoscopy used for bile duct clearance in 5 last cases	100% technical success without fluoroscopy. One case of moderate pancreatitis. All then became asymptomatic. Follow-up of 18 pregnancies: Uneventful delivery of healthy babies-17, premature delivery at 35 wk with low birth weight-1
Sharma SS, 2008[64]	11 patients: first trimester-2, second trimester-6, third trimester-3	Abdominal pain and jaundice-11, cholangitis-2, dilated CBD-11, gallstones-8	All had 2-stage procedures. First stage during pregnancy: biliary sphincterotomy and stenting without radiation, bile aspirated to confirm biliary cannulation. Second stage ERCP postpartum: Stents removed, cholangiogram performed. Stones removed by Dormia basket-8, mechanical lithotripsy-1, or open surgery-1, no residual stones-1	Marked symptomatic improvement after first stage of therapy. All had normal, full-term delivery. “Good” maternal and fetal outcomes

ERCP: Endoscopic retrograde cholangiopancreatography; EUS: Endoscopic ultrasound; CBD: Common bile duct; MRCP: Magnetic resonance cholangiopancreatography.