Systematic Review
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Oct 16, 2018; 10(10): 308-321
Published online Oct 16, 2018. doi: 10.4253/wjge.v10.i10.308
Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography
Mitchell S Cappell, Stavros Nicholas Stavropoulos, David Friedel
Mitchell S Cappell, Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
Mitchell S Cappell, Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, United States
Stavros Nicholas Stavropoulos, David Friedel, Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY 11501, United States
Author contributions: Cappell MS had the most important contributions to the organization, writing, and editing of the manuscript; Stavropoulos SN and Friedel D contributed very significantly to all aspects of the paper, including the organization, writing, and editing of the manuscript; the final manuscript was reviewed, corrected, and approved by all three authors.
Conflict-of-interest statement: All authors have no conflicts of interest to report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Mitchell S Cappell, FACG, MD, PhD, Chief Doctor, Professor, Division of Gastroenterology and Hepatology, William Beaumont Hospital, 3535 W. Thirteen Mile Road, Royal Oak, MI 48073, United States. mitchell.cappell@beaumont.edu
Telephone: +11-1248-5511227 Fax: +11-1248-5517581
Received: April 28, 2018
Peer-review started: April 28, 2018
First decision: May 18, 2018
Revised: July 13, 2018
Accepted: August 26, 2018
Article in press: August 27, 2018
Published online: October 16, 2018
Processing time: 171 Days and 10.9 Hours
ARTICLE HIGHLIGHTS
Research background

Endoscopic retrograde cholangiopancreatography (ERCP) is currently the standard technique for treating choledocholithiasis and associated complications, such as cholangitis, biliary pancreatitis, and biliary stricture, in the non-pregnant population. The approach in pregnant women with suspected choledocholithiasis, however, differs somewhat from that for non-pregnant patients because of concerns about the pregnant mother and the fetus, including procedure time, teratogenicity of intraprocedural medications, and fetal radiation exposure.

Research motivation

This work systematically collates the clinical data from the clinical studies, including the numerous small clinical series, to render these data accessible to clinicians. This work provides a systematic review of the rapidly evolving literature in this clinically booming field to provide highly important and clinically relevant updates on ERCP safety, efficacy, and recent technical improvements in pregnant patients.

Research objectives

This work reports numerous techniques to reduce radiation exposure and other safety precautions to decrease fetal risk from ERCP during pregnancy. Indeed, this work discusses in detail radiation free ERCP during pregnancy to completely eliminate teratogenic risks of radiation.

Research methods

This review encompassed more than 500 cases published in small clinical series and scattered reports, in addition to 58 cases recently reported in a retrospective Swedish registry study.

Research results

This work focuses on techniques to improve ERCP safety during pregnancy, including analysis of the relatively recently introduced radiation-free ERCP to completely eliminate the potential for radiation teratogenicity. Radiation-free ERCP is shown to be a relatively safe, and efficacious technique. However, more clinical data are required on this promising technique.

Research conclusions

This work shows that therapeutic ERCP is a reasonably safe therapy for the mother and the fetus during pregnancy, and it should be performed when indicated for symptomatic choledocholithiasis and its associated complications (including ascending cholangitis, gallstone pancreatitis, and biliary stricture) during pregnancy. This work confirms that solely diagnostic ERCP should generally not be performed during pregnancy due to the risks of fetal radiation teratogenesis and induction of early labor, and should be replaced by diagnostic MRCP or endoscopic ultrasound. ERCP should not be performed during pregnancy for asymptomatic stones because of potential fetal risks; ERCPs can often be delayed to postpartum because patients have minimal clinical findings, or patients can directly undergo cholecystectomy during pregnancy without antecedent ERCP for acute cholecystitis.

Research perspectives

More data are needed on radiation-free ERCPs. This work describes technique modifications for therapeutic ERCP during pregnancy to improve procedural safety. It is hoped that clinicians adapt these technique modifications during ERCP to further improve ERCP safety and efficacy during pregnancy.