Abstract
Introduction
Current guidelines support laparoscopic cholecystectomy as the treatment of choice for pregnant women with symptomatic gallbladder disease, regardless of the trimester. Early intervention has remained the standard of care, but recent evidence has challenged this practice in pregnant women. We sought to compare surgical and maternal–fetal outcomes of antepartum versus postpartum cholecystectomy in New York State.
Methods
Between 2005 and 2014, the New York Statewide Planning and Research Cooperative System (SPARCS) database was queried for patients who underwent cholecystectomy within 3 months before (antepartum cholecystectomy, APCCY: n = 82) and after (postpartum cholecystectomy, PPCCY: n = 5040) childbirth to approximate third-trimester operations. All patients who underwent cholecystectomy during pregnancy (n = 971) were extracted to evaluate inter-trimester differences. Subgroup analysis compared APCCY patients who were not hospitalized within 1 year before APCCY (n = 80) and PPCCY patients who were hospitalized within 1 year before childbirth (n = 29) for symptomatic biliary disease. Multivariable generalized linear regression models were used to characterize the association between timing of cholecystectomy and several primary outcomes: length of stay (LOS), 30-day non-pregnancy, non-delivery readmission (NPND), bile duct injury (BDI), composite maternal outcome (antepartum hemorrhage, preterm delivery, cesarean section), any complications, and fetal demise.
Results
Third-trimester APCCY women had longer LOS (Ratio: 1.44, 95% CI [1.26–1.66], p < 0.0001) and greater incidence of preterm delivery (OR 2.54, 95% CI [1.37–4.43], p = 0.0019). Cholecystectomy timing was not independently associated with differences in composite maternal outcome (p = 0.1480), BDI (p = 0.2578), 30-day NPND readmission (p = 0.7579), any complications (p = 0.2506), and fetal demise (2.44% versus 0.44%, p = 0.0545). Subgroup analysis revealed no differences in any of the seven outcomes.
Conclusions
New York Statewide data suggest that although laparoscopic cholecystectomy is safe in pregnancy, delay of cholecystectomy should be discussed in the third trimester due to an increased risk for preterm delivery.
Similar content being viewed by others
References
Mendez-Sanchez N, Chavez-Tapia NC, Uribe M (2006) Pregnancy and gallbladder disease. Ann Hepatol 5(3):227–230
Lydon-Rochelle M, Holt VL, Martin DP, Easterling TR (2000) Association between method of delivery and maternal rehospitalization. J Am Med Assoc 283:2411–2416. https://doi.org/10.1001/jama.283.18.2411
Ko CW, Beresford SAA, Schulte SJ, Matsumoto AM, Lee SP (2005) Incidence, natural history, and risk factors for biliary sludge and stones during pregnancy. Hepatology 41:359–365. https://doi.org/10.1002/hep.20534
Bolukbas FF, Bolukbas C, Horoz M, Ince AT, Uzunkoy A, Ozturk A, Aka N, Demirci F, Inci E, Ovunc O (2006) Risk factors associated with gallstone and biliary sludge formation during pregnancy. J Gastroenterol Hepatol 21:1150–1153. https://doi.org/10.1111/j.1440-1746.2006.04444.x
Ibiebele I, Schnitzler M, Nippita T, Ford JB (2017) Outcomes of gallstone disease during pregnancy: a population-based data linkage study. Paediatr Perinat Epidemiol 31:522–530. https://doi.org/10.1111/ppe.12406
Sedaghat N, Cao AM, Eslick GD, Cox MR (2017) Laparoscopic versus open cholecystectomy in pregnancy: a systematic review and meta-analysis. Surg Endosc 31:673–679. https://doi.org/10.1007/s00464-016-5019-2
Nasioudis D, Tsilimigras D, Economopoulos KP (2016) Laparoscopic cholecystectomy during pregnancy: a systematic review of 590 patients. Int J Surg 27:165–175
Sachs A, Guglielminotti J, Miller R, Landau R, Smiley R, Li G (2017) Risk factors and risk stratification for adverse obstetrical outcomes after appendectomy or cholecystectomy during pregnancy. JAMA Surg 152:436–441. https://doi.org/10.1001/jamasurg.2016.5045
Veerappan A, Gawron AJ, Soper NJ, Keswani RN (2013) Delaying cholecystectomy for complicated gallstone disease in pregnancy is associated with recurrent postpartum symptoms. J Gastrointest Surg 17:1953–1959. https://doi.org/10.1007/s11605-013-2330-2
Dhupar R, Smaldone GM, Hamad GG (2010) Is there a benefit to delaying cholecystectomy for symptomatic gallbladder disease during pregnancy? Surg Endosc 24:108–112. https://doi.org/10.1007/s00464-009-0544-x
Jackson H, Granger S, Price R, Rollins M, Earle D, Richardson W, Fanelli R (2008) Diagnosis and laparoscopic treatment of surgical diseases during pregnancy: an evidence-based review. Surg Endosc 22:1917–1927
Rollins MD, Chan KJ, Price RR (2004) Laparoscopy for appendicitis an d cholelithiasis during pregnancy: a new standard of care. Surg Endosc 18:237–241
Paramanathan A, Walsh SZ, Zhou J, Chan S (2015) Laparoscopic cholecystectomy in pregnancy: an Australian retrospective cohort study. Int J Surg 18:220–223. https://doi.org/10.1016/j.ijsu.2015.05.005
Visser BC, Glasgow RE, Mulvihill KK, Mulvihill SJ (2001) Safety and timing of nonobstetric abdominal surgery in pregnancy. Dig Surg 18:409–417. https://doi.org/10.1159/000050183
Fong ZV, Pitt HA, Strasberg SM, Molina RL, Perez NP, Kelleher CM, Loehrer AP, Sicklick JK, Talamini MA, Lillemoe KD, Chang DC (2019) Cholecystectomy during the third trimester of pregnancy: proceed or delay? J Am Coll Surg 228:494–502.e1. https://doi.org/10.1016/j.jamcollsurg.2018.12.024
Fong ZV, Pitt HA, Strasberg SM, Loehrer AP, Sicklick JK, Talamini MA, Lillemoe KD, Chang DC (2018) Diminished survival in patients with bile leak and ductal injury: management strategy and outcomes. J Am Coll Surg 226:568–576.e1. https://doi.org/10.1016/j.jamcollsurg.2017.12.023
Sheffield KM, Riall TS, Han Y, Kuo YF, Townsend CM, Goodwin JS (2013) Association between cholecystectomy with vs without intraoperative cholangiography and risk of common duct injury. JAMA J Am Med Assoc 310:812–820. https://doi.org/10.1001/jama.2013.276205
Altieri MS, Brunt LM, Yang J, Zhu C, Talamini MA, Pryor AD (2019) Early cholecystectomy (< 72 h) is associated with lower rate of complications and bile duct injury: a study of 109,862 cholecystectomies in the state of New York. Surg Endosc. https://doi.org/10.1007/s00464-019-07049-6
Peduzzi P, Concato J, Kemper E, Holford TR, Feinstem AR (1996) A simulation study of the number of events per variable in logistic regression analysis. J Clin Epidemiol 49:1373–1379. https://doi.org/10.1016/S0895-4356(96)00236-3
Blohm M, Österberg J, Sandblom G, Lundell L, Hedberg M, Enochsson L (2017) The sooner, the better? The importance of optimal timing of cholecystectomy in acute cholecystitis: data from the national swedish registry for gallstone surgery, gallriks. J Gastrointest Surg 21:33–40. https://doi.org/10.1007/s11605-016-3223-y
Hedström J, Nilsson J, Andersson R, Andersson B (2017) Changing management of gallstone-related disease in pregnancy–a retrospective cohort analysis. Scand J Gastroenterol 52:1016–1021. https://doi.org/10.1080/00365521.2017.1333627
Othman MO, Stone E, Hashimi M, Parasher G (2012) Conservative management of cholelithiasis and its complications in pregnancy is associated with recurrent symptoms and more emergency department visits. YMGE 76:564–569. https://doi.org/10.1016/j.gie.2012.04.475
Jorge AM, Keswani RN, Veerappan A, Soper NJ, Gawron AJ (2015) Non-operative management of symptomatic cholelithiasis in pregnancy is associated with frequent hospitalizations. J Gastrointest Surg 19:598–603. https://doi.org/10.1007/s11605-015-2757-8
Eddy JJ, Gideonsen MD, Song JY, Grobman WA, O’Halloran P (2008) Pancreatitis in pregnancy. Obstet Gynecol 112:1075–1081. https://doi.org/10.1097/AOG.0b013e318185a032
Juo Y-Y, Khrucharoen U, Sanaiha Y, Seo Y-J, Dutson E, Benharash P (2018) Cumulative financial burden of readmissions for biliary pancreatitis in pregnant women. Obstet Gynecol 132:415–422. https://doi.org/10.1097/AOG.0000000000002740
Hernandez A, Petrov MS, Brooks DC, Banks PA, Ashley SW, Tavakkolizadeh A (2007) Acute pancreatitis and pregnancy: a 10-year single center experience. J Gastrointest Surg 11:1623–1627. https://doi.org/10.1007/s11605-007-0329-2
Raju TNK (2017) The “late preterm” birth-ten years later. Pediatrics 139:e20163331
Cheong JL, Doyle LW, Burnett AC, Lee KJ, Walsh JM, Potter CR, Treyvaud K, Thompson DK, Olsen JE, Anderson PJ, Spittle AJ (2017) Association between moderate and late preterm birth and neurodevelopment and social-emotional development at age 2 years. JAMA Pediatr 171:e164805–e164805. https://doi.org/10.1001/jamapediatrics.2016.4805
Date RS, Kaushal M, Ramesh A (2008) A review of the management of gallstone disease and its complications in pregnancy. Am J Surg 196:599–608. https://doi.org/10.1016/j.amjsurg.2008.01.015
Ko CW (2006) Risk factors for gallstone-related hospitalization during pregnancy and the postpartum. Am J Gastroenterol 101:2263–2268. https://doi.org/10.1111/j.1572-0241.2006.00730.x
U.S. Census Bureau QuickFacts: New York. https://www.census.gov/quickfacts/NY. Accessed 18 Mar 2020
U.S. Census Bureau QuickFacts: California. https://www.census.gov/quickfacts/CA. Accessed 18 Mar 2020
Acknowledgements
We acknowledge the biostatistical consultation and support provided by the Biostatistical Consulting Core at School of Medicine, Stony Brook University.
Author information
Authors and Affiliations
Corresponding author
Ethics declarations
Disclosures
Dr. Pryor is a speaker for Gore and Merck. She participates on a scientific advisory board for Obalon. Dr. Spaniolas has research support from Merck and a speaker for Gore. Dr. Hong, Dr. Yang, Ms. Zhang, Dr. Su, Dr. Tumati, Dr. Garry, Dr. Docimo, Dr. Bates, and Dr. Talamini have no relevant disclosures to report.
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Electronic supplementary material
Below is the link to the electronic supplementary material.
Rights and permissions
About this article
Cite this article
Hong, J., Yang, J., Zhang, X. et al. Considering delay of cholecystectomy in the third trimester of pregnancy. Surg Endosc 35, 4673–4680 (2021). https://doi.org/10.1007/s00464-020-07910-z
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00464-020-07910-z