Dr. Amit D Goswami (General Surgery) needs a second opinion on this medical case.
A 27years female presented to us with pain abdomen, vomiting and abdominal distension for 1 day. 2 months back she presented to some other hospital and was treated conservatively. She had mitral valve replacement in 2008. On evaluation, she was diagnosed to be a case of gall stone pancreatitis with 5 weeks pregnancy. We treated her conservatively and discharged her after 7days of admission. She continued to have multiple episodes of vomiting and persistent pain abdomen. On 26th day of pain presented to casualty again. This time, her amylase was 3435U/L and total count was also raised. USG abdomen was suggestive of 10 x 8 cm pseudocyst, thick echogenic debris, slight compression of CBD. Was admitted under gastroenterology department and uneventfully discharged on 29th day of pain. We planned for Laparoscopic/Open Cystogastrostomy in mid second trimester. Around 2months of symptoms she was admitted for consideration of surgery. USG abdomen revealed a 14x7cm pseudocyst with gallstones. MRI was suggestive of a large pseudocyst with multiple gall stones. In view of her persistent pain abdomen and vomiting, there was no confusion that she requires a definitive intervention/drainage procedure. So, ultimately at 13weeks of her pregnancy, admitted her. We faced two main risks: firstly, there was chance of abortion and second in view of her previous history of rheumatic heart disease and mitral valve replacement, there was chance of cardiac vents. Now we were at jeopardy- what should be the type of drainage procedure (Surgical, percutaneous or endoscopic). Each of them had merits and demerits. Endoscopic procedure would have been least invasive, but because of large necrotic debris inside the pseudocyst, it did not look feasible. Percutaneous method would not drain the cyst completely because of the debris and there was chance of infection too. So, considering all pros and cons, we decided to go for surgery in the form of laparoscopy although, there was risk involved pertaining to mother and child as well. Obstetrician and cardiologist’s consultant was sought and their advises were incorporated in the management. Ultimately, we have successfully performed Laparoscopic Cysto-gastrostomy and Cholecystectomy. Fetal wellbeing was confirmed by USG. It has been 2months now and she is doing well. According to the latest SAGES (Society of American Gastrointestinal and Endoscopic Surgeons), laparoscopic Surgery is considered safe in pregnancy. But there are few words of caution. It should be done only there, where expertise is available, and every care is to be ensured for maternal and fetal wellbeing. Approx. in 30-40% cases of pseudocysts, it resolves spontaneously. Very few cases (<20) have been reported in literature on successful outcome in pseudocyst in pregnancy. We are happy to ensure such a safe outcome in this interesting cases.
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