HOW WE DO IT DIFFERENTLY
|Year : 2014 | Volume
| Issue : 1 | Page : 48-50
Combined laparoscopic cholecystectomy with ileostomy reversal: A method of delayed definitive management of postoperative gallstone pancreatitis
Gaurav V Kulkarni, Sharfi Sarker, Joshua M Eberhardt
Department of Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA
|Date of Submission||08-Jun-2012|
|Date of Acceptance||10-Nov-2012|
|Date of Web Publication||6-Jan-2014|
Gaurav V Kulkarni
Department of Surgery, Loyola University Medical Center, Maywood, Illinois 60153
Source of Support: None, Conflict of Interest: None
Traditional management of gallstone pancreatitis (GP) has been to perform cholecystectomy during the same hospital admission after resolution. However, when GP develops in the immediate postoperative period from a major colorectal operation, cholecystectomy may be fraught with difficulty due to the inflammatory response that occurs. Thus, delaying cholecystectomy until the inflammatory response subsides may be worthwhile, and it maximizes the chances of completing the cholecystectomy laparoscopically. We have described our management of 2 patients with GP occurring after colorectal operations, which required proximal diverting ileostomy. In both cases, we deferred management of GP with either endoscopic retrograde cholangiopancreatography (ERCP) or medical conservative measures during the acute attack and performed laparoscopic cholecystectomy during ostomy reversal surgery utilizing the existing ostomy takedown site for port placement. Both patients tolerated this management well.
Keywords: Colorectal resection, gall stone pancreatitis, ileostomy, laparoscopic cholecystectomy
|How to cite this article:|
Kulkarni GV, Sarker S, Eberhardt JM. Combined laparoscopic cholecystectomy with ileostomy reversal: A method of delayed definitive management of postoperative gallstone pancreatitis. J Min Access Surg 2014;10:48-50
|How to cite this URL:|
Kulkarni GV, Sarker S, Eberhardt JM. Combined laparoscopic cholecystectomy with ileostomy reversal: A method of delayed definitive management of postoperative gallstone pancreatitis. J Min Access Surg [serial online] 2014 [cited 2019 May 23];10:48-50. Available from: http://www.journalofmas.com/text.asp?2014/10/1/48/124482
| ¤ Introduction|| |
The traditional management of gallstone pancreatitis (GP) has been to perform cholecystectomy during the same hospital admission after resolution.  However, when GP develops in the immediate postoperative period from a major colorectal operation, cholecystectomy may be fraught with difficulty due to the inflammatory response that occurs. Thus, delaying cholecystectomy until the inflammatory response subsides may be worthwhile, and it maximizes the chances of completing the cholecystectomy laparoscopically. The best management strategy for GP under these circumstances is not well described. Here, we have described our management of 2 patients with GP occurring after colorectal operations requiring proximal diverting ileostomy.
A 31-year-old male with adenomatous polyposis coli gene mutation and familial adenomatous polyposis presented prophylactic surgical treatment. His preoperative endoscopic evaluation revealed no duodenal or ampullary pathology. He underwent an uncomplicated laparoscopic total proctocolectomy with ileal j-pouch anal anastomosis and diverting loop ileostomy. On postoperative day (POD) 8, he developed acute epigastric and right upper quadrant (RUQ) pain. His vital signs were normal and clinical exam was unrevealing. Laboratory studies revealed a white blood cell (WBC) count of 14,000, serum lipase and amylase of 1300, and normal bilirubin. Ultrasonography revealed gallbladder sludge. A diagnosis of GP was made. He was placed on bowel rest with IV hydration until pancreatitis improved clinically and biochemically. Cholecystectomy was deferred until planned ileostomy reversal. To decrease the risk of recurrent episodes of GP, endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP/S) was performed. He was discharged on POD 17. The patient then underwent ileostomy reversal and cholecystectomy as described below 6 weeks later.
A 44-year-old male with a history of sigmoid colectomy for endoscopically unresectable adenoma presented to us with rectal bleeding. Colonoscopy revealed recurrent sessile mass at the colorectal anastomosis. Biopsy revealed villous adenoma with high grade dysplasia. He underwent re-do low anterior resection with diverting loop ileostomy. He had an uneventful recovery and was discharged on POD 10. However, 4 days later he presented with epigastric and RUQ abdominal pain. The patient's clinical examination revealed mild epigastric tenderness. Laboratory studies revealed a WBC count of 13,000, lipase and amylase above 400, and normal bilirubin. Ultrasonography revealed gallstones (GS). GP was diagnosed and then managed non-operatively, similar to our first case. He refused ERCP/S. After discharging, the patient returned in 6 weeks for ileostomy reversal and cholecystectomy as described below.
In both cases, anastomosis was found to be healed on pouchogram and pouchoscopy at 6 weeks postoperatively. After establishing general anesthesia and administration of pre-incisional antibiotics, the operation began with mobilization of the ileostomy using a peristomal incision. The terminal portion of each limb was resected with a stapler. The proximal and distal portions were marked with different colored sutures and placed within the abdomen. The fascial defect was then closed to approximately 1.5≈cm. A 12-mm balloon-tipped port was placed through the residual defect for the laparoscope. Pneumoperitoneum was established. Three 5 mm ports were placed in the RUQ away from any intra-abdominal adhesions [Figure 1]. Laparoscopic cholecystectomy with cholangiogram was performed in the usual fashion. The gallbladder was removed using a laparoscopic specimen bag through the 12 mm port. Next, the fascial aperture was reopened. The two limbs of ileum were eviscerated in proper anatomic position using the colored sutures. A standard side-to-side stapled anastomosis was created. The fascia was then closed with interrupted absorbable sutures. The skin was left open. Both patients had unremarkable recoveries.
| ¤ Discussion|| |
About 20% of patients harboring asymptomatic GS develop symptoms requiring cholecystectomy 3-5 years following colorectal surgery.  The mechanism is unclear, but studies have implicated changes in the enterohepatic circulation and cholesterol metabolism. , The potential for GS related symptoms in these patients caused some to recommend cholecystectomy as an incidental procedure during the time of the index colorectal operation.  Proponents feel that this practice spares patients future complications and the morbidity of another operation. However, incidental surgery can be associated with additional risks and remains controversial.
Previous studies do not focus on the immediate postoperative period or comment on GP specifically. Therefore, the true incidence of this particular postoperative complication is unknown. In the absence of good data, we must rely on what is known about managing routine GP. Most patients presenting with GP undergo cholecystectomy during the same hospital admission to prevent the potential morbidity of future bouts. In our cases, both patients had recent major operations and were within the maximal inflammatory response phase. As such, we felt that delaying cholecystectomy would be preferable. This is also supported by the literature in the management of severe GS pancreatitis.  ERCP/S can be used as a temporizing procedure to prevent recurrent episodes of GP while awaiting cholecystectomy.  In addition, both of our patients had stomas that were planned to be reversed 6-8 weeks after the initial operation and, thus, provided the opportunity for a combined operation.
The technique we used is straightforward. Ports for laparoscopic procedures are routinely placed at sites of planned stomas in order to minimize the number of incisions.  Using the stoma site for the camera avoids an extra incision and is away from the midline, where adhesions are expected from previous operations. We feel that delaying the completion of the anastomosis until after cholecystectomy and marking the proximal and distal limbs are important to avoid trauma to the anastomosis and to prevent un-intended twisting of the bowel.
| ¤ Conclusion|| |
Complications attributable to GS in the immediate postoperative period following colorectal surgery are difficult to manage. When the complication is GP, the episode is mild and resolves with non-operative measures, it may be preferable to delay cholecystectomy until the postoperative inflammatory response subsides. When the index operation is the first stage of a planned 2-stage operation, delaying the cholecystectomy seems even more attractive. As seen in these two cases, the fascial aperture of the ileostomy site can be easily used for the laparoscope, and combining the two operations is straightforward.
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