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
, 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 .
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 .
laboratory studies revealed a white blood cell ( wbc ) count of 14,000 , serum lipase and amylase of 1300 , and normal bilirubin .
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 ,
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 .
laboratory studies revealed a wbc count of 13,000 , lipase and amylase above 400 , and normal bilirubin .
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 proximal and distal portions were marked with different colored sutures and placed within the abdomen .
a 12-mm balloon - tipped port was placed through the residual defect for the laparoscope .
three 5 mm ports were placed in the ruq away from any intra - abdominal adhesions [ figure 1 ] .
the two limbs of ileum were eviscerated in proper anatomic position using the colored sutures .
a 31-year - old male with adenomatous polyposis coli gene mutation and familial adenomatous polyposis presented prophylactic surgical treatment .
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 .
laboratory studies revealed a white blood cell ( wbc ) count of 14,000 , serum lipase and amylase of 1300 , and normal bilirubin .
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 .
a 44-year - old male with a history of sigmoid colectomy for endoscopically unresectable adenoma presented to us with rectal bleeding .
laboratory studies revealed a wbc count of 13,000 , lipase and amylase above 400 , and normal bilirubin .
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 proximal and distal portions were marked with different colored sutures and placed within the abdomen .
a 12-mm balloon - tipped port was placed through the residual defect for the laparoscope .
three 5 mm ports were placed in the ruq away from any intra - abdominal adhesions [ figure 1 ] .
the two limbs of ileum were eviscerated in proper anatomic position using the colored sutures .
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 .
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 ,
most patients presenting with gp undergo cholecystectomy during the same hospital admission to prevent the potential morbidity of future bouts . in our cases ,
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 .
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 .
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 .
 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 . 
INTRODUCTION
Case 1
Case 2
Surgical Technique
DISCUSSION
CONCLUSION