Recurrent pyogenic cholangitis with hepatolithiasis--the role of surgical therapy in North America.

PURPOSE: To determine role of surgical intervention for Recurrent Pyogenic Cholangitis with hepatolithiasis at a North American hepatobiliary center.

METHODS: Retrospective analysis of 42 patients presenting between 1986 and 2005.

RESULTS: Mean age is 54.3 years (24-87). Twenty-seven patients (64%) underwent surgery, after unsuccessful endoscopic retrograde cholangiopancreatography (ERCP) or percutaneous intervention in 19/27 patients. Surgical procedures were: 10 common bile duct explorations with choledochojejunostomy and a Hutson loop and 17 hepatectomies (10 with, 7 without Hutson loop). Liver resection was indicated for lobar atrophy or stones confined to single lobe. Operative mortality was zero; complication rates for hepatectomy and common bile duct exploration were comparable (35% vs. 30%). Median follow-up was 24 months (3-228). Of 21 patients with Hutson loops, only seven (33%) needed subsequent loop utilization, with three failures. At last follow-up, 4/27 (15%) surgical patients had stone-related symptoms requiring percutaneous intervention, compared to 4/11 (36%) surviving nonoperative patients. Cholangiocarcinoma was identified in 5/42 (12%) patients; four were unresectable and one was an incidental in-situ carcinoma in a resected specimen.

CONCLUSION: Surgery is a valuable part of multidisciplinary management of recurrent pyogenic cholangitis with hepatolithiasis. Hepatectomy is a useful option for selected cases. Hutson loops are useful in some cases for managing stone recurrence. Cholangiocarcinoma risk is elevated in this disease.