Surgical treatment of recurrent pyogenic cholangitis.

OBJECTIVE: To examine the evolving operative strategies in the treatment of recurrent pyogenic cholangitis (RPC).

DESIGN: Case series of patients with RPC treated surgically at the Los Angeles County-University of Southern California Medical Center between 1980 and 1994.

SETTING: Public teaching hospital.

PATIENTS: Twenty patients with RPC were studied. The clinical diagnosis of RPC was made in patients with a syndrome of chronic intermittent attacks of biliary sepsis associated with intrahepatic biliary strictures and intrahepatic stones.

MAIN OUTCOME MEASURE: The need for repeated biliary intervention after surgical treatment of RPC.

RESULTS: Four patients had a hepatic lobectomy without biliary enteric bypass. One patient had an uneventful course. Three patients had postoperative biliary sepsis, and one of these patients died. A hepaticojejunostomy without a cutaneous stoma was performed in eight patients. Five (63%) of these eight required repeated operation for biliary sepsis 1 to 4 years after surgery. In eight patients, a Roux-en-Y hepaticojejunostomy was performed after attempted clearance of intrahepatic stones with construction of a temporary cutaneous stoma. Postoperatively, these eight patients had 16 transstomal endoscopic cholangiograms (mean follow-up, 10 months). Stones proximal to intrahepatic strictures were identified in seven endoscopic sessions in five of these patients (63%). The stones were removed, and the strictures were endoscopically dilated. None required repeated biliary operation.

CONCLUSION: RPC is a progressive, lifelong disease. Construction of a hepaticojejunostomy with a cutaneous stoma allows future therapeutic intervention without the need for repeated surgery.