SURGICAL-TREATMENT OF RECURRENT PYOGENIC CHOLANGITIS

Objective: To examine the evolving operative strategies in the treatme nt of recurrent pyogenic cholangitis (RPC). Design: Case series of pat ients 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 stu died. The clinical diagnosis of RPC was made in patients with a syn dr ome 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 tre atment of RPC. Results: Four patients had a hepatic lobectomy without biliary enteric bypass. One patient had an uneventful course. Three pa tients had postoperative biliary sepsis, and one of these patients die d. A hepaticojejunostomy without a cutaneous stoma was performed in ei ght patients. Five (63%) of these eight required repeated operation fo r biliary sepsis 1 to 4 years after surgery. In eight patients, a Roux -en-Y hepaticojejunostomy was performed after attempted clearance of i ntrahepatic stones with construction of a temporary cutaneous stoma. P ostoperatively, these eight patients had 16 transstomal endoscopic cho langiograms (mean follow-up, 10 months). Stones proximal to intrahepat ic 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. Con clusion: RPC is a progressive, lifelong disease. Construction of a hep aticojejunostomy with a cutaneous stoma allows future therapeutic inte rvention without the need for repeated surgery.