COEXISTING SHARP DUCTAL ANGULATION WITH INTRAHEPATIC BILIARY STRICTURES IN RIGHT HEPATOLITHIASIS

Objective: To investigate the clinical characteristics of a coexisting sharp ductal angulation (<90 degrees) with biliary stricture and to e valuate the difficulties it imposes in the management of retained or r ecurrent hepatolithiasis. Design: Case-controlled study. Setting: A re ferral center. Patients: Eighteen consecutive patients having right-si ded hepatolithiasis and a coexisting sharp ductal angulation associate d with biliary stricture (group 1) were compared with 84 patients matc hed with sex, age, and conditions of hepatolithiasis and intrahepatic biliary stricture(s) but no sharp angulated duct (group 2). Interventi on: Postoperative cholangioscopic management (electrohydraulic lithotr ipsy or other lithotripsy, lithotomy, balloon dilation, biopsy, etc, v ia T-tube tract or percutaneous transhepatic route). Main Outcome Meas ures: Sessions of manipulations, incidence of complications associated with interventions or disease, and mortality were compared. Results: Patients of group 1 needed more sessions of postoperative manipulation of stones and strictures (13.7+/-4.2 vs 8.0+/-2.3; P<.001). During ma nagement, there was a significantly increased vulnerability of severe and/or recurrent cholangitis (66.7% vs 9.5%; P<.001), septic shock (77 .8% vs 11.9%; P<.001), liver abscess (55.6% vs 7.1%; P<.001), or massi ve hemobilia (33.3% vs 7.4%) in group 1 than in group 2. Their risks o f coexisting secondary biliary cirrhosis (55.6% vs 9.5%; P<.001) and/o r cholangiocarcinoma, (16.6% vs 2.4%; P<.04) and mortality (27.8% vs 4 .8%; P<.01) were also significantly higher in group 1. Conclusion: Our results suggest that the coexisting sharp ductal angulation with bili ary strictures in right-sided hepatolithiasis is a distinct difficult Clinical entity in the field of biliary tract calculi.