Approach Considerations
Patients must be treated with a multidisciplinary approach by multiple subspecialists; therefore, referral to a tertiary center is prudent. Preferably, care should be rendered by individuals who are regional experts in therapeutic endoscopy, interventional radiology, and hepatobiliary surgery.
Medical care generally involves parenteral antibiotics, avoidance, and/or prompt recognition and treatment of complications. Patients who are malnourished require nutritional rehabilitation.
A biliary drainage procedure is necessary to achieve resolution of the initial infection and to pursue the ultimate goal of preventing further attacks of recurrent cholangitis. The choice of biliary drainage procedure should hinge on patient presentation, comorbidities, cholangiographic findings, and local expertise. To prevent further attacks of cholangitis, these patients are best treated using a multidisciplinary approach of interventional gastroenterology, interventional radiology, and gastrointestinal surgery. Referral to an institution with considerable experience in the management of complex biliary disease is prudent.
Initial biliary decompression is achieved at ERCP, which also allows for the delineation of the biliary tree, an essential step in the planning of the definitive decompressive procedure. Sphincterotomy, stricture dilatation, stone removal (using Dormia basket, balloon or lithotripsy [ie, mechanical, laser, electrohydraulic]) and placement of a biliary endoprosthesis (stent) often are necessary to achieve biliary decompression and, when appropriate, to alleviate stasis or luminal compromise in the biliary tree, thus preventing further episodes of pyogenic cholangitis. The results of endotherapy appear to be durable in well-selected patients. Multiple sessions may be required.
Following hospital discharge, careful follow-up with meticulous imaging studies and serial liver function tests is prudent. These studies often provide the first clue that full clearance of the bile ducts has not been achieved or that stone formation has recurred. Repeat interventions are frequently indicated.
Little or no data are available on prevention; however, an overall improvement in living standards appears to parallel a decline in incidence of this disease.
Medical Care
Ursodeoxycolic acid (UDCA) has no role as stones in recurrent pyogenic cholangitis (RPC) are pigmented stones.
Surgical Care
In some patients, initial medical management may fail and patients may require emergency surgery. These patients often have acute suppurative cholecystitis and require emergent surgical cholecystostomy (catheter drainage of the gall bladder) or choledochostomy (T-tube drainage of the common bile duct) or percutaneous cholecystostomy (as a temporizing measure). Definitive surgery is directed toward optimizing biliary outflow and is determined by the anatomical extent of involvement.
Surgery is necessary in patients who have concomitant cholelithiasis or complex hepatolithiasis. [9, 10] The surgical approach is based on the appearance at cholangiography and on axial imaging or MRCP [11] . Note the following:
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The usual surgical approach includes the following: (1) cholecystectomy, (2) intraoperative stone clearance, (3) intraoperative choledochoscopy (to document stone clearance) and (4) a definitive biliary drainage procedure.
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Definitive drainage procedures include operative sphincteroplasty and appropriate biliodigestive bypass.
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Many surgeons favor performing a Roux-en-Y choledochojejunostomy as close to the hilum as possible. An end-to-side biliary-enteric anastomosis is preferred to a side-to-side anastomosis. Access loop may be created by bringing the Roux limb to the parietes to enable access for reintervention (if necessary) which is achieved percutaneously or endoscopically.
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Patients with disease localized to one lobe of liver (usually left) or with atrophy of a lobe of the liver may require hepatectomy and biliary-enteric anastomosis.
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Reoperations are frequently required for recurrent stones.
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Patients with recurrent bilateral disease and those who develop secondary biliary cirrhosis and liver failure may need liver transplant. [12]
In a retrospective analysis, Lee et al looked at the outcomes of 85 patients who underwent any of the following treatments for recurrent pyogenic cholangitis: hepatectomy (65.9%); hepatectomy combined with drainage (9.4%); drainage alone (14.1%), and percutaneous choledochoscopy (10.6%). [13]
No operative moralities occurred, although 40% of patients suffered complications, half of them involving wound infections. Over a median follow-up period of 45.4 months, patients experienced a residual stone (21.2%), stone recurrence (16.5%), and biliary sepsis recurrence (21.2%), with the greatest incidence of these being in patients who had undergone drainage alone or had been treated with percutaneous choledochoscopy. [13]
In patients who had undergone hepatectomy alone or in combination with drainage, over a median follow-up period of 42.7 months, the frequency of residual stone was 15.6%, stone recurrence was 7.8%, and biliary sepsis recurrence was 9.4%. [13] Based on the study results, the authors recommended that hepatectomy should be considered the treatment of choice for suitable patients with recurrent pyogenic cholangitis. [13]
Ray et al conducted a retrospective review on the outcomes of all patients who underwent surgery for recurrent pyogenic cholangitis at their institution between August 2007 and February 2016 (N=94). They found that 32 postoperative complications developed in 27 patients (29%). After primary surgery, complete stone clearance was possible in 83% of patients, and 71 of 87 patients (81%) remained free of stones over a median follow-up period of 36 months. [14]
Consultations
Optimal management of these cases usually requires many consultants who must work in a synergistic fashion to achieve the desired optimal outcome. Potential consultants include interventional gastroenterologists, interventional radiologists, and hepatobiliary surgeons.
Infectious disease experts often help guide the investigation for and the treatment of concurrent helminthic infection.
In the minority of patients who present with the complication of cholangiocarcinoma, consultation with an oncology specialist is prudent.
