Outcome of a ‘step-up approach’ for recurrent cholangitis in patients with a non-stenotic hepaticojejunostomy after hepato-pancreato-biliary surgery: single center series

Background: Recurrent non-stenotic cholangitis (NSC) is a challenging and poorly understood complication of a surgical hepaticojejunostomy (HJ). Optimal treatment remains unclear. Methods: A retrospective single center series including patients with recurrent cholangitis with a non-stenotic HJ after hepato-pancreato-biliary surgery was conducted (2015–2022). Primary outcome was resolution of NSC (i.e. free of NSC during six months). Secondary outcomes included reduction of NSC monthly episode frequency and secondary sclerosing cholangitis. Results: Overall, 50 of 1179 (4.2%) patients with HJ developed NSC. Treatment included a ‘step-up approach’ with short-course antibiotics (n = 50, 100 %), prolonged antibiotics (n = 26, 52%), and revisional surgery (n = 7, 14 %). Resolution of NSC was achieved in 15 patients (30%) and reduction of NSC frequency in an additional 21 patients (42%). Concomitant ursodeoxycholic acid use and discontinuation of proton pump inhibitors was the only predictor for resolution (OR 4.229, p = 0.035). Secondary sclerosing cholangitis occurred in 12 patients (24%) and was associated with the number of NSC episodes (OR 1.2, p = 0.050). Conclusion: A ‘step-up approach’ to recurrent NSC after HJ resulted in 30 % resolution and further 42 % reduced frequency of NSC although still a quarter of patients developed secondary sclerosing cholangitis. Future prospective studies should assess whether a protocolized approach could improve outcomes.