Xanthogranulomatous inflammatory strictures of extrahepatic biliary tract: presentation and surgical management

Xanthogranulomatous cholecystitis (XGC) is a benign, invasive variant of chronic cholecystitis. Invasion of common bile duct (CBD), termed as xanthogranulomatous choledochitis, may mimic malignancy. We describe clinico-pathological features and management of xanthogranulomatous inflammatory biliary strictures.

A review of a prospectively maintained database for XGC was performed.

Out of 6,150 cholecystectomies performed, 620 patients had XGC (10% incidence). Four patients had biliary strictures with xanthogranulomatous choledochitis on final histology. All four patients presented with jaundice and history of cholangitis. Ultrasonography revealed gallstones and thick-walled gallbladder in all. Two patients had hilar strictures: one had mid-CBD stricture and one had a lower-CBD stricture with a dilated pancreatic duct. In all four patients, preoperative diagnosis of malignancy was entertained. Three patients underwent resection-CBD excision for mid-CBD stricture, pancreaticoduodenectomy for lower-end stricture, and right hepatectomy for hilar stricture with atrophy-hypertrophy complex. One patient with unresectable hilar stricture underwent hepaticojejunostomy.

Xanthogranulomatous choledochitis may be considered as one of the differential diagnosis in patients with biliary stricture especially in a geographical area with a high incidence of XGC, when a patient harbors gall stones and had thick-walled gall bladder on imaging. This stricture can be found anywhere in the biliary tree from hepatic hilum to the lower end. However, preoperative imaging and cytology are unreliable both in confirming the diagnosis or ruling out malignancy. Therefore, resection of the stricture should be attempted wherever feasible.