Ascending cholangitis: surgery versus endoscopic or percutaneous drainage

A retrospective review of 61 patients with calculous cholangitis was carried out. There were 31 men and 30 women and their mean age was 75.8 years. All patients had abdominal pain, 87% had chills and fever, 65% had clinical jaundice, 23% were in shock, and 54% had positive blood cultures. Because intravenous hydration and antibiotics did not help, 33 patients underwent surgery, 25 patients underwent endoscopic papillotomy (EP), and three patients underwent percutaneous transhepatic drainage of the common bile duct (PTD). Morbidity in the surgery group included two wound infections, one respiratory failure, and one renal failure. Morbidity in the EP-PTD group was one case of arterial bleeding requiring surgery and one of pancreatitis treated conservatively. Two patients (6%) died in the surgery group, one of sepsis and the other of cardiorespiratory arrest. In the EP-PTD group nine patients (32%) died of sepsis and multisystem organ failure. These patients were considered too ill to undergo surgery and thus repeat EP-PTD was carried out. Cholangitis persisted, and retained common bile duct stones with sepsis was the cause of death. Thus when initial EP or PTD is unsuccessful, surgical exploration of the common bile duct should be carried out to control sepsis.