Recurrent Nonobstructive Cholangitis After Pancreaticoduodenectomy: Prevalence, Risk Factors, and Treatment

Recurrent nonobstructive cholangitis (RNOC) due to enterobiliary reflux is a late complication of pancreaticoduodenectomy (PD) that should be differentiated from obstructive cholangitis. The risk factors (RFs) of RNOC are poorly known. The goal of this study was to estimate the prevalence, to identify the RF, and to describe the management of RNOC following PD.

This case-control study included 503 patients from a prospective database (2014-2018) who underwent PD; one hundred and eighty-three patients were excluded because they had less than 1-year of follow-up, tumor recurrence during postoperative year one, or cholangitis from anastomotic stenosis or tumor recurrence. RNOC was defined as at least 3 episodes of cholangitis that occurred or persisted more than 1-year after PD, without anastomotic stenosis or tumor recurrence. RF were identified by univariate and multivariate analyses.

Of the 320 analyzed patients, 213 (67%) and 107 (33%) underwent PD for malignancy and a benign lesion, respectively. With a median follow-up of 47 months (IQR: 33-68), 27 of the 320 patients (8%) developed RNOC (median number of episodes = 8 and IQR = 5-12). The only independent RF for RNOC was noninvasive IPMN (OR = 3.222; IC-95% = 1.219-8.514; and p = 0.018). All patients received on-demand antibiotics. Three patients (11%) developed complications from RNOC (hepatic abscesses in 3 and organ failure in one). No patients died from RNOC. Two (7%) patients underwent reoperation to lengthen the biliary Roux-en-Y loop but RNOC persisted in both.

RNOC complicates 8% of PD. Noninvasive IPMN was a RF of RNOC. The value of revision surgery to limit the risk of recurrence seems limited.