Biliary access procedure in the management of oriental cholangiohepatitis

The objective was to review the treatment of oriental cholangiohepatitis using a combined approach of surgical access to the biliary tree with a cutaneous choledochoenteric conduit and interventional radiology to remove intrahepatic stones and dilate biliary strictures. Design was a retrospective case series. Oriental cholangiohepatitis is a condition marked by intrahepatic strictures and extensive formation of pigmented stones leading to recurrent biliary sepsis and hepatic abscesses. It is a common condition in southeast Asia and is seen with increasing frequency in Western populations due to Asian immigration. Ten patients were treated at Tripler Army Medical Center from 1986 to 1994. Tripler is a 500 bed tertiary referral center located in Honolulu, Hawaii, and serves the military community in the Pacific basin as well as beneficiaries of the Trust Territories of Micronesia. Patients underwent cholecystectomy and formation of a Roux-en-Y choledochojejunostomy with a lateral limb that was brought out as a cutaneous stoma. After 4 weeks of healing, the intestinal conduit was used by the interventional radiologist to extract retained stones and dilate strictures using a variety of techniques. This was easily performed under light sedation. After completion of therapy, the stoma was closed and buried subcutaneously. This retains the option for accessing the conduit percutaneously or reopening the stoma if necessary for recurrence. Resolution of symptoms and radiologic clearance of intrahepatic stones, biliary strictures, and hepatic abscesses were the main outcome measures. Eight patients underwent the biliary access procedure and had clearance of stones and strictures after one to 10 interventional sessions. There was no major morbidity associated with treatment. No patient required liver resection, and there was resolution of the hepatic abscesses in all cases. The access procedure could not be completed in one patient due to extensive adhesions; this patient was successfully treated by endoscopic retrograde cannulation of the biliary duct. Another patient was treated by the same method on several occasions and never referred to surgery. A combined approach using surgical access to the biliary tree and interventional radiology offers effective treatment of oriental cholangiohepatitis without the need for hepatic resection.