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CHARACTERSITICS OF NON-OBSTRUCTIVE RECURRENT CHOLANGITIS IN PATIENTS WITH SURGICALLY ALTERED ANATOMY: A RETROSPECTIVE COHORT STUDY
Rahul Karna
*, Gaurav Suryawanshi, Suchapa Arayakarnkul, Gregory Beilman, David Martin, Karthik Ramanathan, Martin L. Freeman, Melena Bellin, Guru Trikudanathan
Gastroenterology, University of Minnesota Medical School, Minneapolis, MN
Introduction: Non obstructive recurrent cholangitis (NORC) following hepatobiliary or pancreatobiliary (HPB) tract surgical diversion is a distinct entity with unique pathophysiology. It is seen in total pancreatectomy with islet autotransplant which involves complete resection of pancreas with partial duodenectomy, roux-en-Y duodenojejunostomy, choledochojejunostomy (CJ), and autotransplantation of islet cells. NORC can lead to repeated hospitalization, antibiotics exposure, endoscopic procedures and increased health care costs. We hereby report our experience in a cohort of HPB tract diversion patients.
Methods: We conducted a retrospective study of all patients admitted with cholangitis in non-stenotic hepaticojejunostomy (HJ) or CJ after HPB tract surgical diversion at University of Minnesota from 2010-2024. Baseline characteristics, clinical, endoscopic and surgical data was extracted and descriptive analyses were performed.
Results: Total 31 patients, median age 40 years, comprising 35.5% (11/31) males with history of surgical HPB tract diversion were included. Majority underwent surgery for chronic pancreatitis 64.5% (20/31) followed by choledochal cyst: 3.2% (1/31), iatrogenic injury :3.2% (1/31) and others: 29% (9/31). Majority underwent total pancreatectomy and islet auto-transplant: 54.9% (17/31), followed by Classic Whipple surgery: 9.7% (3/31) and others: 35.5% (11/35). Others included Roux en Y-HJ: 6, liver transplant: 2, Frey’s procedure: 1; Roux en Y-CJ: 1; Roux en Y gastric bypass:1. Anastomosis type included HJ: 6; CJ:19; choledochoduodenostomy: 3; Unknown: 3. 4 patients had history of anastomotic stenosis, not present at cholangitis. Median length of roux limb was 45 cm. Total 61 episodes of NORC (mean: 2/patient) were recorded. Only 16.4% (10/61) patients had confirmation of cholangitis at time of ERCP. Median days between surgery and first episode of cholangitis was 783 (471.5-3432) days. Patients needed median 4(3.25-12) days of hospital stay. Number of cholangitis episodes did not differ between cohort with roux limb ?60 cm compared to roux limb <60 cm (OR:1.14, p-value: 0.44). No patient died at mean follow up period of 350 days.
Conclusions: This is the first United States retrospective study focusing on NORC in patients with HPB tract diversion. Despite clinical evidence of cholangitis, patients with HPB surgical tract diversion may not have evidence of obstruction/pus on ERCP. Previously, food reflux has been proposed as etiology of NORC, however, length of biliary limb didn’t determine the episodes of cholangitis in our study. This suggests alternate pathophysiology including gut dysbiosis, and transient bacteremia as other potential etiologies apart from food reflux for NORC. Future studies should assess microbiome alteration in roux limb as etiology of NORC and effects of microbiome alteration in patients with NORC.
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