Distinct Clinical Pathways of Recurrent Cholangitis After Pancreaticoduodenectomy: Association With Hepaticojejunostomy Stricture and Early-onset Cholangitis

BACKGROUND/AIM: Postoperative cholangitis (POC) is a late complication occurring after pancreaticoduodenectomy (PD), and recurrent episodes substantially impair quality of life. Although previous studies have identified several risk factors for POC, risk factors specific to recurrent cholangitis remain unclear. This study aimed to identify risk factors for POC after PD, with a particular emphasis on recurrent cholangitis. PATIENTS AND METHODS: This single-center retrospective cohort study included 175 patients who underwent PD between January 2014 and March 2025. Cholangitis was diagnosed according to the Tokyo Guidelines 2018 criteria. Three cholangitis outcomes were assessed: occurrence of any POC, early-onset POC within 3 months after surgery, and recurrent POC defined as ≥2 episodes. Clinicopathological and operative variables were collected, and risk factors for POC and recurrent POC were analyzed using univariate and multivariate analyses. Recurrent cholangitis occurred in eight patients (4.6%), equally divided into two distinct phenotypes. Four patients had anastomotic stricture, whereas four had no evidence of stricture. CONCLUSION: A small preoperative bile duct diameter and anastomotic stricture are independently related to POC after PD. Recurrent cholangitis appeared to comprise two non-overlapping clinical phenotypes: an obstructive type associated with anastomotic stricture - possibly related to external stent placement - and a non-obstructive type characterized by early postoperative onset. Recognition of these distinct clinical phenotypes may guide appropriate management strategies for recurrent cholangitis after PD.