Chances of transplant-free survival in PSC enhanced by colectomy with ileostomy

Proctocolectomy with permanent ileostomy results in better transplant-free survival in patients with primary sclerosing cholangitis (PSC). This was concluded in a study that found higher chances of survival without liver transplantation for PSC patients who underwent a proctocolectomy with ileostomy compared with those who had no surgery or a colectomy with any kind of remnant colon.

“After transplantation, we know that patients who have undergone a colectomy have decreased rates of recurrent PSC and also a better graft survival,” Dr Bregje Mol (Amsterdam UMC, the Netherlands) said [1]. Since the effect of colectomy before transplantation remains unclear to date, Dr Mol and colleagues conducted a retrospective cohort study to explore the effect of proctocolectomy with ileostomy on transplant-free survival in patients with PSC. “The studies that are available either consist of small patient numbers, don’t take known risk factors into account, or sometimes don’t take colectomy into account as a time-dependent variable,” Dr Mol explained. The present study did introduce colectomy as a time-dependent variable. The analysis also corrected for known risk factors like age, sex, concomitant IBD or autoimmune hepatitis, and enrolment in a tertiary centre of care.

The trial enrolled 1,341 adult patients from the EpiPSC2 cohort between 2008 and 2021, leading to over 14,000 patient-years of follow-up. The mean age at PSC diagnosis was 39 years and 36% were women. Most patients had large-duct PSC (86%) and 68% had been diagnosed with IBD. Most of the observed colectomies were indicated by dysplasia/neoplasia or active colitis. During follow-up, the median transplant-free survival was about 19 years.

“We observed 370 liver transplants and almost 400 deaths, of which PSC-related deaths were most common,” Dr Mol stated. Comparison between no colectomy, colectomy with remnant colon, or proctocolectomy with ileostomy showed a protective effect of proctocolectomy with ileostomy regarding liver transplantation and PSC-related death (HR 0.47; 95% CI 0.24–0.93; see Figure). For other forms of colectomy with residual colon, no benefit was found. Interestingly, the IBD status of the participants had no impact.

Figure: Results of patients with primary sclerosing cholangitis undergoing no colectomy, colectomy with remnant colon, or proctocolectomy with ileostomy [1]



“In our data, proctocolectomy with ileostomy seems to be associated with a better transplant-free survival, which points towards a role for the colonic microbiota in the disease course of PSC. You only see this effect when you perform a colectomy with ileostomy, so no colonic microbiota can remain, and this effect was not seen with any remnant colon function,” Dr Mol concluded.

1. Mol B, et al. Proctocolectomy with permanent ileostomy is associated with better transplant-free survival in patients with primary sclerosing cholangitis: a retrospective cohort study. LB02, UEG Week 2022, 8–11 October, Vienna, Austria.

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Posted on 2 December 2022