This Paper of the Month report considers the impact of ileal pouch-anal anastomosis on graft survival following liver transplantation for primary sclerosing cholangitis.

What is known on the subject?

Primary sclerosing cholangitis (PSC) is an extraintestinal manifestation of ulcerative colitis. The clinical course of gut and liver disease are not necessarily parallel. However, when these co-exist, published data show an increased risk of colorectal cancer if colectomy is not undertaken, as well as increased incidence of pouchitis, and worse long-term pouch outcome after restorative proctocolectomy. If PSC demands liver transplantation, colectomy does not appear protective against graft loss per se, but data suggest that preservation of a chronically inflamed colon increases the risk of developing post-transplant complications e.g. recurrent PSC and hepatic artery thrombosis.

What thus study adds

The study group analyzed all patients undergoing liver transplantation with PSC and colitis from 1990 up to 2016 gathered in a predominantly prospective database. The primary clinical endpoint was graft loss. Over the 26-year period the authors identified 240 patients of whom 27 lost their graft and 88 died. Almost 1/3rd of the patients (n=75) underwent colectomy either before or after liver transplantation. Kaplan-Meier estimates showed that colectomy did not protect against recipient loss or patient mortality. The incidence of graft loss was increased in the patients who had restorative proctocolectomy and pouch compared to colectomy with ileostomy or no colectomy patients. Pouch patients had fourfold higher rates of hepatic artery thrombosis and also more strictures compared to colectomy with ileostomy patients. Complications in pouch patients did not differ from those who did not have colectomy. The authors speculated that both pouch patients and patients with an intact colon have ongoing progressive PSC due to frequent pouchitis and persistent colitis respectively (these being drivers of PSC).

Implications for colorectal practice

There are two important indications to offer colectomy to patients with ulcerative colitis: first, refractory colitis; and secondly, the development of multifocal dysplasia or cancer. In the present study most patients underwent colectomy because of refractory colitis. As a first step in the era of biologicals, these patients were offered a colectomy with ileostomy. An efficient and safe operation. In PSC patients there is an increased risk of development of dysplasia or cancer in the remaining rectal stump. This warrants close surveillance. To avoid the latter an intersphincteric proctocolectomy with permanent ileostomy can be suggested although this is a bigger undertaking and potentially more complicated procedure. Most fit patients however would opt for an ileoanal pouch as second stage to avoid a permanent ileostomy. It is well known that patients with ileoanal pouches and PSC do worse, particularly because of a higher incidence of pouchitis. The present study showed in relatively low numbers that patients with PSC requiring liver transplantation have a higher risk of graft loss in the presence of an ileoanal pouch. The take home of this interesting paper is therefor that in the counseling and shared decision making for an ileoanal pouch reconstruction it is important to mention that aside from the higher chance of worse pouch function, there is also a higher risk of graft loss if advanced PSC might require liver transplantation.

Trivedi PJ, Reece J, Laing RW, Slaney E, Cooney R, Gunson BK, Kamarajah SK, Pinkney T, Thompson F, Muiesan P, Schlegel A, Hirschfield GM, Iqbal T, Ferguson J. The impact of ileal pouchanal anastomosis on graft survival following liver transplantation for primary sclerosing cholangitis. Aliment Pharmacol Ther. 2018 Jun 8. doi: 10.1111/apt.14828. [Epub ahead of print]

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