Published online Jul 28, 2018. doi: 10.3748/wjg.v24.i28.3171
Peer-review started: May 16, 2018
First decision: June 6, 2018
Revised: July 8, 2018
Accepted: July 16, 2018
Article in press: July 16, 2018
Published online: July 28, 2018
To study the published evidence on the impact of colectomy in preventing recurrent primary sclerosing cholangitis (rPSC).
An unrestricted systematic literature search in PubMed, EMBASE, Medline OvidSP, ISI Web of Science, Lista (EBSCO) and the Cochrane library was performed on clinical studies investigating colectomy in liver transplantation (LT) recipients with and without rPSC in the liver allograft. Study quality was evaluated according to a modification of the methodological index for non-randomized studies (MINORS) criteria. Primary endpoints were the impact of presence, timing and type of colectomy on rPSC. Overall presence of inflammatory bowel disease (IBD), time of IBD diagnosis, posttransplant IBD and immunosuppressive regimen were investigated as secondary outcome.
The literature search yielded a total of 180 publications. No randomized controlled trial was identified. Six retrospective studies met the inclusion criteria of which 5 studies were graded as high quality articles. Reporting of IBD was heterogenous but in four publications, either inflammatory bowel disease, ulcerative colitis or in particular active colitis post-LT significantly increased the risk of rPSC. The presence of an intact (i.e., retained) colon at LT was identified as risk factor for rPSC in two of the high quality studies while four studies found no effect. Type of colectomy was not associated with rPSC but this endpoint was underreported (only in 33% of included studies). Neither tacrolimus nor cyclosporine A yielded a significant benefit in disease recurrence of primary sclerosing cholangitis (PSC).
The data favours a protective role of pre-/peri-LT colectomy in rPSC but the current evidence is not strong enough to recommend routine colectomy for rPSC prevention.
Core tip: There are no known treatments that can alter the development and/or progression of recurrent primary sclerosing cholangitis (rPSC) after liver transplantation (LT). Shared leukocyte recruitment pathways of the gut-liver axis, bacterial translocation into the portal circulation from an inflamed gut and intestinal dysbiosis might contribute to the pathogenesis of rPSC. Indeed, inflammatory bowel disease, ulcerative colitis and in particular active colitis post-LT significantly increase the risk of rPSC and the available data favours a protective role of pre-/peri-LT colectomy in rPSC. Prospective studies and randomized trials are needed to further elucidate a possible mechanistic link between retained colon and rPSC.