Systematic Reviews
Copyright ©The Author(s) 2018. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jul 28, 2018; 24(28): 3171-3180
Published online Jul 28, 2018. doi: 10.3748/wjg.v24.i28.3171
Role of colectomy in preventing recurrent primary sclerosing cholangitis in liver transplant recipients
Bettina M Buchholz, Panagis M Lykoudis, Reena Ravikumar, Joerg M Pollok, Giuseppe K Fusai
Bettina M Buchholz, Panagis M Lykoudis, Reena Ravikumar, Joerg M Pollok, Giuseppe K Fusai, Department of HPB Surgery and Liver Transplantation, Royal Free Hospital London, London NW32QG, United Kingdom
Author contributions: Buchholz BM, Lykoudis PM, Ravikumar R, Pollok JM and Fusai GK designed the study; Buchholz BM and Lykoudis PM performed the literature review and data analysis; Buchholz BM, Lykoudis PM, Ravikumar R and Fusai GK interpreted the data; Buchholz BM wrote the article; Lykoudis PM, Ravikumar R, Pollok JM and Fusai GK critically revised the manuscript for intellectual content; all authors gave final approval of the final version.
Conflict-of-interest statement: The authors declare no conflict of interest.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Giuseppe Kito Fusai, MSc, FRCS, Surgeon, Department of HPB Surgery and Liver Transplantation, Royal Free Hospital, Pond Street, London NW32QG, United Kingdom. g.fusai@ucl.ac.uk
Telephone: +44-20-78302431 Fax: +44-20-78302688
Received: May 15, 2018
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
Abstract
AIM

To study the published evidence on the impact of colectomy in preventing recurrent primary sclerosing cholangitis (rPSC).

METHODS

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.

RESULTS

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).

CONCLUSION

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.

Keywords: Recurrent primary sclerosing cholangitis, Risk factor, Ulcerative colitis, Colectomy, Liver transplantation

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.