Proctocolectomy in primary sclerosing cholangitis (PSC): Association with improved transplant-free survival
Mol B et al, JHEP Rep. 2025;8(3):101700
This multicenter cohort analysis from the International PSC Study Group Registry (IPSCR) evaluated the impact of proctocolectomy with permanent ileostomy on outcomes in patients with PSC. Patients who had undergone proctocolectomy showed significantly improved transplant-free survival compared to PSC patients without. The findings support a potential role of the gut-liver axis in PSC progression, although residual confounding and selection bias must be considered when interpreting the results.
Background and aims: The gut-liver axis is believed to be crucial in the pathogenesis of primary sclerosing cholangitis (PSC). However, the impact of colectomy on liver disease progression is unclear. The study estimated the effect of colectomy on PSC progression with correction for time dependency and established risk factors by pooling data from several cohorts across different countries.
Methods: The authors analysed data from the International PSC Registry (IPSCR), comprising patients from Finland, The Netherlands, Norway, and Sweden. Primary endpoint was defined as liver transplantation (LT) or PSC-related death. Cox proportional hazards regression onto time-dependent colectomy status, with specification for extent, was performed with adjustment for sex, age at diagnosis, large or small duct PSC, features of autoimmune hepatitis, time-dependent inflammatory bowel disease (IBD) status, centre of inclusion, and country of residence.
Results: A total of 3110 participants were included, of whom 470 (15%) had undergone colectomy. During a total follow-up of 32,236 patient-years, 395 deaths and 653 LTs were observed. Compared with patients with PSC with intact colon, the hazard ratio (HR) of reaching LT or PSC-related death was significantly decreased in patients with proctocolectomy with permanent ileostomy (HR = 0.41; 95% CI: 0.24–0.71). This effect was less pronounced in case of hemi- or subtotal colectomy (HR = 0.81; 95% CI = 0.58–1.12) and not observed for proctocolectomy with pouch (HR = 1.00; 95% CI: 0.73–1.38). The reduced risk was mainly associated with a lower rate of LT or death resulting from liver failure (HR = 0.24; 0.10–0.53).
Conclusions: Proctocolectomy with permanent ileostomy was associated with decreased risk for LT and PSC-related death. These findings support the role of the gut-liver axis in the pathophysiology of PSC and call for consideration in counselling patients who face impending colorectal surgery.