Laproscopic Proctocolectomy/ Ileal anal anastomosis/ loop ileostomy

March 3, 2009

So I have met with my primary care, my gi dr, transplant surgeon, colorectal

surgeon, hep dr etc and everyone has told me to have this wonderfully fun

surgery done. My colorectal surgeon told me after a transplant my uc (severe

pancolitis) will " blow up " and take away from the healing process of my liver.

He actually said BLOW UP. So I scheduled my surgery for April 17 with a lot of

thinking, this is probably the best thing to do. I know with PSC my risk of

pouchitis will be much higher etc. My PSC is between stage 2 and 3. They told me

prob about 10 years for transplant if my ERCP's are not suspicious (they have

been) and FISH tests remain negative.

Have other people been told this? I remember some have a jpouch. I just want

some reinforcement I guess. I won't be changing my mind, I just want to be

reassured.

Thanks guys!

Holly

March 3, 2009

Dear Holly;

This must be a tough decision. The only reinforcement I can give you is that

studies in England suggest that the recurrence rate of PSC after transplant is

lower in those who have had a colectomy:

_____________________

Liver Transpl. 15: 330-340 (2009)

A re-evaluation of the risk factors for the recurrence of primary sclerosing

cholangitis in liver allografts.

Alabraba E, Nightingale P, Gunson B, Hubscher S, Olliff S, Mirza D, Neuberger J

Liver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham,

United Kingdom.

Previously, we have found that the absence of the colon after liver

transplantation (LT) protects the patient from recurrent primary sclerosing

cholangitis (rPSC). As our previous observation has not been confirmed in other

series, we have reviewed our cohort of patients grafted for primary sclerosing

cholangitis (PSC) with greater numbers and longer follow-up to reassess the

rate, consequences, and risk factors for rPSC. We collected data on patients who

underwent LT for PSC between January 1986 and April 2006. Data were collected

for cytomegalovirus status, inflammatory bowel disease status, time of

colectomy, type of colectomy, donor-recipient gender mismatch, recipient sex,

extended donor criteria (EDC), and donor risk index. Accepted criteria were used

to diagnose rPSC. Of a total of 230 consecutive adult patients, 61 (27%)

underwent colectomy pre-/peri-LT, and 54 (23.5%) developed rPSC at a median of

4.6 (range, 0.5-12.9) years post-LT. A total of 263 deceased donor grafts were

used, and 73 were EDC grafts. A diagnosis of rPSC was made in 61 of the 263

grafts (23%). The recurrence-free patient survival was significantly better (P <

0.05) in patients who underwent pre-/peri-LT colectomy and in those with non-EDC

grafts. In conclusion, in this larger cohort of 230 patients and with longer

follow-up of 82.5 (range, 0.0-238.6) months [in comparison with the previous

report of 152 recipients with a follow-up of 52.8 (range, 1-146) months], we

have shown that colectomy remains a significant risk factor for rPSC and that

colectomy before and during initial LT for PSC confers a protective effect

against rPSC in subsequent graft(s). Moreover, we have shown that EDC grafts are

also a significant risk factor for rPSC. PMID: 19243003.

______________________

and there is some evidence to suggest that ulcerative colitis can have a more

aggressive course after liver transplantation:

__________________________

Gut 43: 639-644 (1998)

Ulcerative colitis has an aggressive course after orthotopic liver

transplantation for primary sclerosing cholangitis.

Papatheodoridis GV, Hamilton M, Mistry PK, son B, Rolles K, Burroughs AK

Liver Transplantation and Hepatobiliary Medicine, Royal Free Hospital, London,

UK.

BACKGROUND: The course of inflammatory bowel disease after liver transplantation

has been reported as variable with usually no change or improvement, but there

may be an increased risk of early colorectal neoplasms. In many centres steroids

are often withdrawn early after transplantation and this may affect inflammatory

bowel disease activity. AIMS: To evaluate the course of inflammatory bowel

disease in primary sclerosing cholangitis transplant patients who were treated

without long term steroids. METHODS: Between 1989 and 1996, there were 30

patients transplanted for primary sclerosing cholangitis who survived more than

12 months. Ulcerative colitis was diagnosed in 18 (60%) patients before

transplantation; two had previous colectomy. All patients underwent colonoscopy

before and after transplantation and were followed for 38 (12-92) months. All

received cyclosporin or tacrolimus with or without azathioprine as maintenance

immunosuppression. RESULTS: Ulcerative colitis course after transplantation

compared with that up to five years before transplantation was the same in eight

(50%) and worse in eight (50%) patients. It remained quiescent in eight and

worsened in four of the 12 patients with pretransplant quiescent course, whereas

it worsened in all four patients with pretransplant active course (p=0.08). New

onset ulcerative colitis developed in three (25%) of the 12 patients without

inflammatory bowel disease before transplantation. No colorectal cancer has been

diagnosed to date. CONCLUSIONS: Preexisting ulcerative colitis often has an

aggressive course, while de novo ulcerative colitis may develop in patients

transplanted for primary sclerosing cholangitis and treated without long term

steroids.

PMID: 9824344.

__________________________

I'm guessing that this is what your doctor meant about the colitis " blowing up "

after liver transplantation.

Best regards,

Dave

(father of (23); PSC 07/03; UC 08/03)

March 4, 2009

I assume that this confirms that cholangitis plays a significant role in causing PSC if removing a colon helps prevent problems with the liver, PSC???

To: Sent: Tuesday, March 3, 2009 11:42:09 PMSubject: Re: Laproscopic Proctocolectomy/ Ileal anal anastomosis/ loop ileostomy

Dear Holly;This must be a tough decision. The only reinforcement I can give you is that studies in England suggest that the recurrence rate of PSC after transplant is lower in those who have had a colectomy:____________ _________Liver Transpl. 15: 330-340 (2009)A re-evaluation of the risk factors for the recurrence of primary sclerosing cholangitis in liver allografts.Alabraba E, Nightingale P, Gunson B, Hubscher S, Olliff S, Mirza D, Neuberger JLiver Unit, University Hospital Birmingham NHS Foundation Trust, Birmingham, United Kingdom.Previously, we have found that the absence of the colon after liver transplantation (LT) protects the patient from recurrent primary sclerosing cholangitis (rPSC). As our previous observation has not been confirmed in other series, we have reviewed our cohort of patients grafted for primary sclerosing cholangitis (PSC) with greater numbers and longer follow-up to

reassess the rate, consequences, and risk factors for rPSC. We collected data on patients who underwent LT for PSC between January 1986 and April 2006. Data were collected for cytomegalovirus status, inflammatory bowel disease status, time of colectomy, type of colectomy, donor-recipient gender mismatch, recipient sex, extended donor criteria (EDC), and donor risk index. Accepted criteria were used to diagnose rPSC. Of a total of 230 consecutive adult patients, 61 (27%) underwent colectomy pre-/peri-LT, and 54 (23.5%) developed rPSC at a median of 4.6 (range, 0.5-12.9) years post-LT. A total of 263 deceased donor grafts were used, and 73 were EDC grafts. A diagnosis of rPSC was made in 61 of the 263 grafts (23%). The recurrence-free patient survival was significantly better (P < 0.05) in patients who underwent pre-/peri-LT colectomy and in those with non-EDC grafts. In conclusion, in this larger cohort of 230 patients and with longer follow-up of

82.5 (range, 0.0-238.6) months [in comparison with the previous report of 152 recipients with a follow-up of 52.8 (range, 1-146) months], we have shown that colectomy remains a significant risk factor for rPSC and that colectomy before and during initial LT for PSC confers a protective effect against rPSC in subsequent graft(s). Moreover, we have shown that EDC grafts are also a significant risk factor for rPSC. PMID: 19243003.____________ _________ _and there is some evidence to suggest that ulcerative colitis can have a more aggressive course after liver transplantation:____________ _________ _____Gut 43: 639-644 (1998)Ulcerative colitis has an aggressive course after orthotopic liver transplantation for primary sclerosing cholangitis.Papatheodoridis GV, Hamilton M, Mistry PK, son B, Rolles K, Burroughs AKLiver Transplantation and Hepatobiliary Medicine, Royal Free Hospital, London,

UK.BACKGROUND: The course of inflammatory bowel disease after liver transplantation has been reported as variable with usually no change or improvement, but there may be an increased risk of early colorectal neoplasms. In many centres steroids are often withdrawn early after transplantation and this may affect inflammatory bowel disease activity. AIMS: To evaluate the course of inflammatory bowel disease in primary sclerosing cholangitis transplant patients who were treated without long term steroids. METHODS: Between 1989 and 1996, there were 30 patients transplanted for primary sclerosing cholangitis who survived more than 12 months. Ulcerative colitis was diagnosed in 18 (60%) patients before transplantation; two had previous colectomy. All patients underwent colonoscopy before and after transplantation and were followed for 38 (12-92) months. All received cyclosporin or tacrolimus with or without azathioprine as maintenance

immunosuppression. RESULTS: Ulcerative colitis course after transplantation compared with that up to five years before transplantation was the same in eight (50%) and worse in eight (50%) patients. It remained quiescent in eight and worsened in four of the 12 patients with pretransplant quiescent course, whereas it worsened in all four patients with pretransplant active course (p=0.08). New onset ulcerative colitis developed in three (25%) of the 12 patients without inflammatory bowel disease before transplantation. No colorectal cancer has been diagnosed to date. CONCLUSIONS: Preexisting ulcerative colitis often has an aggressive course, while de novo ulcerative colitis may develop in patients transplanted for primary sclerosing cholangitis and treated without long term steroids.PMID: 9824344.____________ _________ _____I'm guessing that this is what your doctor meant about the colitis "blowing up" after liver

transplantation.Best regards,Dave (father of (23); PSC 07/03; UC 08/03)

March 4, 2009