title: Orthotopic liver transplantation for primary sclerosing cholangitis. A 12-year single center experience.
abstract: OBJECTIVE
  The purpose of this study was to analyze a single center's 12-year experience with 127 orthotopic liver transplantations (OLT) for primary sclerosing cholangitis (PSC).
  
  
  BACKGROUND
  Primary sclerosing cholangitis is a chronic cholestatic liver disease of unknown origin that occurs most commonly in young men and is associated frequently (70-80%) with inflammatory bowel disease (IBD). Patients with PSC also are at risk for the development of cholangiocarcinoma (CCA) and those with IBD for colon carcinoma. Although the course of PSC is variable, it frequently is progressive, leading to cirrhosis and requirement for OLT.
  
  
  METHODS
  The medical records of 127 consecutive patients undergoing OLT for PSC from July 1, 1984, to May 30, 1996, were reviewed. Actuarial patient and graft survival was determined at 1,2, and 5 years. The incidence and outcome of patients with CCA, recurrent sclerosing cholangitis, and post-transplant colon carcinoma was determined. Results were analyzed by way of stepwise Cox regression to determine the statistical strength of independent associations between pretransplant covariates and patient survival. The median follow-up period was 3.01 years. Incidental cholangiocarcinoma (ICCA) was defined as a tumor < 1 cm in size that was discovered at the time of pathologic sectioning of the explanted liver.
  
  
  RESULTS
  Ninety-two patients (72%) had associated IBD. Seventy-nine (62%) had undergone previous biliary tract surgery. One hundred seven patients (84%) received a single graft, whereas 20 patients (16%) required 22 retransplants. Patients received either cyclosporine- (n = 76) or tacrolimus- (n = 51) based immunosuppression. The 1-, 2-, and 5-year actuarial patient survivals were 90%, 86%, and 85%, respectively, whereas graft survival was 82%, 77%, and 72%, respectively. The presence of previous biliary surgery had no effect on patient survival. Ten patients (8%) had ICCA and their survival was not significantly different from patients without ICCA (100%, 83%, and 83% at 1, 2, and 5 years, respectively). Four patients were known to have CCA at the time of OLT, all recurred within 6 months, and had a significantly worse outcome (p < 0.0001). Recurrent sclerosing cholangitis developed in 11 patients (8.6%). The patient and graft survival in this group was not different from those in whom recurrence did not develop (patient; 100%, 90%, and 90%; graft: 80%, 70%, and 52%). Thirty patients (23%) underwent colectomy after liver transplantation for dysplasia-carcinoma or symptomatic colitis. Of the nine covariates entered into the Cox multivariate regression analysis, only common bile duct frozen section biopsy specimen showing CCA was predictive of a survival disadvantage.
  
  
  CONCLUSIONS
  Liver transplantation provides excellent patient and graft survival rates for patients affected with PSC independent of pretransplant biliary tract surgery. Incidental cholangiocarcinoma does not affect patient survival significantly. However, known CCA or common duct frozen section biopsy specimen or both showing CCA are associated with poor recipient survival, and OLT should be proscribed in these cases. Recurrent PSC occurs in approximately 9% of cases but does not affect patient survival. Post-transplant colectomy does not affect patient survival adversely.
authors.affiliation: Department of Surgery, School of Medicine, University of California, Los Angeles, USA.
authors.forename: J A
authors.initials: JA
authors.lastname: Goss
authors.forename: C R
authors.initials: CR
authors.lastname: Shackleton
authors.forename: D G
authors.initials: DG
authors.lastname: Farmer
authors.forename: W S
authors.initials: WS
authors.lastname: Arnaout
authors.forename: P
authors.initials: P
authors.lastname: Seu
authors.forename: J S
authors.initials: JS
authors.lastname: Markowitz
authors.forename: P
authors.initials: P
authors.lastname: Martin
authors.forename: R J
authors.initials: RJ
authors.lastname: Stribling
authors.forename: L I
authors.initials: LI
authors.lastname: Goldstein
authors.forename: R W
authors.initials: RW
authors.lastname: Busuttil
mesh_terms: D000206:Actuarial Analysis; D000293:Adolescent; D000328:Adult; D000368:Aged; D001650:Bile Duct Neoplasms / Q000150:complications / Q000453:epidemiology; D001653:Bile Ducts, Intrahepatic; D002648:Child; D018281:Cholangiocarcinoma / Q000150:complications / Q000453:epidemiology; D015209:Cholangitis, Sclerosing / Q000150:complications / Q000401:mortality / Q000601:surgery*; D003110:Colonic Neoplasms / Q000453:epidemiology; D005260:Female; D005500:Follow-Up Studies; D006085:Graft Survival; D006801:Humans; D015994:Incidence; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D011183:Postoperative Complications / Q000453:epidemiology; D012008:Recurrence