Colectomy type and transplant-free survival in PSC-UC

What is known

• Proctocolectomy with permanent ileostomy remained the most notable predictor for transplant or PSC-related death (HR 0.41; 95% CI 0.24–0.71), while subtotal colectomy/hemicolectomy and proctocolectomy with pouch were not significantly associated. ¹
• Survival differed significantly between proctocolectomy with ileostomy and proctocolectomy with pouch, and between ileostomy and subtotal colectomy/hemicolectomy. ¹
• The benefit was mainly attributed to postponement of transplantation and death from liver failure, and was more pronounced in the subset with both PSC and IBD. ¹
• Other studies (Trivedi, Matar) similarly found a benefit of ileostomy over pouch reconstruction on PSC recurrence rates after transplantation. ¹

What is unknown / caveats

• One prior study (Schabl et al.) could not confirm the ileostomy benefit, though it was likely underpowered (only nine ileostomy participants) ¹
• An earlier systematic review found no clear effect of colectomy on hard endpoints such as transplant-free survival ¹
• Findings come from registry/cohort data (association, not proven causation)
• Mechanism proposed (leaky gut, gut lymphocyte homing) remains hypothetical ¹
• Whether the survival difference reflects a true causal effect of removing colonic/pouch tissue or unmeasured confounding is not resolved by these observational data.

References

1. Mol B, van Nieuwamerongen M, van Munster KN, Färkkilä M, Folseraas T, Tjønnfjord SKV, Hov JR, Boberg K, Vesterhus M, Jørgensen KK, Bergquist A, Goet JC, de Vries AC, van der Meer AJP, Weersma RK, Inderson A, Bogaards JA, Ponsioen CY, IPSCR study G. Proctocolectomy with permanent ileostomy is associated with improved transplant-free survival in patients with PSC. JHEP Rep. 2026. PMID: 41757378.

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