Effect of scheduled endoscopic dilatation of dominant strictures on outcome in patients with primary sclerosing cholangitis.

Autor:	Rupp C; Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany.; Department of Internal Medicine IV, Interdisciplinary Endoscopy Center, University Hospital Heidelberg, Heidelberg, Germany., Hippchen T; Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany., Bruckner T; Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany., Klöters-Plachky P; Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany., Schaible A; Department of General, Visceral and Transplantation Surgery, Interdisciplinary Endoscopy Center, University Hospital of Heidelberg, Heidelberg, Germany., Koschny R; Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany.; Department of Internal Medicine IV, Interdisciplinary Endoscopy Center, University Hospital Heidelberg, Heidelberg, Germany., Stiehl A; Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany., Gotthardt DN; Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany., Sauer P; Department of Internal Medicine IV, University Hospital of Heidelberg, Heidelberg, Germany.; Department of Internal Medicine IV, Interdisciplinary Endoscopy Center, University Hospital Heidelberg, Heidelberg, Germany.
Jazyk:	angličtina
Zdroj:	Gut [Gut] 2019 Dec; Vol. 68 (12), pp. 2170-2178. Date of Electronic Publication: 2019 Mar 25.
DOI:	10.1136/gutjnl-2018-316801
Abstrakt:	Objective: Scheduled endoscopic dilatation of dominant strictures (DS) in primary sclerosing cholangitis (PSC) might improve outcome relative to endoscopic treatment on demand, but evidence is limited. Since randomisation is difficult in clinical practice, we present a large retrospective study comparing scheduled versus on-demand endoscopic retrograde cholangiopancreatography (ERCP) based on patient preferences. Design: Between 1987 and 2017, all new patients with PSC had been offered scheduled ERCP with dilatation of a DS if diagnosed; the latter was repeated at defined intervals until morphological resolution, independent of clinical symptoms (treatment group). Patients who refused participation were clinically evaluated annually and received endoscopic treatment only on demand (control group). The primary clinical endpoint was transplantation-free survival. Secondary outcomes were overall survival, bacterial cholangitis episodes, hepatic decompensation of liver cirrhosis and endoscopy-related adverse events. Results: The final study included 286 patients, 133 (46.5%) receiving scheduled ERCP and 153 (53.5%) receiving on-demand ERCP. After a mean follow-up of 9.9 years, the rate of transplantation-free survival was higher in patients receiving scheduled ERCP (51% vs 29.3%; p<0.001), as was transplantation-free survival time (median: 17.9 vs 15.2 years; log-rank: p=0.008). However, the benefit of scheduled ERCP was significant only in patients with the initial (17.1%) or later (45.5%) diagnosis of a DS (17.8 vs 11.1 years; log-rank: p<0.001). IBD (p=0.03), DS (p=0.006), higher Mayo Risk Score (p=0.02) and non-adherence to scheduled endoscopy (p=0.005) were independently associated with transplantation-free survival. Conclusion: In our large retrospective study, regular ERCP with endoscopic balloon dilatation significantly benefits patients with PSC with DS, diagnosed both at initial presentation and during surveillance, even if asymptomatic. Further studies have to find out how to best identify stricture patients non-invasively. Competing Interests: Competing interests: None declared. (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)
Databáze:	MEDLINE
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