ENDOTHERAPY IN PATIENTS WITH PRIMARY SCLEROSING CHOLANGITIS: OVER 30 YEARS’ EXPERIENCE

Aims Primary Sclerosing Cholangitis(PSC) is a chronic cholestatic liver disease characterized by inflammation and periductal fibrosis of the intrahepatic and/or extrahepatic bile ducts. Endoscopic dilation of symptomatic dominant biliary strictures is a temporary therapeutic option in these patients frequently candidate to liver transplantation. Our experience over a 30-years period is reported.

Methods Between March-1984 and April-2019, 73 patients with PSC(46 Males,mean age 46±18 years) were identified from a prospectively collected database. Indications for endoscopic drainage were the presence of symptomatic “dominant” biliary strictures located at the common bile duct or main hepatic confluence. Strictures were dilated with balloon and/or temporary plastic stents insertion. Brush cytology of dominant strictures was performed in patients with new onset or worsening strictures. When MRC was not routinely available, abdominal US and/or CT-Scan were performed before ERCP.

Results Indications for ERCP were:cholangitis(n=28,38.3%), anicteric cholestasis and pruritus(n=18,24.6%) and jaundice(n=27,36.9%).

A total of 161 ERCPs were performed in 73 pts [mean 4.3(range 1-13)]. Naso-biliary drains were placed in 81.3% of cases(n=131), while balloon dilation in 44.1%(n=71) and single or multiple plastic stents in 19.9%(n=34).

One patient(0.6%) developed severe post-ERCP pancreatitis that resolved after surgical treatment.

Cholangitis recurrence requiring re-treatment occurred after a mean of 28.2 months after stents removal and 16.6 months after balloon dilation.

Brush cytology was performed in 42 patients(57.5%):4 patients(5.4 %) resulted positive for high-grade dysplasia,1 patient(1.3 %) for carcinoma.

A mean follow-up of 7.4 years(range 0.2-21.7) is available in 46 patients(63%):29 patients(63%) had no further episodes of cholangitis,7(15.2%) underwent OLT,3(6.5%) died for cholangiocarcinoma,6(13%) died for unrelated other disease,1(2.2%) had an incidental finding during laparoscopic cholecystectomy of gallbladder cancer and is still alive.

Conclusions According to our experience endotherapy of dominant biliary strictures secondary to PSC is effective in the long term-follow-up and can delay liver transplantation. Early diagnosis of cholangiocarcinoma in PSC is still an unsolved issue.