I recently had the opportunity to review the practice guideline for the long-term management of the patient who has undergone successful adult liver transplantation, which was published in the January 2013 issue of Liver Transplantation. Under recommendation 42, the authors suggest that in patients with primary sclerosing cholangitis and inflammatory bowel disease, colectomy should be considered “when colonic biopsy reveals moderate or severe dysplasia.” This suggestion is at odds with recent guidelines published by the American Gastroenterological Association and the American College of Gastroenterology in 2 respects.[2, 3]
First, when biopsy samples from patients with underlying inflammatory bowel disease are being interpreted, it is recommended that the samples be classified as negative, indefinite, or positive for dysplasia. For those biopsy samples that are positive for dysplasia, 2 grades are recognized: low-grade dysplasia and high-grade dysplasia. Moderate dysplasia is not a presently accepted classification.[2, 3] Second, for patients with flat, low-grade dysplasia, colectomy is considered a treatment option, especially if the dysplasia is multifocal.[2, 3] Furthermore, primary sclerosing cholangitis has been shown to increase the risk of ulcerative colitis–related colorectal cancer. As such, liver transplant recipients on long-term immunosuppressants who have underlying primary sclerosing cholangitis could be considered to be at greater risk for colorectal cancer in comparison with their respective counterparts who have not undergone liver transplantation. Colectomy should, therefore, be strongly considered in this patient population when low-grade dysplasia is confirmed during surveillance colonoscopy. I would be interested in the authors' thoughts on these matters.