CHOLECYSTECTOMY in primary sclerosing cholangitis (PSC) showed a strong association with poorer outcomes when performed before diagnosis, according to a large registry study. Patients who had undergone the procedure before their PSC diagnosis had a higher risk of liver transplantation, liver-related death or hepatobiliary malignancy than those with an intact gallbladder or those who underwent surgery after diagnosis.
PSC is a chronic inflammatory disease of the bile ducts that can cause strictures and eventually liver cirrhosis. Gallbladder abnormalities are common, and cholecystectomy is recommended for PSC patients with gallbladder polyps of at least 8 mm or smaller polyps that are growing due to gallbladder carcinoma risk.
The study included 977 patients with PSC in the Helsinki PSC registry who underwent endoscopic retrograde cholangiopancreatography. Of these, 163 had undergone cholecystectomy: 100 before PSC diagnosis and 63 afterwards.
Before diagnosis, patients who had undergone cholecystectomy had more advanced disease, including higher ERCP and Mayo risk scores, FIB-4 indices and fibrosis.
The composite endpoint of liver-related death, hepatobiliary malignancy or liver transplantation occurred in 37% of patients with prior cholecystectomy, compared with 6.5% of those with an intact gallbladder and 5.9% of those who underwent surgery after diagnosis. After adjustment for age, sex and disease severity, prior cholecystectomy was linked to a more than fivefold increased risk (HR 5.16, 95% CI 3.00–8.88; p<0.001).
Restricted mean survival time was five years shorter with prior cholecystectomy than with an intact gallbladder. Liver transplantation-free survival was 4.7 years shorter.
The findings could indicate that gallbladder loss accelerated disease progression or identified a higher-risk PSC phenotype, but causality was not established. Limitations included the single-centre retrospective design and lack of information about the indication for some pre-diagnosis cholecystectomies. The researchers also lacked data on the timing of the first abnormal liver function tests and PSC diagnosis. The findings require validation in independent cohorts.
The results support a more individualised approach to cholecystectomy and suggest that PSC should be considered when liver enzyme levels remain elevated after cholecystectomy.
Reference
Färkkilä MA et al. Cholecystectomy before diagnosis of primary sclerosing cholangitis is associated with markedly worsened transplant free survival. JHEP Rep. 2026;DOI:10.1016/j.jhepr.2026.101967.
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