Primer Sklerozan Kolanjitte Dominant Darlıkların Endoskopik Yönetimi: 12 Yıllık Tek Merkez ve Tek Endoskopist Deneyimi

Yıl 2026, Cilt: 24 Sayı: 3, 130 - 138, 20.02.2026

Kerem Kenarlı , Bülent Ödemiş , Nazmi Gökhan Ünver , Emir Tuğrul Keskin , Alper Macif , Kübra Köken , Göktürk Karataş , Ahmet Burak Fedai , Erdoğan Deniz

https://doi.org/10.17941/agd.1779521

https://izlik.org/JA46DB26KZ

Öz

Giriş ve Amaç: Primer sklerozan kolanjitte görülen dominant biliyer darlıklar, klinik açıdan önemli bir komplikasyon olup sıklıkla endoskopik tedavi gerektirmektedir. Önerilen endoskopik yaklaşım, balon dilatasyonu ile kısa süreli stentleme kombinasyonu veya tek başına balon dilatasyonu şeklindedir. Ancak, bu alandaki uzun dönem gerçek yaşam verileri sınırlıdır. Gereç ve Yöntem: 2011–2023 yılları arasında üçüncü basamak bir merkezde dominant darlık nedeniyle endoskopik retrograd kolanjiyopankreatografi uygulanan ardışık primer sklerozan kolanjit hastaları retrospektif olarak değerlendirildi. Tüm girişimler deneyimli tek bir endoskopist tarafından gerçekleştirildi. Uygulamalar, endoskopik balon veya buji dilatasyonunu takiben kısa süreli biliyer drenajı içermekteydi. Çalışmanın primer sonlanım noktası, 24. ayda nüksüz sağkalım olarak belirlendi. Sekonder sonlanım noktaları ise klinik ve biyokimyasal yanıt, hastalık progresyonu ve güvenlik sonuçlarıydı. Bulgular: Toplam 35 hasta (ortalama yaş: 42.0 ± 13.5 yıl; %68.6 erkek) üzerinde 138 endoskopik girişim gerçekleştirildi; hasta başına medyan üç işlem yapıldı. Olguların %94.3’ünde dilatasyon uygulandı ve tüm hastalara kısa süreli stent veya nazobiliyer drenaj sağlandı (medyan süre: 15 gün). Üçüncü ayda hastaların %78.8’i asemptomatikti ve %80.0’inde alkalen fosfataz düzeyinde ≥ %20 azalma saptandı. Yirmi dördüncü ayda nüksüz sağkalım oranı %45.4 olarak bulundu. Genel komplikasyon oranı %8.0 olup en sık görülenler kolanjit, pankreatit ve stent migrasyonuydu. İşlem ilişkili mortalite izlenmedi. Sonuç: Endoskopik tedavi, özellikle kısa süreli drenaj ile birlikte uygulanan balon dilatasyonu, primer sklerozan kolanjitte dominant darlıkların yönetiminde güvenli ve etkili bir yöntem olarak görünmektedir. Bu yaklaşım kısa dönemde anlamlı klinik ve biyokimyasal düzelme sağlamakta ve kabul edilebilir bir güvenlik profili sunmaktadır. Bununla birlikte, yüksek nüks oranı hastalığın kronik ve tekrarlayıcı doğasına işaret etmekte olup uzun dönemli yapılandırılmış izlemin önemini vurgulamaktadır.

Anahtar Kelimeler

Primer Sklerozan Kolanjit , Safra Yolu Darlıkları , Endoskopik retrograd kolanjiyopankreatografi , Balon Dilatasyonu , Biliyer Drenaj

Endoscopic Management of Dominant Strictures in Primary Sclerosing Cholangitis: Real-World Outcomes from a 12-Year Single-Endoscopist Experience

https://izlik.org/JA46DB26KZ

Öz

Background and Aims: Dominant biliary strictures are a clinically important complication in primary sclerosing cholangitis that often require endoscopic therapy. Although balloon dilation with or without short-term stenting is recommended, long-term real-world outcome data remain limited. Materials and Methods: We retrospectively evaluated consecutive primary sclerosing cholangitis patients who underwent endoscopic retrograde cholangiopancreatography for dominant strictures between 2011 and 2023 at a tertiary referral center. All procedures were performed by a single experienced endoscopist. Interventions included endoscopic balloon or bougie dilation with subsequent short-term biliary drainage. The primary endpoint was recurrence-free survival at 24 months; secondary endpoints included clinical and biochemical response, disease progression, and safety outcomes. Results: Total of 35 patients (mean age 42.0 ± 13.5 years; 68.6% male) underwent 138 endoscopic procedures, with a median of three interventions per patient. Dilation was performed in 94.3% of cases, and all patients received short-term stenting or nasobiliary drainage (median duration 15 days). At three months, 78.8% of patients were asymptomatic and 80.0% achieved a ≥ 20% reduction in alkaline phosphatase. The 24-month recurrence-free survival rate was 45.4%. The overall complication rate was 8.0% (including cholangitis, pancreatitis, and stent migration), with no procedure-related mortality. Conclusion: Endoscopic management -particularly balloon dilation with short-term drainage- appears to be a safe and effective strategy for dominant strictures in primary sclerosing cholangitis, offering substantial short-term clinical and biochemical improvement with an acceptable safety profile. Nevertheless, the high recurrence rate highlights the chronic relapsing nature of the disease and emphasizes the need for structured long-term surveillance.

Anahtar Kelimeler

Sclerosing Cholangitis , Bile Duct Strictures , Endoscopic retrograde cholangiopancreatography , Balloon Dilation , Biliary Drainage

Kaynakça

• 1. Lazaridis KN, LaRusso NF. Primary Sclerosing Cholangitis. N Engl J Med. 2016;375(12):1161-70. doi: 10.1056/NEJMra1506330.
• 2. Björnsson E, Olsson R, Bergquist A, et al. The natural history of small-duct primary sclerosing cholangitis. Gastroenterology. 2008;134(4):975-80. doi: 10.1053/j.gastro.2008.01.042.
• 3. Boonstra K, Weersma RK, van Erpecum KJ, et al; EpiPSCPBC Study Group. Population-based epidemiology, malignancy risk, and outcome of primary sclerosing cholangitis. Hepatology. 2013;58(6):2045-55. doi: 10.1002/hep.26565.
• 4. Schramm C, Eaton J, Ringe KI, Venkatesh S, Yamamura J; MRI working group of the IPSCSG. Recommendations on the use of magnetic resonance imaging in PSC-A position statement from the International PSC Study Group. Hepatology. 2017;66(5):1675-88. doi: 10.1002/hep.29293.
• 5. Naitoh I, Isayama H, Akamatsu N, et al. The 2024 diagnostic criteria for primary sclerosing cholangitis. J Gastroenterol. 2025;60(10):1221-31. doi: 10.1007/s00535-025-02265-5.
• 6. Aabakken L, Karlsen TH, Albert J, et al. Role of endoscopy in primary sclerosing cholangitis: European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) Clinical Guideline. Endoscopy. 2017;49(6):588-608. doi: 10.1055/s-0043-107029.
• 7. Thylin M, Färkkilä M, Kautiainen H, et al. The new definition of dominant stricture in primary sclerosing cholangitis: Prevalence and clinical significance. Liver Int. 2024;44(9):2351-8. doi: 10.1111/liv.15985.
• 8. Bowlus CL, Arrivé L, Bergquist A, et al. AASLD practice guidance on primary sclerosing cholangitis and cholangiocarcinoma. Hepatology. 2023;77(2):659-702. doi: 10.1002/hep.32771.
• 9. Mizuno S, Uchida Y, Ando S, et al. Endoscopic management of primary sclerosing cholangitis. Dig Endosc. 2025 Jul;37(7):723-32. doi: 10.1111/den.15010.
• 10. Lindor KD, Kowdley KV, Harrison ME; American College of Gastroenterology. ACG Clinical Guideline: Primary Sclerosing Cholangitis. Am J Gastroenterol. 2015;110(5):646-59; quiz 660. doi: 10.1038/ajg.2015.112.
• 11. Chapman MH, Thorburn D, Hirschfield GM, et al. British Society of Gastroenterology and UK-PSC guidelines for the diagnosis and management of primary sclerosing cholangitis. Gut. 2019;68(8):1356-78. doi: 10.1136/gutjnl-2018-317993.
• 12. Isayama H, Tazuma S, Kokudo N, et al; PSC guideline committee Members: Ministry of Health, Labour and Welfare (Japan) Research Project, The Intractable Hepatobiliary Disease Study Group. Clinical guidelines for primary sclerosing cholangitis 2017. J Gastroenterol. 2018;53(9):1006-34. doi: 10.1007/s00535-018-1484-9. Erratum in: J Gastroenterol. 2022;57(6):453-4. doi: 10.1007/s00535-022-01867-7.
• 13. European Association for the Study of the Liver. EASL Clinical Practice Guidelines on sclerosing cholangitis. J Hepatol. 2022;77(3):761-806. doi: 10.1016/j.jhep.2022.05.011. Erratum in: J Hepatol. 2023;79(5):1339. doi: 10.1016/j.jhep.2023.09.005.
• 14. Ferreira MTGB, Ribeiro IB, de Moura DTH, et al. Stent versus Balloon Dilation for the Treatment of Dominant Strictures in Primary Sclerosing Cholangitis: A Systematic Review and Meta-Analysis. Clin Endosc. 2021;54(6):833-42. doi: 10.5946/ce.2021.052.
• 15. Dhaliwal AS, Naga Y, Ramai D, et al. A comparison of balloon- versus stent-based approach for dominant strictures in primary sclerosing cholangitis: a meta-analysis. Ann Gastroenterol. 2022;35(3):307-16. doi: 10.20524/aog.2022.0701.
• 16. Han S, Shah RJ. Benefit of endoscopic stenting for dominant strictures in patients with primary sclerosing cholangitis. Endosc Int Open. 2022;10(9):E1163-8. doi: 10.1055/a-1873-0961.
• 17. Banks PA, Bollen TL, Dervenis C, et al; Acute Pancreatitis Classification Working Group. Classification of acute pancreatitis--2012: revision of the Atlanta classification and definitions by international consensus. Gut. 2013;62(1):102-11. doi: 10.1136/gutjnl-2012-302779.
• 18. Mukai S, Itoi T, Baron TH, et al. Indications and techniques of biliary drainage for acute cholangitis in updated Tokyo Guidelines 2018. J Hepatobiliary Pancreat Sci. 2017;24(10):537-49. doi: 10.1002/jhbp.496.
• 19. Gotthardt DN, Rudolph G, Klöters-Plachky P, Kulaksiz H, Stiehl A. Endoscopic dilation of dominant stenoses in primary sclerosing cholangitis: outcome after long-term treatment. Gastrointest Endosc. 2010;71(3):527-34. doi: 10.1016/j.gie.2009.10.041.
• 20. Gluck M, Cantone NR, Brandabur JJ, et al. A twenty-year experience with endoscopic therapy for symptomatic primary sclerosing cholangitis. J Clin Gastroenterol. 2008;42(9):1032-9. doi: 10.1097/MCG.0b013e3181646713.
• 21. Kaya M, Petersen BT, Angulo P, et al. Balloon dilation compared to stenting of dominant strictures in primary sclerosing cholangitis. Am J Gastroenterol. 2001;96(4):1059-66. doi: 10.1111/j.1572-0241.2001.03690.x.
• 22. Natt N, Michael F, Michael H, Dubois S, Al Mazrou'i A. ERCP-Related Adverse Events in Primary Sclerosing Cholangitis: A Systematic Review and Meta-Analysis. Can J Gastroenterol Hepatol. 2022;2022:2372257. doi: 10.1155/2022/2372257.
• 23. Baluyut AR, Sherman S, Lehman GA, Hoen H, Chalasani N. Impact of endoscopic therapy on the survival of patients with primary sclerosing cholangitis. Gastrointest Endosc. 2001;53(3):308-12. doi: 10.1016/s0016-5107(01)70403-8.