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Fernandez AM, Chan WW. Update on extraesophageal manifestations of gastroesophageal reflux. Curr Opin Gastroenterol 2024; 40:305-313. [PMID: 38662405 DOI: 10.1097/mog.0000000000001037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/26/2024]
Abstract
PURPOSE OF REVIEW Symptoms/complications related to extraesophageal reflux (EER) are increasingly prevalent presentations and pose significant challenges for clinicians. We summarize and discuss clinical advances and developments in pathophysiology, testing and treatment algorithms of upper/lower airway manifestations of EER. RECENT FINDINGS Growing evidence supports likely multifactorial causes of laryngeal symptoms, including EER, oropharyngeal pathologies, allergic conditions, and cognitive-affective processes (brain-larynx interaction). Diagnostic paradigm for laryngopharyngeal reflux (LPR) is shifting towards a personalized approach with noninvasive strategies/prediction tools to risk-stratify patients for upfront reflux testing over empiric acid suppression trials. Management should be multipronged to include antireflux therapies and treatments targeting other causes. Lower airway complications of EER may result in lung dysfunction and poor transplant outcomes. Esophageal symptoms are often absent and routine esophageal/reflux testing to guide timely antireflux therapies may lead to improved outcomes. Modalities that leverage impedance technology may be important, given the potential role of nonacidic reflux. Novel impedance-based metrics such as mean nocturnal baseline impedance and postreflux swallow-induced peristaltic wave index may provide adjunctive diagnostic values. SUMMARY Standardized approach to diagnosis/management of EER should include multidisciplinary care teams and consider different phenotypes, nonreflux contributors, and the complex gut-airway relationships. Prompt antireflux therapies after careful candidate selection may improve outcomes of these airway complications.
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Affiliation(s)
- Annel M Fernandez
- Department of Medicine, Brigham and Women's Hospital
- Harvard Medical School
| | - Walter W Chan
- Department of Medicine, Brigham and Women's Hospital
- Harvard Medical School
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
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Latorre-Rodríguez AR, Razia D, Omar A, Bremner RM, Mittal SK. Pulmonary and esophageal function in lung transplantation: Fundamental principles and clinical application. Transplant Rev (Orlando) 2024; 38:100796. [PMID: 37840002 DOI: 10.1016/j.trre.2023.100796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Revised: 09/14/2023] [Accepted: 09/22/2023] [Indexed: 10/17/2023]
Abstract
The lungs and esophagus have a close anatomical and physiological relationship. Over the years, reflux-induced pulmonary injury has gained wider recognition, but the full effects of pulmonary disease on esophageal function are still unknown. Intrathoracic pressure dynamics potentially affect esophageal function, especially in patients with end-stage lung disease, both obstructive and restrictive. Lung transplantation is the only viable option for patients with end-stage pulmonary disease and has provided us with a unique opportunity to study these effects as transplantation restores the intrathoracic environment. Esophageal and foregut functional testing before and after transplantation provide insights into the pathophysiology of the foregut-pulmonary axis, such as how underlying pulmonary disease and intrathoracic pressure changes affect esophageal physiology. This review summarizes the available literature and shares the research experience of a lung transplant center, covering topics such as pre- and posttransplant foregut function, esophageal motility in lung transplant recipients, immune-mediated mechanisms of graft rejection associated with gastroesophageal reflux, and the role of antireflux surgery in this population.
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Affiliation(s)
| | - Deepika Razia
- Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA; Creighton University School of Medicine - Phoenix Regional Campus, Phoenix, AZ, USA.
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Lo WK, Flanagan R, Sharma N, Goldberg HJ, Chan WW. Pre-Lung transplant reflux testing demonstrates high prevalence of gastroesophageal reflux in cystic fibrosis and reduces chronic rejection risk. World J Transplant 2023; 13:138-146. [PMID: 37388387 PMCID: PMC10303416 DOI: 10.5500/wjt.v13.i4.138] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2022] [Revised: 03/22/2023] [Accepted: 03/31/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux (GER) has been associated with poor outcomes after lung transplantation for chronic lung disease, including increased risk of chronic rejection. GER is common in cystic fibrosis (CF), but factors influencing the likelihood of pre-transplant pH testing, and the impact of testing on clinical management and transplant outcomes in patients with CF are unknown.
AIM To evaluate the role of pre-transplant reflux testing in the evaluation of lung transplant candidates with CF.
METHODS This was a retrospective study from 2007-2019 at a tertiary medical center that included all patients with CF undergoing lung transplant. Patients with pre-transplant anti-reflux surgery were excluded. Baseline characteristics (age at transplantation, gender, race, body mass index), self-reported GER symptoms prior to transplantation, and pre-transplant cardiopulmonary testing results, were recorded. Reflux testing consisted of either 24-h pH- or combined multichannel intraluminal impedance and pH monitoring. Post-transplant care included a standard immunosuppressive regimen, and regular surveillance bronchoscopy and pulmonary spirometry in accordance with institutional practice as well as in symptomatic patients. The primary outcome of chronic lung allograft dysfunction (CLAD) was defined clinically and histologically per International Society of Heart and Lung Transplantation criteria. Statistical analysis was performed with Fisher’s exact test to assess differences between cohorts, and time-to-event Cox proportional hazards modeling.
RESULTS After applying inclusion and exclusion criteria, a total of 60 patients were included in the study. Among all CF patients, 41 (68.3%) completed reflux monitoring as part of pre-lung transplant evaluation. Objective evidence of pathologic reflux, defined as acid exposure time > 4%, was found in 24 subjects, representing 58% of the tested group. CF patients with pre-transplant reflux testing were older (35.8 vs 30.1 years, P = 0.01) and more commonly reported typical esophageal reflux symptoms (53.7% vs 26.3%, P = 0.06) compared to those without reflux testing. Other patient demographics and baseline cardiopulmonary function did not significantly differ between CF subjects with and without pre-transplant reflux testing. Patients with CF were less likely to undergo pre-transplant reflux testing compared to other pulmonary diagnoses (68% vs 85%, P = 0.003). There was a decreased risk of CLAD in patients with CF who underwent reflux testing compared to those who did not, after controlling for confounders (Cox Hazard Ratio 0.26; 95%CI: 0.08-0.92).
CONCLUSION Pre-transplant reflux testing revealed high prevalence of pathologic reflux in CF patients and was associated with decreased risk of CLAD. Systematic reflux testing may enhance outcomes in this patient population.
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Affiliation(s)
- Wai-Kit Lo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Ryan Flanagan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Nirmal Sharma
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, United States
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Razia D, Mittal SK, Walia R, Tokman S, Huang JL, Smith MA, Bremner RM. Morbidity of antireflux surgery in lung transplant and matched nontransplant cohorts is comparable. Surg Endosc 2023; 37:1114-1122. [PMID: 36131161 PMCID: PMC9491650 DOI: 10.1007/s00464-022-09598-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND Safety data on perioperative outcomes of laparoscopic antireflux surgery (LARS) after lung transplantation (LT) are lacking. We compared the 30-day readmission rate and short-term morbidity after LARS between LT recipients and matched nontransplant (NT) controls. METHODS Adult patients who underwent LARS between January 1, 2015, and October 31, 2021, were included. The participants were divided into two groups: LT recipients and NT controls. First, we compared 30-day readmission rates after LARS between the LT and NT cohorts. Next, we compared 30-day morbidity after LARS between the LT cohort and a 1-to-2 propensity score-matched NT cohort. RESULTS A total of 1328 patients (55 LT recipients and 1273 NT controls) were included. The post-LARS 30-day readmission rate was higher in LT recipients than in the overall NT controls (14.5% vs. 2.8%, p < 0.001). Compared to matched NT controls, LT recipients had a lower prevalence of paraesophageal hernia, a smaller median hernia size, and higher peristaltic vigor. Also compared to the matched NT controls, the LT recipients had a lower median operative time but a longer median length of hospital stay. The proportion of patients with a post-LARS event within 30 postoperative days was comparable between the LT and matched NT cohorts (21.8% vs 14.5%, p = 0.24). CONCLUSIONS Despite a higher perceived risk of comorbidity burden, LT recipients and matched NT controls had similar rates of post-LARS 30-day morbidity at our large-volume center with expertise in transplant and foregut surgery. LARS after LT is safe.
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Affiliation(s)
- Deepika Razia
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Sumeet K. Mittal
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Sofya Tokman
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Jasmine L. Huang
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Michael A. Smith
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
| | - Ross M. Bremner
- Norton Thoracic Institute, St. Joseph’s Hospital and Medical Center, 500 W Thomas Rd, Suite 500, Phoenix, AZ 85013 USA ,Creighton University School of Medicine – Phoenix Regional Campus, Phoenix, AZ USA
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Davidson JR, Franklin D, Kumar S, Mohammadi B, Dawas K, Eaton S, Curry J, De Coppi P, Abbassi-Ghadi N. Fundoplication to preserve allograft function after lung transplant: Systematic review and meta-analysis. J Thorac Cardiovasc Surg 2020; 160:858-866. [DOI: 10.1016/j.jtcvs.2019.10.185] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2019] [Revised: 10/08/2019] [Accepted: 10/25/2019] [Indexed: 12/29/2022]
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Li SS, Tumin D, Krone KA, Boyer D, Kirkby SE, Mansour HM, Hayes D. Risks associated with lung transplantation in cystic fibrosis patients. Expert Rev Respir Med 2018; 12:893-904. [PMID: 30198350 DOI: 10.1080/17476348.2018.1522254] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
INTRODUCTION Survival after lung transplantation lags behind outcomes of other solid organ transplants, and complications from lung transplant are the second most common cause of death in cystic fibrosis. Evolving surgical techniques, therapeutics, and perioperative management have improved short-term survival after lung transplantation, yet have not translated into significant improvement in long-term mortality. Areas covered: We review risk factors for poor long-term outcomes among patients with cystic fibrosis undergoing lung transplantation to highlight areas for improvement. This includes reasons for organ dysfunction, complications of immunosuppression, further exacerbation of extrapulmonary complications of cystic fibrosis, and quality of life. A literature search was performed using PubMed-indexed journals. Expert commentary: There are multiple medical and socioeconomic barriers that threaten long-term survival following lung transplant for patients with cystic fibrosis. An understanding of the causes of each could elucidate treatment options. There is a lack of prospective, multicenter, randomized control trials due to cost, complexity, and feasibility. Ongoing prospective studies should be reserved for the most promising interventions identified in retrospective studies in order to improve long-term outcomes.
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Affiliation(s)
- Susan S Li
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Dmitry Tumin
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Katie A Krone
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Debra Boyer
- b Division of Respiratory Diseases, Boston Children's Hospital , Harvard Medical School , Boston , MA, OH , USA
| | - Stephen E Kirkby
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
| | - Heidi M Mansour
- c Department of Pharmacology and Toxicology , The University of Arizona Colleges of Pharmacy and Medicine , Tucson , AZ , USA
| | - Don Hayes
- a Department of Pediatrics, Nationwide Children's Hospital , The Ohio State University College of Medicine , Columbus , OH , USA
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Early fundoplication is associated with slower decline in lung function after lung transplantation in patients with gastroesophageal reflux disease. J Thorac Cardiovasc Surg 2018; 155:2762-2771.e1. [DOI: 10.1016/j.jtcvs.2018.02.009] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 01/26/2018] [Accepted: 02/05/2018] [Indexed: 01/17/2023]
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Tangaroonsanti A, Vela MF, Crowell MD, DeVault KR, Houghton LA. Esophageal dysmotility according to Chicago classification v3.0 vs v2.0: Implications for association with reflux, bolus clearance, and allograft failure post-lung transplantation. Neurogastroenterol Motil 2018; 30:e13296. [PMID: 29411918 DOI: 10.1111/nmo.13296] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2017] [Accepted: 12/28/2017] [Indexed: 12/17/2022]
Abstract
BACKGROUND Proximal reflux and incomplete transit of boluses swallowed are risk factors for obstructive chronic lung allograft dysfunction (o-CLAD) post-lung transplantation (LTx). Likewise, so is esophagogastric junction outflow obstruction (EGJOO), but not hypo-contractility, when diagnosed using Chicago Classification (CC) v3.0. Given, peristaltic breaks as defined using CCv2.0 can prolong esophageal clearance, both swallowed and refluxed, but which are deemed within normality using CCv3.0, our aim was to determine whether hypo-contractility as diagnosed using CCv2.0, influences the association with reflux, along with its clearance, and that of boluses swallowed, and thus its association to allograft failure. METHODS Esophageal motility abnormalities were classified using CC v3.0 and v2.0 in 50 patients post-LTx (26 female, 55 years (20-73 years)). RESULTS Reclassification from CCv3.0 to v2.0 resulted in 7 patients with normal motility being reclassified to hypo-contractility (n = 6) or hyper-contractility (n = 1); 2 patients with hypo-contractility to normal motility; and 3 patients with EGJOO without hyper-contractility to EGJOO with hyper-contractility. The main consequence of reclassification was that the sub-group exhibiting hypo-contractility became more likely to have abnormal numbers of reflux events (P = .025) and incomplete bolus transit (P = .002) than those with normal motility using CCv2.0; associations not seen using CCv3.0. Irrespective of CC used only patients with EGJOO appeared more likely to develop o-CLAD than those with normal motility (P < .05). CONCLUSIONS Irrespective of CC used, o-CLAD appears linked to EGJOO. CCv2.0 however, accentuates the increased reflux and incomplete bolus transit associated with hypo-contractility post-LTx, suggesting that these motor abnormalities, though considered minor, may be of importance after lung transplant.
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Affiliation(s)
- A Tangaroonsanti
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.,Department of Gastroenterology, Thammasat University Hospital, Pathumthani, Thailand
| | - M F Vela
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - M D Crowell
- Division of Gastroenterology and Hepatology, Mayo Clinic, Scottsdale, AZ, USA
| | - K R DeVault
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA
| | - L A Houghton
- Division of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, FL, USA.,Leeds Institute of Biomedical and Clinical Sciences, Leeds Gastroenterology Institute, Leeds Teaching Hospitals Trust, University of Leeds, Leeds, UK.,Centre for Gastrointestinal Sciences, University Hospital of South Manchester, Manchester Academic Health Sciences Centre, University of Manchester, Manchester, UK
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9
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Antonoff MB. How much does early fundoplication for lung transplant recipients with gastroesophageal reflux disease truly help? Challenges in escaping the perils of retrospective review. J Thorac Cardiovasc Surg 2018; 155:2772-2773. [DOI: 10.1016/j.jtcvs.2018.02.057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 02/23/2018] [Indexed: 10/17/2022]
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Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) may present with heartburn, regurgitation, dysphagia, chronic cough, laryngitis, or even asthma. The clinical presentation of GERD is therefore varied and poses certain challenges to the physician, especially given the limitations of the diagnostic testing. DISCUSSION The evaluation of patients with suspected GERD might be challenging. It is based on the evaluation of clinical features, objective evidence of reflux on diagnostic testing, correlation of symptoms with episodes of reflux, evaluation of anatomical abnormalities, and excluding other causes that might account for the presence of the patient's symptoms. CONCLUSIONS The diagnostic evaluation should include multiple tests, in addition to a thorough clinical examination.
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Hirji SA, Gulack BC, Englum BR, Speicher PJ, Ganapathi AM, Osho AA, Shimpi RA, Perez A, Hartwig MG. Lung transplantation delays gastric motility in patients without prior gastrointestinal surgery-A single-center experience of 412 consecutive patients. Clin Transplant 2017; 31. [DOI: 10.1111/ctr.13065] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/25/2017] [Indexed: 02/03/2023]
Affiliation(s)
- Sameer A. Hirji
- Department of Surgery; Brigham and Women's Hospital; Harvard Medical School; Boston MA USA
| | - Brian C. Gulack
- Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Brian R. Englum
- Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Paul J. Speicher
- Department of Surgery; Duke University Medical Center; Durham NC USA
| | | | - Asishana A. Osho
- Department of Surgery; Massachusetts General Hospital; Boston MA USA
| | - Rahul A. Shimpi
- Department of Surgery; Duke University Medical Center; Durham NC USA
| | - Alexander Perez
- Department of Surgery; Duke University Medical Center; Durham NC USA
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Hathorn KE, Chan WW, Lo WK. Role of gastroesophageal reflux disease in lung transplantation. World J Transplant 2017; 7:103-116. [PMID: 28507913 PMCID: PMC5409910 DOI: 10.5500/wjt.v7.i2.103] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Revised: 11/16/2016] [Accepted: 02/13/2017] [Indexed: 02/05/2023] Open
Abstract
Lung transplantation is one of the highest risk solid organ transplant modalities. Recent studies have demonstrated a relationship between gastroesophageal reflux disease (GERD) and lung transplant outcomes, including acute and chronic rejection. The aim of this review is to discuss the pathophysiology, evaluation, and management of GERD in lung transplantation, as informed by the most recent publications in the field. The pathophysiology of reflux-induced lung injury includes the effects of aspiration and local immunomodulation in the development of pulmonary decline and histologic rejection, as reflective of allograft injury. Modalities of reflux and esophageal assessment, including ambulatory pH testing, impedance, and esophageal manometry, are discussed, as well as timing of these evaluations relative to transplantation. Finally, antireflux treatments are reviewed, including medical acid suppression and surgical fundoplication, as well as the safety, efficacy, and timing of such treatments relative to transplantation. Our review of the data supports an association between GERD and allograft injury, encouraging a strategy of early diagnosis and aggressive reflux management in lung transplant recipients to improve transplant outcomes. Further studies are needed to explore additional objective measures of reflux and aspiration, better compare medical and surgical antireflux treatment options, extend follow-up times to capture longer-term clinical outcomes, and investigate newer interventions including minimally invasive surgery and advanced endoscopic techniques.
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Huang L, Xu AM. Post-surgical gastrointestinal reflux disease: Status quo and treatment. Shijie Huaren Xiaohua Zazhi 2016; 24:2601-2607. [DOI: 10.11569/wcjd.v24.i17.2601] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Reflux is a common and tricky morbidity after gastrointestinal surgery which is caused by the destruction of physiological anti-reflux barriers, greatly affecting patients' postoperative quality of life. Gastroenterologists are now actively trying very hard to explore feasible, effective, and safe anti-reflux approaches. Conservative medical treatment, typically with proton pump inhibitors, is easily accepted by patients, however, its long-term adverse events are noteworthy. In the surgical aspect, laparoscopic anti-reflux surgery is gaining more and more popularity, after the first case of fundoplication. Besides, other operations, such as bariatric surgery, pediatric surgery, and pulmonary transplantation, are also frequently complicated by post-operative digestive reflux. Herein we systematically review the status quo and treatment modalities for post-surgical reflux disease, with the hope to facilitate surgeons to cope with this challenging issue appropriately.
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Patti MG, Vela MF, Odell DD, Richter JE, Fisichella PM, Vaezi MF. The Intersection of GERD, Aspiration, and Lung Transplantation. J Laparoendosc Adv Surg Tech A 2016; 26:501-5. [PMID: 27218671 DOI: 10.1089/lap.2016.0170] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Lung transplantation is a radical but life-saving treatment option for patients with end-stage lung diseases, such as idiopathic pulmonary fibrosis (IPF) and scleroderma. In light of the proposed association and controversy linking gastroesophageal reflux disease (GERD) to IPF and lung transplant outcome, the American Gastroenterological Association convened during the DDW in Washington in May 2015 a multidisciplinary group of experts in the field of GERD and lung transplantation to make considerations about the care of these patients based on available data and subsequent expert panel discussion at this symposium. The following topics were discussed: (1) pathophysiology of GERD-induced pulmonary symptoms, (2) GERD evaluation before and after lung transplantation, (3) outcome of lung transplantation for IPF and scleroderma, and (4) role of laparoscopic fundoplication before or after lung transplantation.
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Affiliation(s)
- Marco G Patti
- 1 Pritzker School of Medicine, University of Chicago , Chicago, Illinois
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15
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Lo WK, Goldberg HJ, Wee J, Fisichella PM, Chan WW. Both Pre-Transplant and Early Post-Transplant Antireflux Surgery Prevent Development of Early Allograft Injury After Lung Transplantation. J Gastrointest Surg 2016; 20:111-8; discussion 118. [PMID: 26493975 DOI: 10.1007/s11605-015-2983-0] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 10/10/2015] [Indexed: 01/31/2023]
Abstract
BACKGROUND Antireflux surgery (ARS) has been associated with improved lung transplant outcomes. Pre-transplant ARS has been shown in small studies to improve pulmonary function among transplant candidates with gastroesophageal reflux disease (GERD). Although early post-transplant ARS has been shown to be effective in reducing chronic rejection, the optimal timing of ARS in transplant recipients remains unclear. The aim of this study is to evaluate the time to early allograft injury among lung transplant recipients by timing of ARS. METHODS This was a retrospective cohort study of lung transplant recipients undergoing ARS before or after transplantation at a tertiary care center since 2007, with at least 1-year follow-up. Early allograft injury was defined clinically and histologically as acute rejection or lymphocytic bronchiolitis, occurring within the first year after transplantation. In accordance with prior studies, the cutoff between early and late post-transplant ARS was set at 6 months. Time-to-event analysis using the Cox proportional hazards model was applied to assess the relationship between timing of surgery and early allograft injury. Subjects not meeting this outcome were censored at 1 year in the time-to-event analysis. Fisher’s exact test for binary variables and Student’s t test for continuous variables were performed to assess for differences among the three groups: ARS pre-transplant, ARS early post-transplant, and ARS late post-transplant. RESULTS Forty-eight subjects (60% men, mean age 55) met the inclusion criteria for the study. Patient demographics, pre-transplant cardiopulmonary function, BMI, CMV status, and PPI exposure were similar between groups. Kaplan-Meier analysis demonstrated significantly increased early allograft injury in late post-transplant ARS patients compared with both pre-transplant (log-rank p = 0.007) and early post-transplant (log-rank p = 0.05) patients, as well as a significant trend across groups (log-rank p = 0.005). No significant difference between pre- and early post-transplant groups was noted. Three ARS failures were noted in the pre- and late post-transplant groups. Complications included one death due to aspiration pneumonia in a late post-transplant ARS recipient. No early post-transplant ARS patients experienced ARS failure or complications. CONCLUSION Late post-lung transplant ARS resulted in increased risk of early allograft injury compared to pre-transplant and early post-transplant ARS. Both pre- and early post-transplant ARS appear equally safe and effective in improving lung transplant outcomes. These findings support consideration of aggressive reflux testing and application of antireflux measures before or soon after transplantation to minimize the impact of reflux on allograft injury.
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Dirou S, Germaud P, Bruley des Varannes S, Magnan A, Blanc FX. [Gastro-esophageal reflux and chronic respiratory diseases]. Rev Mal Respir 2015; 32:1034-46. [PMID: 26071979 DOI: 10.1016/j.rmr.2015.03.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 03/06/2015] [Indexed: 01/22/2023]
Abstract
Gastroesophageal reflux disease (GERD) frequently occurs in association with chronic respiratory diseases although the casual link is not always clear. Several pathophysiological and experimental factors are considered to support a role for GERD in respiratory disease. Conversely, respiratory diseases and bronchodilator treatment can themselves exacerbate GERD. When cough or severe asthma is being investigated, GERD does not need to be systematically looked for and a therapeutic test with proton pump inhibitors is not always recommended. pH impedance monitoring is now the reference diagnostic tool to detect non acid reflux, a form of reflux for which proton pump inhibitor treatment is ineffective. Recent data have shown a potential role of GERD in idiopathic pulmonary fibrosis and bronchiolitis obliterans following lung transplantation, leading to discussions about the place of surgery in this context. However, studies using pH impedance monitoring are still needed to better understand and manage the association between GERD and chronic respiratory diseases.
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Affiliation(s)
- S Dirou
- Université de Nantes, Nantes 44000, France; Institut du thorax, service de pneumologie, hôpital G. et R. Laënnec, CHU de Nantes, boulevard J.-Monod, 44093 Nantes cedex 1, France
| | - P Germaud
- Institut du thorax, service de pneumologie, hôpital G. et R. Laënnec, CHU de Nantes, boulevard J.-Monod, 44093 Nantes cedex 1, France
| | - S Bruley des Varannes
- Institut des maladies de l'appareil digestif, service d'hépatogastroentérologie et assistance nutritionnelle, CHU de Nantes, Nantes 44093, France; DHU2020 médecine personnalisée des maladies chroniques, Nantes 44000, France
| | - A Magnan
- Université de Nantes, Nantes 44000, France; Institut du thorax, service de pneumologie, hôpital G. et R. Laënnec, CHU de Nantes, boulevard J.-Monod, 44093 Nantes cedex 1, France; DHU2020 médecine personnalisée des maladies chroniques, Nantes 44000, France; Inserm, UMR1087, institut du thorax, Nantes 44093, France; CNRS, UMR 6291, Nantes 44000, France
| | - F-X Blanc
- Université de Nantes, Nantes 44000, France; Institut du thorax, service de pneumologie, hôpital G. et R. Laënnec, CHU de Nantes, boulevard J.-Monod, 44093 Nantes cedex 1, France; DHU2020 médecine personnalisée des maladies chroniques, Nantes 44000, France; Inserm, UMR1087, institut du thorax, Nantes 44093, France; CNRS, UMR 6291, Nantes 44000, France.
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17
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Gulack BC, Meza JM, Lin SS, Hartwig MG, Davis RD. Reflux and Allograft Dysfunction: Is There a Connection? Thorac Surg Clin 2015; 25:97-105. [DOI: 10.1016/j.thorsurg.2014.09.006] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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18
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Meyer KC, Raghu G, Verleden GM, Corris PA, Aurora P, Wilson KC, Brozek J, Glanville AR. An international ISHLT/ATS/ERS clinical practice guideline: diagnosis and management of bronchiolitis obliterans syndrome. Eur Respir J 2014; 44:1479-503. [PMID: 25359357 DOI: 10.1183/09031936.00107514] [Citation(s) in RCA: 382] [Impact Index Per Article: 38.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Bronchiolitis obliterans syndrome (BOS) is a major complication of lung transplantation that is associated with poor survival. The International Society for Heart and Lung Transplantation, American Thoracic Society, and European Respiratory Society convened a committee of international experts to describe and/or provide recommendations for 1) the definition of BOS, 2) the risk factors for developing BOS, 3) the diagnosis of BOS, and 4) the management and prevention of BOS. A pragmatic evidence synthesis was performed to identify all unique citations related to BOS published from 1980 through to March, 2013. The expert committee discussed the available research evidence upon which the updated definition of BOS, identified risk factors and recommendations are based. The committee followed the GRADE (Grading of Recommendation, Assessment, Development and Evaluation) approach to develop specific clinical recommendations. The term BOS should be used to describe a delayed allograft dysfunction with persistent decline in forced expiratory volume in 1 s that is not caused by other known and potentially reversible causes of post-transplant loss of lung function. The committee formulated specific recommendations about the use of systemic corticosteroids, cyclosporine, tacrolimus, azithromycin and about re-transplantation in patients with suspected and confirmed BOS. The diagnosis of BOS requires the careful exclusion of other post-transplant complications that can cause delayed lung allograft dysfunction, and several risk factors have been identified that have a significant association with the onset of BOS. Currently available therapies have not been proven to result in significant benefit in the prevention or treatment of BOS. Adequately designed and executed randomised controlled trials that properly measure and report all patient-important outcomes are needed to identify optimal therapies for established BOS and effective strategies for its prevention.
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Affiliation(s)
- Keith C Meyer
- School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, USA
| | - Ganesh Raghu
- School of Medicine, University of Washington, Seattle, WA, USA
| | | | | | - Paul Aurora
- Great Ormond Street Hospital for Children, London, UK
| | | | - Jan Brozek
- McMaster University, Hamilton, ON, Canada
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19
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Aramini B, D’Ovidio F. Gastroesophageal reflux disease and the lung transplant recipient. ACTA ACUST UNITED AC 2014. [DOI: 10.1007/s13665-014-0092-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
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20
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Neujahr DC, Uppal K, Force SD, Fernandez F, Lawrence C, Pickens A, Bag R, Lockard C, Kirk AD, Tran V, Lee K, Jones DP, Park Y. Bile acid aspiration associated with lung chemical profile linked to other biomarkers of injury after lung transplantation. Am J Transplant 2014; 14:841-8. [PMID: 24666830 PMCID: PMC5505513 DOI: 10.1111/ajt.12631] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Revised: 12/12/2013] [Accepted: 12/13/2013] [Indexed: 01/25/2023]
Abstract
Aspiration of gastrointestinal contents has been linked to worse outcomes following lung transplantation but uncertainty exists about underlying mechanisms. We applied high-resolution metabolomics of bronchoalveolar lavage fluid (BALF) in patients with episodic aspiration (defined by bile acids in the BALF) to identify potential metabolic changes associated with aspiration. Paired samples, one with bile acids and another without, from 29 stable lung transplant patients were studied. Liquid chromatography coupled to high-resolution mass spectroscopy was used to interrogate metabolomic contents of these samples. Data were obtained for 7068 ions representing intermediary metabolites, environmental agents and chemicals associated with microbial colonization. A substantial number (2302) differed between bile acid positive and negative samples when analyzed by false discovery rate at q = 0.01. These included pathways associated with microbial metabolism. Hierarchical cluster analysis defined clusters of chemicals associated with bile acid aspiration that were correlated to previously reported biomarkers of lung injury including T cell granzyme B level and the chemoattractants CXCL9 and CXCL10. These data specifically link bile acids presence in lung allografts to inflammatory pathways known to segregate with worsening allograft outcome, and provide additional mechanistic insight into the association between reflux and lung allograft injury.
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Affiliation(s)
- D. C. Neujahr
- Emory Transplant Center, Emory University, Atlanta, GA,Corresponding author: David C. Neujahr,
| | - K. Uppal
- Clinical Biomarkers Laboratory Medicine, Emory University, Atlanta, GA
| | - S. D. Force
- Emory Transplant Center, Emory University, Atlanta, GA
| | - F. Fernandez
- Emory Transplant Center, Emory University, Atlanta, GA
| | - C. Lawrence
- Emory Transplant Center, Emory University, Atlanta, GA
| | - A. Pickens
- Emory Transplant Center, Emory University, Atlanta, GA
| | - R. Bag
- Emory Transplant Center, Emory University, Atlanta, GA
| | - C. Lockard
- Emory Transplant Center, Emory University, Atlanta, GA
| | - A. D. Kirk
- Emory Transplant Center, Emory University, Atlanta, GA
| | - V. Tran
- Clinical Biomarkers Laboratory Medicine, Emory University, Atlanta, GA
| | - K. Lee
- Department of Industrial Engineering, Hanyang University, Hanyang, Korea
| | - D. P. Jones
- Clinical Biomarkers Laboratory Medicine, Emory University, Atlanta, GA
| | - Y. Park
- Clinical Biomarkers Laboratory Medicine, Emory University, Atlanta, GA,College of Pharmacy, Korea University, Sejong City, Korea
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21
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Fisichella PM, Jalilvand A. The role of impaired esophageal and gastric motility in end-stage lung diseases and after lung transplantation. J Surg Res 2014; 186:201-6. [DOI: 10.1016/j.jss.2013.09.023] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2013] [Revised: 08/07/2013] [Accepted: 09/18/2013] [Indexed: 01/29/2023]
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22
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Allaix ME, Fisichella PM, Noth I, Mendez BM, Patti MG. The pulmonary side of reflux disease: from heartburn to lung fibrosis. J Gastrointest Surg 2013; 17:1526-35. [PMID: 23615806 DOI: 10.1007/s11605-013-2208-3] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2013] [Accepted: 04/10/2013] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Gastroesophageal reflux disease (GERD) is the most prevalent gastrointestinal disorder in the USA. Heartburn is the symptom most commonly associated with this disease, and the highly commercialized medical treatment directed toward relief of this symptom represents a 10-billion-dollar-per-year industry. DISCUSSION Unfortunately, there is often little awareness that GERD can be potentially a lethal disease as it can cause esophageal cancer. Furthermore, there is even less awareness about the relationship between GERD and respiratory disorders with the potential for severe morbidity and even mortality.
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Affiliation(s)
- Marco E Allaix
- Center for Esophageal Diseases, Department of Surgery, University of Chicago Pritzker School of Medicine, Chicago, IL 60637, USA
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23
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McFadden D, Souba WW. The Journal of Surgical Research–2013. J Surg Res 2013. [DOI: 10.1016/j.jss.2013.03.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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24
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Aspiration, localized pulmonary inflammation, and predictors of early-onset bronchiolitis obliterans syndrome after lung transplantation. J Am Coll Surg 2013; 217:90-100; discussion 100-1. [PMID: 23628225 DOI: 10.1016/j.jamcollsurg.2013.03.008] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Revised: 02/28/2013] [Accepted: 03/12/2013] [Indexed: 12/18/2022]
Abstract
BACKGROUND We hypothesized that immune mediator concentrations in the bronchoalveolar fluid (BALF) are predictive of bronchiolitis obliterans syndrome (BOS) and demonstrate specific patterns of dysregulation, depending on the presence of acute cellular rejection, BOS, aspiration, and timing of lung transplantation. STUDY DESIGN We prospectively collected 257 BALF samples from 105 lung transplant recipients. The BALF samples were assessed for absolute and differential white blood cell counts and 34 proteins implicated in pulmonary immunity, inflammation, fibrosis, and aspiration. RESULTS There were elevated BALF concentrations of interleukin (IL)-15, IL-17, basic fibroblast growth factor, tumor necrosis factor-α, and myeloperoxidase, and reduced concentrations of α1-antitrypsin, which were predictive of early-onset BOS. Patients with BOS had an increased percentage of BALF lymphocytes and neutrophils, with a reduced percentage of macrophages (p < 0.05). The BALF concentrations of IL-1β; IL-8; interferon-γ-induced protein 10; regulated upon activation, normal T-cell expressed and secreted; neutrophil elastase; and pepsin were higher in patients with BOS (p < 0.05). Among those with BOS, BALF concentrations of IL-1RA; IL-8; eotaxin; interferon-γ-induced protein 10; regulated upon activation, normal T-cell expressed and secreted; myeloperoxidase; and neutrophil elastase were positively correlated with time since transplantation (p < 0.01). Those with worse grades of acute cellular rejection had an increased percentage of lymphocytes in their BALF (p < 0.0001) and reduced BALF concentrations of IL-1β, IL-7, IL-9, IL-12, granulocyte colony-stimulating factor, granulocyte-macrophage colony-stimulating factor, interferon-γ, and vascular endothelial growth factor (p ≤ 0.001). Patients with aspiration based on detectable pepsin had increased percentage of neutrophils (p < 0.001) and reduced BALF concentrations of IL-12 (p < 0.001). CONCLUSIONS The BALF levels of IL-15, IL-17, basic fibroblast growth factor, tumor necrosis factor-α, myeloperoxidase, and α1-antitrypsin at 6 to 12 months after lung transplantation are predictive of early-onset BOS, and those with BOS and aspiration have an augmented chemotactic and inflammatory balance of pulmonary leukocytes and immune mediators. These data justify the surgical prevention of aspiration and argue for the refinement of antirejection regimens.
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25
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Kilic A, Shah AS, Merlo CA, Gourin CG, Lidor AO. Early outcomes of antireflux surgery for United States lung transplant recipients. Surg Endosc 2012; 27:1754-60. [DOI: 10.1007/s00464-012-2674-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2012] [Accepted: 10/22/2012] [Indexed: 10/27/2022]
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26
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Fisichella PM, Davis CS, Kovacs EJ. A review of the role of GERD-induced aspiration after lung transplantation. Surg Endosc 2012; 26:1201-4. [PMID: 22083335 PMCID: PMC3690196 DOI: 10.1007/s00464-011-2037-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2011] [Accepted: 09/18/2011] [Indexed: 01/06/2023]
Abstract
The increased prevalence of gastroesophageal reflux disease (GERD) in lung transplantation patients has been established; however, many questions persist regarding the relationship of GERD to aspiration and its potential to induce pulmonary allograft failure. Moreover, the biological implications of aspiration in lung transplantation have yet to be fully elucidated. The goal of this review was to assess the relationship between GERD and aspiration, focusing on the role of these events in the development of allograft injury after lung transplantation.
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Affiliation(s)
- P Marco Fisichella
- Department of Surgery, Swallowing Center, Loyola University Medical Center, 2160 South 1st Ave., Maywood, IL 60153, USA.
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