1
|
Alghubari A, Cheah R, Z Shah S, Naser ARN, Lee AS, DeVault KR, Houghton LA. The impact of lung transplantation on esophageal motility and inter-relationships with reflux and lung mechanics in patients with restrictive and obstructive respiratory disease. Neurogastroenterol Motil 2024; 36:e14788. [PMID: 38523356 DOI: 10.1111/nmo.14788] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 03/06/2024] [Accepted: 03/12/2024] [Indexed: 03/26/2024]
Abstract
BACKGROUND For many patients with lung disease the only proven intervention to improve survival and quality of life is lung transplantation (LTx). Esophageal dysmotility and gastroesophageal reflux (GER) are common in patients with respiratory disease, and often associate with worse prognosis following LTx. Which, if any patients, should be excluded from LTx based on esophageal concerns remains unclear. Our aim was to understand the effect of LTx on esophageal motility diagnosis and examine how this and the other physiological and mechanical factors relate to GER and clearance of boluses swallowed. METHODS We prospectively recruited 62 patients with restrictive (RLD) and obstructive (OLD) lung disease (aged 33-75 years; 42 men) who underwent high resolution impedance manometry and 24-h pH-impedance before and after LTx. KEY RESULTS RLD patients with normal motility were more likely to remain normal (p = 0.02), or if having abnormal motility to change to normal (p = 0.07) post-LTx than OLD patients. Esophageal length (EL) was greater in OLD than RLD patients' pre-LTx (p < 0.001), reducing only in OLD patients' post-LTx (p = 0.02). Reduced EL post-LTx associated with greater contractile reserve (r = 0.735; p = 0.01) and increased likelihood of motility normalization (p = 0.10). Clearance of reflux improved (p = 0.01) and associated with increased mean nocturnal baseline impedance (p < 0.001) in RLD but not OLD. Peristaltic breaks and thoraco-abdominal pressure gradient impact both esophageal clearance of reflux and boluses swallowed (p < 0.05). CONCLUSIONS AND INFERENCES RLD patients are more likely to show improvement in esophageal motility than OLD patients post-LTx. However, the effect on GER is more difficult to predict and requires other GI, anatomical and pulmonary factors to be taken into consideration.
Collapse
Affiliation(s)
- Ali Alghubari
- Division of Gastroenterology and Surgical Sciences, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Ramsah Cheah
- Division of Gastroenterology and Surgical Sciences, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
| | - Sadia Z Shah
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Abdel-Rahman N Naser
- Department of Surgery, University of Florida College of Medicine, Jacksonville, Florida, USA
| | | | - Kenneth R DeVault
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| | - Lesley A Houghton
- Division of Gastroenterology and Surgical Sciences, Leeds Institute of Medical Research, University of Leeds, Leeds, UK
- Department of Gastroenterology and Hepatology, Mayo Clinic, Jacksonville, Florida, USA
| |
Collapse
|
2
|
Latorre-Rodríguez AR, Golla M, Arjuna A, Bremner RM, Mittal SK. Impaired esophagogastric junction relaxation and lung transplantation outcomes. Dis Esophagus 2024:doae030. [PMID: 38688726 DOI: 10.1093/dote/doae030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Revised: 03/13/2024] [Accepted: 04/08/2024] [Indexed: 05/02/2024]
Abstract
The implications of impaired esophagogastric junction relaxation (i.e. esophagogastric junction outflow obstruction and achalasia) in lung transplants recipients (LTRs) are unclear. Thus, we examined the prevalence and clinical outcomes of LTRs with an abnormally elevated integrated relaxation pressure (IRP) on high-resolution manometry before lung transplantation (LTx). After IRB approval, we reviewed data on LTRs who underwent LTx between January 2019 and August 2022 with a preoperative median IRP >15 mmHg. Differences in overall survival and chronic lung allograft dysfunction (CLAD)-free survival between LTRs with a normalized median IRP after LTx (N-IRP) and those with persistently high IRP (PH-IRP) were assessed using Kaplan-Meier curves and the log-rank test. During the study period, 352 LTx procedures were performed; 44 (12.5%) LTRs had an elevated IRP before LTx, and 37 (84.1%) completed a postoperative manometry assessment (24 [70.6%] males; mean age, 65.2 ± 9.1 years). The median IRP before and after LTx was 18.7 ± 3.8 mmHg and 12 ± 5.6 mmHg, respectively (P < 0.001); the median IRP normalized after LTx in 24 (64.9%) patients. Two-year overall survival trended lower in the N-IRP group than the PH-IRP group (77.2% vs. 92.3%, P = 0.086), but CLAD-free survival (P = 0.592) and rates of primary graft dysfunction (P = 0.502) and acute cellular rejection (P = 0.408) were similar. An abnormally elevated IRP was common in LTx candidates; however, it normalized in roughly two-thirds of patients after LTx. Two-year survival trended higher in the PH-IRP group, despite similar rates of primary graft dysfunction and acute cellular rejection as well as similar CLAD-free survival between the groups.
Collapse
Affiliation(s)
- Andrés R Latorre-Rodríguez
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- Grupo de Investigación Clínica, Escuela de Medicina y Ciencias de la Salud, Universidad del Rosario, Bogotá, D.C., Colombia
| | - Madison Golla
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Creighton University, Phoenix, AZ, USA
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Creighton University, Phoenix, AZ, USA
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
- School of Medicine, Creighton University, Phoenix, AZ, USA
| |
Collapse
|
3
|
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.
Collapse
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.
| |
Collapse
|
4
|
Yamamoto M, Kamal AN, Gabbard S, Clarke J, Gyawali CP, Leiman DA. Esophageal Function Testing Patterns in the Evaluation and Management of Lung Transplantation: Results of a National Survey. J Clin Gastroenterol 2023:00004836-990000000-00242. [PMID: 38047589 DOI: 10.1097/mcg.0000000000001955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 11/12/2023] [Indexed: 12/05/2023]
Abstract
GOALS We surveyed esophageal motility laboratories affiliated with adult pulmonary transplant centers to determine esophageal function testing (EFT) practices. BACKGROUND Gastroesophageal reflux and esophageal dysmotility are associated with worse lung transplant outcomes, yet no consensus guidelines for EFT exist in this population. STUDY A deidentified online survey was sent to gastrointestinal motility laboratory directors of 49 academic and community-affiliated medical centers that perform lung transplants. Practice characteristics, including annual lung transplant volume and institutional EFT practices pre-lung transplantation and post-lung transplantation were queried. Respondents were categorized by transplant volume into small and large programs based on median annual volume. RESULTS Among 35 respondents (71% response rate), the median annual transplant volume was 37, and there were 18 large programs. Institutional EFT protocols were used pretransplant by 24 programs (68.6%) and post-transplant by 12 programs (34.2%). Among small and large programs, 52.9% and 72.2% always obtained high-resolution manometry before transplant, respectively. Endoscopy before transplant was performed more often in small programs (n=17, 100%) compared with large programs (n=15,83.3%). Pretransplant endoscopy (P=0.04), barium esophagram (P<0.01), and high-resolution manometry (P=0.04) were more common than post-transplant. In contrast, post-transplant reflux monitoring off-therapy was more common than pretransplant (P=0.01). In general, pulmonologists direct referrals for EFT and gastroenterology consultation (n=28, 80.0%), with symptoms primarily prompting testing. CONCLUSIONS In the absence of established guidelines, substantial variability exists in pretransplant and post-transplant EFT, directed by pulmonologists. Standardized EFT protocols and gastroenterologist-directed management of esophageal dysfunction has potential to improve lung transplant outcomes.
Collapse
Affiliation(s)
| | - Afrin N Kamal
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA
| | - Scott Gabbard
- Division of Gastroenterology, Cleveland Clinic, Cleveland, OH
| | - John Clarke
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Redwood City, CA
| | - C Prakash Gyawali
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO
| | - David A Leiman
- Division of Gastroenterology, Duke University
- Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
5
|
Bailey ME, Borges LF, Goldberg HJ, Hathorn KE, Gavini S, Lo WK, Chan WW. Abnormal bolus reflux on impedance-pH testing independently predicts 3-year pulmonary outcome and mortality in pulmonary fibrosis. J Gastroenterol Hepatol 2023; 38:1998-2005. [PMID: 37605548 PMCID: PMC10761196 DOI: 10.1111/jgh.16325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 07/07/2023] [Accepted: 07/30/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND AND AIM Gastroesophageal reflux has been associated with idiopathic pulmonary fibrosis (IPF), although the directionality of the relationship has been debated. Data on the value of objective reflux measures in predicting IPF disease progression and mortality remain limited. We aimed to evaluate the association between multichannel intraluminal impedance and pH testing (MII-pH) and 3-year pulmonary outcomes in IPF patients. METHODS This was a retrospective cohort study of adults with IPF who underwent pre-lung transplant MII-pH off acid suppression at a tertiary center. Patients were followed for 3 years after MII-pH for poor pulmonary outcomes (hospitalization for respiratory exacerbation or death). A secondary analysis was performed using mortality as outcome of interest. Time-to-event analyses using Kaplan-Meier and Cox regression were performed to evaluate associations between MII-pH and poor outcomes. RESULTS One hundred twenty-four subjects (mean age = 61.7 ± 8 years, 62% male) were included. Increased bolus exposure time (BET) on MII-pH was associated with decreased time to poor pulmonary outcomes and death (log-ranked P-value = 0.017 and 0.031, respectively). On multivariable Cox regression analyses controlling for potential confounders including age, sex, smoking history, body mass index, proton pump inhibitor use, baseline pulmonary function, and anti-fibrotic therapy, increased BET was an independent predictor for poor pulmonary outcomes [hazard ratio 3.18 (95% confidence interval: 1.25-8.09), P = 0.015] and mortality [hazard ratio 11.3 (95% confidence interval: 1.37-63.9), P = 0.025] over 3 years. CONCLUSIONS Increased BET on MII-pH is an independent predictor of poor pulmonary outcomes and mortality over 3 years in IPF patients. These findings also support a role for gastroesophageal reflux in IPF disease progression and the potential impact of routine reflux testing and treatment.
Collapse
Affiliation(s)
- Mariel E Bailey
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence F Borges
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hilary J Goldberg
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kelly E Hathorn
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sravanya Gavini
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Wai-Kit Lo
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Walter W Chan
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA
| |
Collapse
|
6
|
Ramendra R, Fernández-Castillo JC, Huszti E, Ghany R, Aversa M, Havlin J, Riddell P, Chaparro CM, Singer LG, Liu L, Keshavjee S, Yeung JC, Martinu T. Oesophageal stasis is a risk factor for chronic lung allograft dysfunction and allograft failure in lung transplant recipients. ERJ Open Res 2023; 9:00222-2023. [PMID: 37817870 PMCID: PMC10561084 DOI: 10.1183/23120541.00222-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 07/04/2023] [Indexed: 10/12/2023] Open
Abstract
Background Morbidity and mortality in lung transplant recipients are often triggered by recurrent aspiration events, potentiated by oesophageal and gastric disorders. Previous small studies have shown conflicting associations between oesophageal function and the development of chronic lung allograft dysfunction (CLAD). Herein, we sought to investigate the relationship between oesophageal motility disorders and long-term outcomes in a large retrospective cohort of lung transplant recipients. Methods All lung transplant recipients at the Toronto Lung Transplant Program from 2012 to 2018 with available oesophageal manometry testing within the first 7 months post-transplant were included in this study. Patients were categorised according to the Chicago Classification of oesophageal disorders (v3.0). Associations between oesophageal motility disorders with the development of CLAD and allograft failure (defined as death or re-transplantation) were assessed. Results Of 487 patients, 57 (12%) had oesophagogastric junction outflow obstruction (OGJOO) and 47 (10%) had a disorder of peristalsis (eight major, 39 minor). In a multivariable analysis, OGJOO was associated with an increased risk of CLAD (HR 1.71, 95% CI 1.15-2.55, p=0.008) and allograft failure (HR 1.69, 95% CI 1.13-2.53, p=0.01). Major disorders of peristalsis were associated with an increased risk of CLAD (HR 1.55, 95% CI 1.01-2.37, p=0.04) and allograft failure (HR 3.33, 95% CI 1.53-7.25, p=0.002). Minor disorders of peristalsis were not significantly associated with CLAD or allograft failure. Conclusion Lung transplant recipients with oesophageal stasis characterised by OGJOO or major disorders of peristalsis were at an increased risk of adverse long-term outcomes. These findings will help with risk stratification of lung transplant recipients and personalisation of treatment for aspiration prevention.
Collapse
Affiliation(s)
- Rayoun Ramendra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Juan C. Fernández-Castillo
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, ON, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Meghan Aversa
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Peter Riddell
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Cecilia M. Chaparro
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
| | - Lianne G. Singer
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Louis Liu
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Jonathan C. Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, ON, Canada
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| |
Collapse
|
7
|
Amaris MA, Atkinson C, Machuca T, Estores D, Alakrad E, Rogers C, Shahmohammadi A, Kukrety SP, Ayzengart A, Pipkin M, Mindaugas R, Nandavaram S, Pelaez A. Acute transcutaneous electrical stimulation (TES) augments esophageal contractility in patients with weak peristalsis. Clin Transplant 2023; 37:e15005. [PMID: 37144846 DOI: 10.1111/ctr.15005] [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: 09/23/2022] [Revised: 02/25/2023] [Accepted: 04/17/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Lung transplantation (LTx) remains controversial in patients with absent peristalsis (AP) given the increased risk for gastroesophageal reflux (GER), and chronic lung allograft dysfunction. Furthermore, specific treatments to facilitate LTx in those with AP have not been widely described. Transcutaneous Electrical Stimulation (TES) has been reported to improve foregut contractility in LTx patients and therefore we hypothesize that TES may augment the esophageal motility of patients with ineffective esophageal motility (IEM). METHODS We included 49 patients, 14 with IEM, 5 with AP, and 30 with normal motility. All subjects underwent standard high-resolution manometry and intraluminal impedance (HRIM) with additional swallows as TES was delivered. RESULTS TES induced a universal impedance change observable in real-time by a characteristic spike activity. TES significantly augmented the contractile vigor of the esophagus measured by the distal contractile integral (DCI) in patients with IEM [median DCI (IQR) 0 (238) mmHg-cm-s off TES vs. 333 (858) mmHg-cm-s on TES; p = .01] and normal peristalsis [median DCI (IQR) 1545 (1840) mmHg-cm-s off TES vs. 2109 (2082) mmHg-cm-s on TES; p = .01]. Interestingly, TES induced measurable contractile activity (DCI > 100 mmHg-cm-s) in three out of five patients with AP [median DCI (IQR) 0 (0) mmHg-cm-s off TES vs. 0 (182) mmHg-cm-s on TES; p < .001]. CONCLUSION TES acutely augmented contractile vigor in patients with normal and weak/ AP. The use of TES may positively impact LTx candidacy, and outcomes for patients with IEM/AP. Nevertheless, further studies are needed to determine the long-term effects of TES in this patient population.
Collapse
Affiliation(s)
- Manuel A Amaris
- Department of Internal Medicine, Division of Gastroenterology, GI Motility Program, University of Florida, Gainesville, Florida, USA
| | - Carl Atkinson
- Department of Internal Medicine, Division of Pulmonary Critical Care & Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | | | - David Estores
- Department of Internal Medicine, Division of Gastroenterology, GI Motility Program, University of Florida, Gainesville, Florida, USA
| | - Eyad Alakrad
- Department of Internal Medicine, Division of Gastroenterology, GI Motility Program, University of Florida, Gainesville, Florida, USA
| | - Candice Rogers
- Department of Internal Medicine, Division of Gastroenterology, GI Motility Program, University of Florida, Gainesville, Florida, USA
| | - Abbas Shahmohammadi
- Department of Internal Medicine, Division of Pulmonary Critical Care & Sleep Medicine, University of Florida, Gainesville, Florida, USA
| | - Shweta P Kukrety
- Department of Internal Medicine, Division of Pulmonary Critical Care & Sleep Medicine, University of Nebraska, Omaha, Nebraska, USA
| | - Alexander Ayzengart
- Department of Surgery, Division of Gastrointestinal Surgery, University of Florida, Gainesville, Florida, USA
| | | | - Rackauskas Mindaugas
- Department of Surgery, Division of Thoracic Surgery, University of Florida, Gainesville, Florida, USA
| | - Sravanthi Nandavaram
- Division of Cardiothoracic Surgery, University of Kentucky, Lexington, Kentucky, USA
| | | |
Collapse
|
8
|
Lo WK, Hiramoto B, Goldberg HJ, Sharma N, Chan WW. Ineffective esophageal motility is associated with acute rejection after lung transplantation independent of gastroesophageal reflux. World J Gastroenterol 2023; 29:3292-3301. [PMID: 37377592 PMCID: PMC10292138 DOI: 10.3748/wjg.v29.i21.3292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/14/2023] [Accepted: 04/28/2023] [Indexed: 06/01/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux is associated with poorer outcomes after lung transplant, likely through recurrent aspiration and allograft injury. Although prior studies have demonstrated a relationship between impedance-pH results and transplant outcomes, the role of esophageal manometry in the assessment of lung transplant patients remains debated, and the impact of esophageal dysmotility on transplant outcomes is unclear. Of particular interest is ineffective esophageal motility (IEM) and its associated impact on esophageal clearance.
AIM To assess the relationship between pre-transplant IEM diagnosis and acute rejection after lung transplantation.
METHODS This was a retrospective cohort study of lung transplant recipients at a tertiary care center between 2007 and 2018. Patients with pre-transplant anti-reflux surgery were excluded. Manometric and reflux diagnoses were recorded from pre-transplant esophageal function testing. Time-to-event analysis using Cox proportional hazards model was applied to evaluate outcome of first episode of acute cellular rejection, defined histologically per International Society of Heart and Lung Transplantation guidelines. Subjects not meeting this endpoint were censored at time of post-transplant anti-reflux surgery, last clinic visit, or death. Fisher’s exact test for binary variables and student’s t-test for continuous variables were performed to assess for differences between groups.
RESULTS Of 184 subjects (54% men, mean age: 58, follow-up: 443 person-years) met criteria for inclusion. Interstitial pulmonary fibrosis represented the predominant pulmonary diagnosis (41%). During the follow-up period, 60 subjects (33.5%) developed acute rejection. The all-cause mortality was 16.3%. Time-to-event univariate analyses demonstrated significant association between IEM and acute rejection [hazard ratio (HR): 1.984, 95%CI: 1.03-3.30, P = 0.04], confirmed on Kaplan-Meier curve. On multivariable analysis, IEM remained independently associated with acute rejection, even after controlling for potential confounders such as the presence of acid and nonacid reflux (HR: 2.20, 95%CI: 1.18-4.11, P = 0.01). Nonacid reflux was also independently associated with acute rejection on both univariate (HR: 2.16, 95%CI: 1.26-3.72, P = 0.005) and multivariable analyses (HR: 2.10, 95%CI: 1.21-3.64, P = 0.009), adjusting for the presence of IEM.
CONCLUSION Pre-transplant IEM was associated with acute rejection after transplantation, even after controlling for acid and nonacid reflux. Esophageal motility testing may be considered in lung transplant to predict outcomes.
Collapse
Affiliation(s)
- Wai-Kit Lo
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Brent Hiramoto
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Hilary J Goldberg
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Nirmal Sharma
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Boston, MA 02115, United States
| | - Walter W Chan
- Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, MA 02115, United States
| |
Collapse
|
9
|
Reedy EL, Simpson AN, O'Rourke AK, Bonilha HS. Characterizing Swallowing Impairment in a Post-Lung Transplant Population. AMERICAN JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2023; 32:1236-1251. [PMID: 37000923 DOI: 10.1044/2023_ajslp-22-00266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/06/2023]
Abstract
BACKGROUND Lung transplant recipients carry significant pre- and post-lung transplant dysphagia risk factors related to altered respiratory-swallow coordination as well as acute injury and decompensation resulting in the acute post-lung transplant recovery period. However, we are only beginning to understand the potential physiological contributors to altered swallowing in this population. METHOD A retrospective, cross-sectional, cohort study of post-lung transplant patients was performed. All participants received a modified barium swallow study (MBSS) as part of standard care during their acute hospitalization using the Modified Barium Swallow Impairment Profile (MBSImP) protocol and scoring metric. A combination of MBSImP scores, Penetration-Aspiration Scale (PAS) scores, Functional Oral Intake Scale (FOIS) scores, International Dysphagia Diet Standardization Initiative (IDDSI) scale levels, and the time from lung transplant to MBSS was collected, as well as measures of swallowing impairment and swallowing-related outcomes. Differences in swallowing physiology and swallowing-related outcomes between participants with typical versus atypical PAS were explored. RESULTS Forty-two participants met our prespecified inclusion criteria. We identified atypical laryngeal penetration and/or aspiration in 52.4% of our post-lung transplant cohort. Silent aspiration occurred in 75% of those patients who aspirated. Comparing typical versus atypical PAS scores, we found statistically significant associations with laryngeal elevation (Component 8), p < .0001; anterior hyoid excursion (Component 9), p = .0046; epiglottic movement (Component 10), p = .0031; laryngeal vestibule closure (Component 11), p < .0001; pharyngeal stripping (Component 12), p = .0058; pharyngeal total scores, p = .0001; FOIS scores, p = .00264; and IDDSI liquid levels, p = .0009. CONCLUSIONS Swallowing impairment resulting in abnormal bolus invasion is prevalent in post-lung transplant patients. Airway invasion in this cohort was related to pharyngeal swallow impairment and resulted in modified oral intake. Our findings help expand upon prior literature, which only reported the incidence of aspiration and pathological laryngeal penetration. Our results suggest that the potential for aerodigestive system impairment and negative sequela should not be underestimated in the post-lung transplant population.
Collapse
Affiliation(s)
- Erin L Reedy
- Health Sciences and Research, The Medical University of South Carolina, Charleston
| | - Annie N Simpson
- Health Sciences and Research, The Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head & Neck Surgery, The Medical University of South Carolina, Charleston
| | - Ashli K O'Rourke
- Department of Otolaryngology-Head & Neck Surgery, The Medical University of South Carolina, Charleston
| | - Heather Shaw Bonilha
- Health Sciences and Research, The Medical University of South Carolina, Charleston
- Department of Otolaryngology-Head & Neck Surgery, The Medical University of South Carolina, Charleston
- Department of Rehabilitation Medicine, Emory University, Atlanta, GA
| |
Collapse
|
10
|
Jadcherla AV, Litzenberg K, Balasubramanian G. Esophageal Dysfunction in Post-lung Transplant: An Enigma. Dysphagia 2022; 38:731-743. [PMID: 35960395 DOI: 10.1007/s00455-022-10508-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 08/01/2022] [Indexed: 11/30/2022]
Abstract
The prevalence of lung transplants has increased over the years, albeit with a low survival rate amongst all solid organ transplants, including liver and heart transplantation. Microaspiration is one of the primary mechanisms that has been implicated in the pathogenesis of lung injury following lung transplants. Of late, esophageal dysfunction such as gastroesophageal reflux and esophageal hypercontractility is often noted post-lung transplant. However, reflux is associated with chronic allograft lung injury such as bronchiolitis obliterans syndrome, which is one of the predictors for long-term survival in this specialized population. Its role in acute lung injury post-lung transplant is still being explored. This review critically examines the salient points which provide the current understanding of the characteristics, pathophysiology, and implications of esophageal dysfunction following lung transplant.
Collapse
Affiliation(s)
| | - Kevin Litzenberg
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Gokulakrishnan Balasubramanian
- Division of Gastroenterology, Hepatology and Nutrition, Gastrointestinal Motility Laboratory, Department of Internal Medicine, The Ohio State University Wexner Medical Center, 395 W. 12th Avenue, 2nd Floor, Columbus, OH, USA.
| |
Collapse
|
11
|
Leiva-Juarez MM, Benvenuto L, Costa J, Blackett JW, Aversa M, Robbins H, Shah L, Stanifer BP, Lemaître PH, Jodorkovsky D, Arcasoy S, Sonett JR, D'Ovidio F. Identification of Lung Transplant Recipients with a Survival Benefit after Fundoplication. Ann Thorac Surg 2021; 113:1801-1810. [PMID: 34280376 DOI: 10.1016/j.athoracsur.2021.05.098] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 05/02/2021] [Accepted: 05/28/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) and aspiration of enteric contents is associated with worse outcomes after lung transplant. The purpose of this study is to elucidate populations that benefit the most from fundoplication after lung transplant. METHODS Lung transplants from 2001-2019 (n=971) were retrospectively reviewed and stratified by a fundoplication before (n=128) or after (n=24) chronic lung allograft dysfunction (CLAD) development vs those who didn't. Patients with a fundoplication prior to CLAD were propensity-matched to those without a fundoplication. The primary outcome of interest was post-transplant survival. Time-to-event rates were calculated using a multivariable Cox proportional hazards model and Kaplan-Meier functions. RESULTS A fundoplication prior to CLAD improved post-transplant survival before and after propensity-matching, and remained a significant predictor after adjusting for baseline characteristics (HR:0.57, 95% CI:0.4-0.8, P=0.001). Recipients with a restrictive disorder (HR: 0.46, 95% CI:0.3-0.73, P=0.001), age <65 (HR:0.48, 95% CI:0.32-0.71, P<0.001), and both single (HR:0.47, 95% CI:0.28-0.79, P=0.005) or double (HR:0.55, 95% CI:0.32-0.93, P=0.027) lung transplants had a significant decrease in mortality after fundoplication. The effect was present after excluding early deaths and/or CLAD diagnoses. GERD diagnosed by pH, impedance or EGD was not associated with worse outcomes. Among patients with CLAD, a fundoplication was an independent predictor of post-CLAD survival (HR:0.27, 95% CI:0.12-0.61, P=0.002). CONCLUSIONS A fundoplication before or after CLAD development is an independent predictor of survival. Younger patients with restrictive disease, independent of the type of transplant, have a survival benefit. GERD diagnosed by conventional methods was not associated with worse survival.
Collapse
Affiliation(s)
- Miguel M Leiva-Juarez
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Joseph Costa
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - John W Blackett
- Division of Gastroenterology, Columbia University Medical Center, New York, New York
| | - Meghan Aversa
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Hilary Robbins
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Lori Shah
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Bryan P Stanifer
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Phillippe H Lemaître
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Daniela Jodorkovsky
- Division of Gastroenterology, Columbia University Medical Center, New York, New York
| | - Selim Arcasoy
- Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York
| | - Joshua R Sonett
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York
| | - Frank D'Ovidio
- Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York.
| |
Collapse
|
12
|
Lanuti M, Lin J, Ng T, Burt BM. A year in general thoracic surgery published in the Journal of Thoracic and Cardiovascular Surgery: 2020. J Thorac Cardiovasc Surg 2021; 162:253-258. [PMID: 34024614 PMCID: PMC8139187 DOI: 10.1016/j.jtcvs.2021.03.106] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 03/17/2021] [Accepted: 03/19/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Michael Lanuti
- Division of Thoracic, Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Mass
| | - Jules Lin
- Section of Thoracic Surgery, University of Michigan, Ann Arbor, Mich
| | - Thomas Ng
- Division of Thoracic Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, Tenn
| | - Bryan M Burt
- Division of General Thoracic Surgery, Michael E. DeBakey Department of Surgery, Baylor College of Medicine, Houston, Tex.
| |
Collapse
|
13
|
Fukumoto K, Chen-Yoshikawa TF. Commentary: Look Before You Leap. Semin Thorac Cardiovasc Surg 2021; 34:1074. [PMID: 34174405 DOI: 10.1053/j.semtcvs.2021.06.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 06/18/2021] [Indexed: 11/11/2022]
Affiliation(s)
- Koichi Fukumoto
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | |
Collapse
|
14
|
Csucska M, Razia D, Masuda T, Omar A, Giulini L, Smith MA, Walia R, Bremner RM, Mittal SK. Bilateral Lung Transplant for a Connective Tissue Disorder: Esophageal Motility and 3-year Survival. Semin Thorac Cardiovasc Surg 2021; 34:1065-1073. [PMID: 34144147 DOI: 10.1053/j.semtcvs.2021.06.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 06/04/2021] [Indexed: 02/07/2023]
Abstract
Connective tissue disorders (CTDs) are associated with esophageal dysmotility and gastroesophageal reflux disease, which may diminish survival after lung transplantation (LTx). We studied LTx outcomes in patients with a CTD stratified by esophageal motility. We identified patients who underwent bilateral LTx from 2012 to 2017. Patients with a CTD were classified by pre-LTx diagnosis: absent esophageal motility (AEM), ineffective esophageal motility (IEM), or preserved esophageal motility (PEM). The primary endpoint was 3-year survival. Sub-analysis compared survival between the AEM group and a propensity-matched (lung allocation score), non-CTD control group. Kaplan-Meier method and log-rank test were used. In total, 495 patients underwent LTx; 33 (6.7%) had a CTD. Median (IQR) age was 62 years (55.5-67.0); 24 (72.7%) were women. Survival trended lower for recipients with a CTD than without a CTD at 1-year (84.8% vs 91.8%; p = 0.2) and 3-years (66.7% vs 73.5%; p = 0.5). Within the CTD cohort, 1- and 3-year survival was significantly higher in the PEM (100%, 87.5%) and IEM (100%, 85.7%) groups than in the AEM group (50%, 20%; p < 0.001). The AEM group had significantly lower survival at 1-year (50% vs 92.5%) and 3-years (20% vs 65%) than a lung allocation score-matched cohort of patients without a CTD. LTx recipients with a CTD and AEM had significantly lower survival than those with PEM or IEM as well as significantly lower survival than that of a propensity-matched cohort of patients without a CTD. Patients with a CTD and AEM should be considered for LTx with extreme caution and counseled appropriately.
Collapse
Affiliation(s)
- Máté Csucska
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona
| | - Deepika Razia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona
| | - Takahiro Masuda
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Ashraf Omar
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Luca Giulini
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona
| | - Michael A Smith
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Ross M Bremner
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona
| | - Sumeet K Mittal
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Department of Thoracic Disease and Transplantation, Phoenix, Arizona; Creighton University School of Medicine-Phoenix Regional Campus, Phoenix, Arizona.
| |
Collapse
|
15
|
Nakanishi K, Chen-Yoshikawa TF. Commentary: To know yourself is to know your neighbor. J Thorac Cardiovasc Surg 2021; 163:1988-1989. [PMID: 33583583 DOI: 10.1016/j.jtcvs.2021.01.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Revised: 01/08/2021] [Accepted: 01/08/2021] [Indexed: 11/28/2022]
Affiliation(s)
- Keita Nakanishi
- Department of Thoracic Surgery, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | |
Collapse
|
16
|
Hsin MKY, Law SYK. Commentary: Protecting lung transplant allografts by improving esophageal motility: Selecting the right patients. J Thorac Cardiovasc Surg 2021; 163:1987-1988. [PMID: 33632524 DOI: 10.1016/j.jtcvs.2021.01.043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 01/12/2021] [Accepted: 01/12/2021] [Indexed: 10/22/2022]
Affiliation(s)
- Michael K Y Hsin
- Department of Cardiothoracic Surgery, Queen Mary Hospital, Hong Kong, SAR China.
| | - Simon Y K Law
- Department of Surgery, The University of Hong Kong, Hong Kong, SAR China
| |
Collapse
|
17
|
Factors associated with esophageal motility improvement after bilateral lung transplant in patients with an aperistaltic esophagus. J Thorac Cardiovasc Surg 2021; 163:1979-1986. [PMID: 33568319 DOI: 10.1016/j.jtcvs.2020.12.130] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 12/03/2020] [Accepted: 12/27/2020] [Indexed: 01/18/2023]
Abstract
OBJECTIVES We reported that esophageal peristalsis can improve after lung transplant (LTx), even in patients with pretransplant esophageal aperistalsis. This improvement was associated with better outcomes. We analyzed preoperative factors and sought to predict persistent aperistalsis or motility improvement in patients with pre-LTx esophageal aperistalsis. METHODS Patients with esophageal aperistalsis who underwent LTx between January 2013 and December 2016 were included. Preoperative barium esophagrams were blinded and re-examined; subjective scores were assigned to motility and dilation patterns. Postoperative high-resolution manometry was used to divide patients into 2 groups: persistent esophageal aperistalsis (PEA) or improved esophageal peristalsis (IEP). RESULTS We identified 29 patients: 20 with restrictive lung disease, 7 with obstructive lung disease, and 2 with pulmonary arterial hypertension. Post-LTx, 10 patients had PEA and 19 had IEP (mean age, 53.3 ± 6.6 years and 61.2 ± 10.6 years, respectively; P = .04). All 9 patients (100%) with obstructive lung disease or pulmonary arterial hypertension but only 10 of 20 patients (50%) with restrictive lung disease had IEP post-LTx (P = .01). All 4 patients with scleroderma had PEA. Nearly absent contractility on preoperative esophagrams was more prevalent in the PEA group than in the IEP group (100% vs 58.8%; P = .06). No further differences were observed between the groups. CONCLUSIONS Patients with esophageal aperistalsis and obstructive lung disease or pulmonary arterial hypertension, but not patients with restrictive lung disease and scleroderma, are likely to have IEP post-LTx. Additional studies may determine whether subjective esophagram assessment can help predict IEP post-LTx in patients with restrictive lung disease without scleroderma.
Collapse
|
18
|
Commentary: Esophageal aperistalsis should not preclude lung transplant candidacy in well-selected patients. J Thorac Cardiovasc Surg 2020; 160:1629-1630. [DOI: 10.1016/j.jtcvs.2020.03.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 03/04/2020] [Indexed: 11/18/2022]
|
19
|
Jeffrey Yang CF. Commentary: The return of peristalsis after lung transplant in patients with an aperistaltic esophagus-is it possible? J Thorac Cardiovasc Surg 2020; 160:1630-1631. [PMID: 32417053 DOI: 10.1016/j.jtcvs.2020.03.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2020] [Accepted: 03/09/2020] [Indexed: 11/25/2022]
Affiliation(s)
- Chi-Fu Jeffrey Yang
- Department of Cardiothoracic Surgery, Stanford University Medical Center, Stanford, Calif.
| |
Collapse
|
20
|
Shrager JB. Commentary: Can the esophagus curse a lung transplant? J Thorac Cardiovasc Surg 2020; 160:1628. [PMID: 32417061 DOI: 10.1016/j.jtcvs.2020.02.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Revised: 02/26/2020] [Accepted: 02/26/2020] [Indexed: 10/24/2022]
Affiliation(s)
- Joseph B Shrager
- Division of Thoracic Surgery, Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
| |
Collapse
|
21
|
Date H. Commentary: To do, or not to do, that is the question. J Thorac Cardiovasc Surg 2020; 160:1627. [PMID: 32197909 DOI: 10.1016/j.jtcvs.2020.02.070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Accepted: 02/17/2020] [Indexed: 11/27/2022]
Affiliation(s)
- Hiroshi Date
- Department of Thoracic Surgery, Graduate School of Medicine, Kyoto University, Kyoto, Japan.
| |
Collapse
|