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Latorre-Rodríguez AR, Golla M, Arjuna A, Bremner RM, Mittal SK. Impaired esophagogastric junction relaxation and lung transplantation outcomes. Dis Esophagus 2024; 37:doae030. [PMID: 38688726 DOI: 10.1093/dote/doae030] [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: 01/11/2024] [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.
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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
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Ramendra R, Duong A, Zhang CYK, Huszti E, Zhou X, Havlin J, Ghany R, Cypel M, Yeung JC, Keshavjee S, Sage AT, Martinu T. Airway pepsinogen A4 identifies lung transplant recipients with microaspiration and predicts chronic lung allograft dysfunction. J Heart Lung Transplant 2024; 43:973-982. [PMID: 38211836 DOI: 10.1016/j.healun.2024.01.002] [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: 08/13/2023] [Revised: 12/04/2023] [Accepted: 01/02/2024] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND Aspiration is a known risk factor for adverse outcomes post-lung transplantation. Airway bile acids are the gold-standard biomarker of aspiration; however, they are released into the duodenum and likely reflect concurrent gastrointestinal dysmotility. Previous studies investigating total airway pepsin have found conflicting results on its relationship with adverse outcomes post-lung transplantation. These studies measured total pepsin and pepsinogen in the airways. Certain pepsinogens are constitutively expressed in the lungs, while others, such as pepsinogen A4 (PGA4), are not. We sought to evaluate the utility of measuring airway PGA4 as a biomarker of aspiration and predictor of adverse outcomes in lung transplant recipients (LTRs) early post-transplant. METHODS Expression of PGA4 was compared to other pepsinogens in lung tissue. Total pepsin and PGA4 were measured in large airway bronchial washings and compared to preexisting markers of aspiration. Two independent cohorts of LTRs were used to assess the relationship between airway PGA4 and chronic lung allograft dysfunction (CLAD). Changes to airway PGA4 after antireflux surgery were assessed in a third cohort of LTRs. RESULTS PGA4 was expressed in healthy human stomach but not lung. Airway PGA4, but not total pepsin, was associated with aspiration. Airway PGA4 was associated with an increased risk of CLAD in two independent cohorts of LTRs. Antireflux surgery was associated with reduced airway PGA4. CONCLUSIONS Airway PGA4 is a marker of aspiration that predicts CLAD in LTRs. Measuring PGA4 at surveillance bronchoscopies can help triage high-risk LTRs for anti-reflux surgery.
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Affiliation(s)
- Rayoun Ramendra
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Allen Duong
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Chen Yang Kevin Zhang
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Ella Huszti
- Biostatistics Research Unit, University Health Network, Toronto, Ontario, Canada
| | - Xuanzi Zhou
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Jan Havlin
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Rasheed Ghany
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Marcelo Cypel
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Jonathan C Yeung
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Shaf Keshavjee
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Andrew T Sage
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada
| | - Tereza Martinu
- Toronto Lung Transplant Program, Ajmera Transplant Centre, University Health Network, Toronto, Ontario, Canada; Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
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Stącel T, Sybila P, Mędrala A, Ochman M, Nęcki M, Pasek P, Kegler K, Przybyłowski P, Hrapkowicz T, Borowik D, Urlik M. Lung Transplantation in Patients With Systemic Scleroderma-Description of the First Consecutive Cases in Poland: Case Series Report and a Short Literature Review. Transplant Proc 2024; 56:868-876. [PMID: 38702265 DOI: 10.1016/j.transproceed.2024.04.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 04/08/2024] [Accepted: 04/08/2024] [Indexed: 05/06/2024]
Abstract
Pulmonary complications of systemic scleroderma (SSc), such as interstitial lung disease and pulmonary hypertension (PH), are responsible for up to 60% of deaths among patients. For many years, most centers considered SSc a contraindication to lung transplantation (LTx); however, recent publications show that appropriately selected SSc candidates for LTx give results comparable to patients with idiopathic PH or idiopathic pulmonary fibrosis. This paper presents the cases of a 60-year-old male patient (patient 1) and a 42-year-old female patient (patient 2) diagnosed with SSc in 2019 and 2013, respectively. In both patients, interstitial-fibrotic changes in the lungs leading to respiratory failure were confirmed by high-resolution computed tomography as well as pulmonary hypertension (WHO group 3), which was also diagnosed during right heart catheterization. In both cases, despite pharmacotherapy, pulmonary fibrosis progressed, leading to severe respiratory failure. The patients were referred for LTx qualification. LTx was possible to consider in patients due to the lack of significant changes in other internal organs. Double LTx was successfully performed in both patients (patient 1-July 19, 2022; patient 2-September 14, 2022). They were discharged from the hospital in good condition on the 22nd and 20th postoperative day, respectively. LTx is a last-chance therapy that saves lives among patients with extreme respiratory failure in the course of SSc. It prolongs and improves the quality of life. The selection of appropriate patients is key to the success of the procedure.
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Affiliation(s)
- Tomasz Stącel
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Paweł Sybila
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland.
| | - Agata Mędrala
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Marek Ochman
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Mirosław Nęcki
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Piotr Pasek
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Kamil Kegler
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Piotr Przybyłowski
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Tomasz Hrapkowicz
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
| | - Dawid Borowik
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac Anaesthesia and Intensive Care, Medical University of Silesia, Katowice, Poland
| | - Maciej Urlik
- Silesian Centre for Heart Diseases in Zabrze, Department of Cardiac, Vascular and Endovascular Surgery and Transplantology, Medical University of Silesia, Katowice, Poland
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Klouda T, Ryan E M, Leonard JB, Freiberger D, Midyat L, Dahlberg S, Rosen R, Visner G. Gastrointestinal complications in pediatric lung transplant recipients: Incidence, risk factors, and effects on patient outcomes. Pediatr Transplant 2024; 28:e14665. [PMID: 38317336 DOI: 10.1111/petr.14665] [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: 06/20/2022] [Revised: 09/25/2023] [Accepted: 11/21/2023] [Indexed: 02/07/2024]
Abstract
BACKGROUND Gastrointestinal (GI) complications in lung transplant recipients can occur any time during the post-operative period, leading to prolonged morbidity and mortality. Despite the negative association between GI complications and patient outcomes, little is known about their incidence and risk factors for their development in pediatric lung transplant recipients. METHODS We performed a retrospective chart review at one pediatric tertiary center to describe the frequency of GI complications in lung transplant recipients. We identified potential risk factors for the diagnosis of gastroparesis, gastroesophageal reflux disease (GERD) and aspiration in the post-transplant period. Lastly, we investigated the association of these complications with mortality and graft survival. RESULTS 84.3% of lung transplant recipients experienced at least one GI complication in the post-transplant period. Gastroparesis (52.9%), GERD (41.2%), and oropharyngeal dysphagia/laryngeal penetration (33.3%) were the most common complications diagnosed. Post-operative opioid exposure was a risk factor for gastroparesis, with the odds increasing 3.0% each day a patient was prescribed opioids (p = .021). The risk of death or retransplant in individuals who experienced gastroparesis was 2.7 times higher than those not diagnosed with gastroparesis (p = .027). CONCLUSION Exposure to opioids in the post-operative period is a risk factor for gastroparesis and a prolonged hospitalization placed patients at risk for aspiration. Gastroparesis was associated with increased patient mortality and graft failure, while aspiration and GERD had no effect on long term outcomes. Future prospective studies investigating the relationship between opioid use and the development of a gastroparesis are necessary to improve patient outcomes.
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Affiliation(s)
- Timothy Klouda
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Morgan Ryan E
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Jessica Brie Leonard
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Dawn Freiberger
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Levent Midyat
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Suzanne Dahlberg
- Division of Pulmonary Medicine, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Rachel Rosen
- Division of Gastroenterology, Hepatology and Nutrition, Boston Children's Hospital, Boston, Massachusetts, USA
| | - Gary Visner
- Division of Pulmonary Medicine, Boston Children'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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6
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Shakour N, Karami S, Iranshahi M, Butler AE, Sahebkar A. Antifibrotic effects of sodium-glucose cotransporter-2 inhibitors: A comprehensive review. Diabetes Metab Syndr 2024; 18:102934. [PMID: 38154403 DOI: 10.1016/j.dsx.2023.102934] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 11/25/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND AND AIMS Scar tissue accumulation in organs is the underlying cause of many fibrotic diseases. Due to the extensive array of organs affected, the long-term nature of fibrotic processes and the large number of people who suffer from the negative impact of these diseases, they constitute a serious health problem for modern medicine and a huge economic burden on society. Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are a relatively new class of anti-diabetic pharmaceuticals that offer additional benefits over and above their glucose-lowering properties; these medications modulate a variety of diseases, including fibrosis. Herein, we have collated and analyzed all available research on SGLT2is and their effects on organ fibrosis, together with providing a proposed explanation as to the underlying mechanisms. METHODS PubMed, ScienceDirect, Google Scholar and Scopus were searched spanning the period from 2012 until April 2023 to find relevant articles describing the antifibrotic effects of SGLT2is. RESULTS The majority of reports have shown that SGLT2is are protective against lung, liver, heart and kidney fibrosis as well as arterial stiffness. According to the results of clinical trials and animal studies, many SGLT2 inhibitors are promising candidates for the treatment of fibrosis. Recent studies have demonstrated that SGLT2is affect an array of cellular processes, including hypoxia, inflammation, oxidative stress, the renin-angiotensin system and metabolic activities, all of which have been linked to fibrosis. CONCLUSION Extensive evidence indicates that SGLT2is are promising treatments for fibrosis, demonstrating protective effects in various organs and influencing key cellular processes linked to fibrosis.
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Affiliation(s)
- Neda Shakour
- Department of Medicinal Chemistry, School of Pharmacy, Mashhad University of Medical Sciences, Mashhad, Iran; Student Research Committee, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Shima Karami
- Department of Clinical Biochemistry, Faculty of Medicine, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mehrdad Iranshahi
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Alexandra E Butler
- Research Department, Royal College of Surgeons in Ireland, Adliya, Bahrain
| | - Amirhossein Sahebkar
- Biotechnology Research Center, Pharmaceutical Technology Institute, Mashhad University of Medical Sciences, Mashhad, Iran; Applied Biomedical Research Center, Mashhad University of Medical Sciences, Mashhad, Iran.
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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.
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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
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Yergin CG, Herremans KM, Patel S, Pelaez A, Machuca TN, Ayzengart AL, Amaris MA. Laparoscopic Toupet fundoplication: a safe and effective anti-reflux option in lung transplant recipients. Surg Endosc 2023; 37:8429-8437. [PMID: 37438480 DOI: 10.1007/s00464-023-10245-0] [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: 02/14/2023] [Accepted: 06/23/2023] [Indexed: 07/14/2023]
Abstract
BACKGROUND Fundoplication is known to improve allograft outcomes in lung transplant recipients by reducing retrograde aspiration secondary to gastroesophageal reflux disease, a modifiable risk factor for chronic allograft dysfunction. Laparoscopic Nissen fundoplication has historically been the anti-reflux procedure of choice, but the procedure is associated with discernable rates of postoperative dysphagia and gas-bloat syndrome. Laparoscopic Toupet fundoplication, an alternate anti-reflux surgery with lower rates of foregut complications in the general population, is the procedure of choice on our institution's lung transplant protocol. In this work, we evaluated the efficacy and safety of laparoscopic Toupet fundoplication in our lung transplant recipients. METHODS A prospective case series of 44 lung transplant recipients who underwent laparoscopic Toupet fundoplication by a single surgeon between September 2018 and November 2020 was performed. Preoperative and postoperative results from 24-h pH, esophageal manometry, gastric emptying, and pulmonary function studies were collected alongside severity of gastroesophageal reflux disease and other gastrointestinal symptoms. RESULTS Median DeMeester score decreased from 25.9 to 5.4 after fundoplication (p < 0.0001), while percentage of time pH < 4 decreased from 7 to 1.1% (p < 0.0001). The severity of heartburn and regurgitation were also reduced (p < 0.0001 and p = 0.0029 respectively). Overall, pulmonary function, esophageal motility, gastric emptying, severity of bloating, and dysphagia were not significantly different post-fundoplication than pre-fundoplication. Patients with decreasing rates of FEV1 pre-fundoplication saw improvement in their rate of change of FEV1 post-fundoplication (p = 0.011). Median follow-up was 32.2 months post-fundoplication. CONCLUSIONS Laparoscopic Toupet fundoplication provides objective pathologic acid reflux control and symptomatic gastroesophageal reflux improvement in lung transplant recipients while preserving lung function and foregut motility. Thus, laparoscopic Toupet fundoplication is a safe and effective antireflux surgery alternative in lung transplant recipients.
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Affiliation(s)
| | - Kelly M Herremans
- University of Florida College of Medicine, Gainesville, FL, USA
- Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sheetal Patel
- University of Florida College of Medicine, Gainesville, FL, USA
- Department of Medicine, University of Florida College of Medicine, PO Box 100214, Gainesville, FL, 3261, USA
| | - Andres Pelaez
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tiago N Machuca
- Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Manuel A Amaris
- University of Florida College of Medicine, Gainesville, FL, USA.
- Department of Medicine, University of Florida College of Medicine, PO Box 100214, Gainesville, FL, 3261, USA.
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9
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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.
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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
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10
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López-Muñiz Ballesteros B, Lopez-de-Andres A, Jimenez-Garcia R, Zamorano-Leon JJ, Carabantes-Alarcon D, Cuadrado-Corrales N, Del-Barrio JL, Perez-Farinos N, De Miguel-Díez J. Trends and Outcomes in Lung Transplantation in Patients with and without Idiopathic Pulmonary Fibrosis in Spain during the Period 2016-2020. Healthcare (Basel) 2023; 11:healthcare11111534. [PMID: 37297674 DOI: 10.3390/healthcare11111534] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 05/19/2023] [Accepted: 05/23/2023] [Indexed: 06/12/2023] Open
Abstract
(1) Background: This paper aims to assess temporal trends (2016-2020) in incidence, patient's characteristics, complications, length of hospital stay (LOHS) and in-hospital mortality (IHM) among patients with and without idiopathic pulmonary fibrosis (IPF) undergoing lung transplantation (LTx). We also analyse the effect of the COVID-19 pandemic on LTx in these populations. (2) Methods: A retrospective, population-based observational study was conducted using the Spanish National Hospital Discharge Database. Multivariable adjustment was conducted with logistic regression to analyse the IHM. (3) Results: We identified 1777 admissions for LTx during the study period, of which 573 (32.2%) were performed in patients with IPF. The number of hospital admissions for LTx rose from 2016 to 2020, both in patients with and without IPF, but a marked reduction was observed from year 2019 to year 2020. Over time, the proportion of single LTx decreased and bilateral LTx increased significantly in both groups. The incidence of LTx complications increased significantly over time along with the increase in the incidence of IPF. No significant differences in the incidence of complications or in the IHM between patients with and without IPF were found. Suffering any complication of the LTx and pulmonary hypertension were conditions positively associated with IHM in patients with and without IPF. The IHM remained stable from 2016 to 2020 in both study populations and was not affected by the COVID pandemic. (4) Conclusions: Patients with IPF account for almost a third of all lung transplants. The number of LTx increased over time in patients with and without IPF, but a marked reduction was observed from 2019 to 2020. Although the proportion of LTx complications increased significantly over time in both groups, the IHM did not change. IPF was not associated with increased complications or IHM after LTx.
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Affiliation(s)
| | - Ana Lopez-de-Andres
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Rodrigo Jimenez-Garcia
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Jose J Zamorano-Leon
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - David Carabantes-Alarcon
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Natividad Cuadrado-Corrales
- Department of Public Health and Maternal & Child Health, Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
| | - Jose L Del-Barrio
- Preventive Medicine and Public Health Teaching and Research Unit, Health Sciences Faculty, Universidad Rey Juan Carlos, 28933 Alcorcón, Spain
| | - Napoleon Perez-Farinos
- Epi-PHAAN Research Group, Instituto de Investigación Biomédica de Málaga (IBIMA), School of Medicine, Universidad de Málaga, 29071 Málaga, Spain
| | - Javier De Miguel-Díez
- Respiratory Department, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón (IiSGM), Faculty of Medicine, Universidad Complutense de Madrid, 28040 Madrid, Spain
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11
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Blackett JW, Benvenuto L, Leiva-Juarez MM, D'Ovidio F, Arcasoy S, Jodorkovsky D. Risk Factors and Outcomes for Gastroparesis After Lung Transplantation. Dig Dis Sci 2022; 67:2385-2394. [PMID: 34524597 DOI: 10.1007/s10620-021-07249-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 07/12/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastroparesis is common after lung transplantation and is associated with worse transplant outcomes, including the development of chronic lung allograft dysfunction (CLAD). This study sought to identify the prevalence, risk factors, and outcomes associated with a new diagnosis of gastroparesis after lung transplantation. METHODS This was a single-center retrospective study of patients who underwent lung transplantation in 2008-2018. The primary outcome was a new diagnosis of gastroparesis within 3 years of transplant. Secondary outcomes included a new diagnosis of gastroesophageal reflux and the association between gastroparesis and both post-transplant survival and CLAD-free survival. Multivariable logistic regression was used to compare diagnosis of gastroparesis and gastroesophageal reflux, while multivariable Cox proportional hazards models were used to analyze gastroparesis and post-transplant outcomes. RESULTS Of 616 patients with no prior history of gastroparesis, 107 (17.4%) were diagnosed with delayed gastric emptying within 3 years of transplant. On multivariable logistic regression, black race (OR 2.16, 95% CI 1.18-3.98, p = 0.013) was significantly associated with a new diagnosis of gastroparesis. Age, sex, history of diabetes, connective tissue disease, type of transplant, diagnosis group, renal function, and body mass index were not predictive of gastroparesis post-transplant. Gastroparesis was significantly associated with CLAD (HR 1.76, 95% CI 1.20-2.59, p = 0.004), but not with overall mortality (HR 1.16, p = 0.43). CONCLUSION While gastroparesis is common after lung transplantation, it remains difficult to predict which patients will develop these complications post-transplant. Black patients were more likely to be diagnosed with gastroparesis after adjusting for relevant confounders. Gastroparesis is associated with increased risk of CLAD, and further studies are needed to assess whether early detection and treatment can reduce the incidence of CLAD.
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Affiliation(s)
- John W Blackett
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Medical Center, 622 West 168th Street, New York, NY, USA.
| | - Luke Benvenuto
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Miguel M Leiva-Juarez
- Division of Cardiac, Vascular, and Thoracic Surgery, Department of Surgery, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Frank D'Ovidio
- Division of Cardiac, Vascular, and Thoracic Surgery, Department of Surgery, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Selim Arcasoy
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, New York Presbyterian Columbia University Medical Center, New York, NY, USA
| | - Daniela Jodorkovsky
- Division of Digestive and Liver Diseases, Department of Medicine, New York Presbyterian Columbia University Medical Center, 622 West 168th Street, New York, NY, USA
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12
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Farina N, Benanti G, De Luca G, Palmisano A, Peretto G, Tomassetti S, Giorgione V, Forma O, Esposito A, Danese S, Dagna L, Matucci-Cerinic M, Campochiaro C. The Role of the Multidisciplinary Health Care Team in the Management of Patients with Systemic Sclerosis. J Multidiscip Healthc 2022; 15:815-824. [PMID: 35480063 PMCID: PMC9035450 DOI: 10.2147/jmdh.s295478] [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: 12/11/2021] [Accepted: 04/11/2022] [Indexed: 11/23/2022] Open
Abstract
Systemic sclerosis (SSc) is a rare connective tissue disease characterised by immune dysfunction, vascular damage and fibrosis affecting the skin and multiple internal organs. The clinical spectrum of SSc is wide and its manifestations may lead to severe morbidity and mortality, in addition to a great impact on patients’ quality of life. Due to the multifaceted clinical manifestations of SSc, its management requires a combined expertise of different medical specialists to guarantee an adequate disease control and prevent organ complications. Multi-disciplinary teams (MDT), which are composed by physicians and other specialized health professionals, represent therefore a key element for the comprehensive management of SSc patients. Moreover, MTD can improve communication and patients’ empowerment while the presence of dedicated nurses can help patients to ask questions about their condition. The scope of this narrative review is to analyse the available evidences regarding the role of MDT in the management of SSc patients, and how this holistic approach may improve different disease domains and the overall prognosis. MDT regarding the cardiovascular and lung complication are the more represented in literature, given the great impact in prognosis. Nonetheless, MDT have been shown to be fundamental also in other disease domains as they can intercept early manifestations, thus stratifying patients based on the individual risks in order to personalize patients’ follow-up. MDTs may also minimize the treatment delay, enabling fast-track specialist referral. On the other hand, there are few trials specifically studying MDT in SSc and several authors have highlight the lack of standardization.
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Affiliation(s)
- Nicola Farina
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Benanti
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Giacomo De Luca
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Anna Palmisano
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Unit of Clinical and Experimental Radiology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Giovanni Peretto
- Unit of Cardiac Electrophysiology and Arrhythmology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Sara Tomassetti
- Department of Experimental and Clinical Medicine, Careggi University Hospital, Florence, Italy
| | - Veronica Giorgione
- Molecular and Clinical Sciences Research Institute, Fetal Medicine Unit, Department of Obstetrics and Gynaecology, St. George’s University Hospitals NHS Foundation Trust, London, UK
| | - Ornella Forma
- Vulnology Nursing Service, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Antonio Esposito
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Unit of Clinical and Experimental Radiology, IRCCS San Raffaele Hospital, Milan, Italy
| | - Silvio Danese
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Unit of Gastroenterology and Endoscopy, IRCCS San Raffaele Hospital, Milan, Italy
| | - Lorenzo Dagna
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
| | - Marco Matucci-Cerinic
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
- Department of Experimental and Clinical Medicine, University of Florence and Division of Rheumatology AOUC, Florence, Italy
| | - Corrado Campochiaro
- Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Milan, Italy
- School of Medicine, Vita-Salute San Raffaele University, Milan, Italy
- Correspondence: Corrado Campochiaro, Unit of Immunology, Rheumatology, Allergy and Rare Diseases, IRCCS San Raffaele Hospital, Via Olgettina 60, Milan, 20132, Italy, Tel +39 0226437060, Fax +39 0226433729, Email
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13
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Kou L, Kou P, Luo G, Wei S. Progress of Statin Therapy in the Treatment of Idiopathic Pulmonary Fibrosis. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2022; 2022:6197219. [PMID: 35345828 PMCID: PMC8957418 DOI: 10.1155/2022/6197219] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/31/2021] [Accepted: 02/24/2022] [Indexed: 11/18/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) is a type of interstitial lung disease (ILD) characterized by the proliferation of fibroblasts and aberrant accumulation of extracellular matrix. These changes are accompanied by structural destruction of the lung tissue and the progressive decline of pulmonary function. In the past few decades, researchers have investigated the pathogenesis of IPF and sought a therapeutic approach for its treatment. Some studies have shown that the occurrence of IPF is related to pulmonary inflammatory injury; however, its specific etiology and pathogenesis remain unknown, and no effective treatment, with the exception of lung transplantation, has been identified yet. Several basic science and clinical studies in recent years have shown that statins, the traditional lipid-lowering drugs, exert significant antifibrotic effects, which can delay the progression of IPF and impairment of pulmonary function. This article is aimed at summarizing the current understanding of the pathogenesis of IPF, the progress of research on the use of statins in IPF models and clinical trials, and its main molecular targets.
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Affiliation(s)
- Leiya Kou
- Department of Respiratory Medicine, Wuhan No. 1 Hospital, Wuhan 430022, China
- Hubei University of Chinese Medicine, Wuhan 430065, China
| | - Pei Kou
- Department of Medical Record, Wuhan No. 1 Hospital, Wuhan 430022, China
| | - Guangwei Luo
- Department of Respiratory Medicine, Wuhan No. 1 Hospital, Wuhan 430022, China
| | - Shuang Wei
- Department of Respiratory and Critical Care Medicine, Tongji Hospital Tongji Medical College Huazhong University of Science and Technology, Wuhan 430030, China
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14
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Glass DS, Grossfeld D, Renna HA, Agarwala P, Spiegler P, DeLeon J, Reiss AB. Idiopathic pulmonary fibrosis: Current and future treatment. THE CLINICAL RESPIRATORY JOURNAL 2022; 16:84-96. [PMID: 35001525 PMCID: PMC9060042 DOI: 10.1111/crj.13466] [Citation(s) in RCA: 87] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Revised: 10/21/2021] [Accepted: 11/25/2021] [Indexed: 12/12/2022]
Abstract
Objectives Idiopathic pulmonary fibrosis (IPF) is a chronic fibrotic lung disease characterized by dry cough, fatigue, and progressive exertional dyspnea. Lung parenchyma and architecture is destroyed, compliance is lost, and gas exchange is compromised in this debilitating condition that leads inexorably to respiratory failure and death within 3–5 years of diagnosis. This review discusses treatment approaches to IPF in current use and those that appear promising for future development. Data Source The data were obtained from the Randomized Controlled Trials and scientific studies published in English literature. We used search terms related to IPF, antifibrotic treatment, lung transplant, and management. Results Etiopathogenesis of IPF is not fully understood, and treatment options are limited. Pathological features of IPF include extracellular matrix remodeling, fibroblast activation and proliferation, immune dysregulation, cell senescence, and presence of aberrant basaloid cells. The mainstay therapies are the oral antifibrotic drugs pirfenidone and nintedanib, which can improve quality of life, attenuate symptoms, and slow disease progression. Unilateral or bilateral lung transplantation is the only treatment for IPF shown to increase life expectancy. Conclusion Clearly, there is an unmet need for accelerated research into IPF mechanisms so that progress can be made in therapeutics toward the goals of increasing life expectancy, alleviating symptoms, and improving well‐being.
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Affiliation(s)
- Daniel S Glass
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - David Grossfeld
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Heather A Renna
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Priya Agarwala
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Peter Spiegler
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Joshua DeLeon
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
| | - Allison B Reiss
- Department of Medicine and Biomedical Research Institute, NYU Long Island School of Medicine, Mineola, New York, USA
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15
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Arjuna A, Olson MT, Walia R. Current trends in candidate selection, contraindications, and indications for lung transplantation. J Thorac Dis 2022; 13:6514-6527. [PMID: 34992831 PMCID: PMC8662491 DOI: 10.21037/jtd-2021-09] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Accepted: 01/27/2021] [Indexed: 12/23/2022]
Abstract
Lung transplantation is an established treatment option that can improve quality of life and prolong survival for select patients diagnosed with end-stage lung disease. Given the gaps in organ donation and failures to make effective use of available organs, careful selection of candidates for lung transplant remains one of the most important considerations of the transplant community. Toward this end, we briefly reviewed recent trends in pretransplant evaluation, candidate selection, organ allocation, and organ preservation techniques. Since the latest consensus statement regarding appropriate selection of lung transplant candidates, many advances in the science and practice of lung transplantation have emerged and influenced our perspective of ‘contraindications’ to transplant. These advances have made it increasingly possible to pursue lung transplant in patients with risk factors for decreased survival—namely, older recipient age, increased body mass index, previous chest surgery, poorer nutritional status, and presence of chronic infection, cardiovascular disease, or extrapulmonary comorbid conditions. Therefore, we reviewed the updated evidence demonstrating the prognostic impact of these risk factors in lung transplant recipients. Lastly, we reviewed the salient evidence for current trends in disease-specific indications for lung transplantation, such as chronic obstructive pulmonary disease, idiopathic pulmonary fibrosis, cystic fibrosis, emphysema due to alpha-1 antitrypsin deficiency, and pulmonary arterial hypertension, among other less common end-stage diseases. Overall, lung transplant remains an exciting field with considerable hope for patients as they experience remarkable improvements in quality of life and survival in the modern era.
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Affiliation(s)
- Ashwini Arjuna
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
| | - Michael T Olson
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA.,University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA
| | - Rajat Walia
- Norton Thoracic Institute, St. Joseph's Hospital and Medical Center, Phoenix, AZ, USA
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16
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Black RJ, Novakovic D, Plit M, Miles A, MacDonald P, Madill C. Swallowing and laryngeal complications in lung and heart transplantation: Etiologies and diagnosis. J Heart Lung Transplant 2021; 40:1483-1494. [PMID: 34836605 DOI: 10.1016/j.healun.2021.08.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2021] [Revised: 07/29/2021] [Accepted: 08/19/2021] [Indexed: 10/20/2022] Open
Abstract
Despite continued surgical advancements in the field of cardiothoracic transplantation, post-operative complications remain a burden for the patient and the multidisciplinary team. Lesser-known complications including swallowing disorders (dysphagia), and voice disorders (dysphonia), are now being reported. Such disorders are known to be associated with increased morbidity and mortality in other medical populations, however their etiology amongst the heart and lung transplant populations has received little attention in the literature. This paper explores the potential mechanisms of oropharyngeal dysphagia and dysphonia following transplantation and discusses optimal modalities of diagnostic evaluation and management. A greater understanding of the implications of swallowing and laryngeal dysfunction in the heart and lung transplant populations is important to expedite early diagnosis and management in order to optimize patient outcomes, minimize allograft injury and improve quality of life.
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Affiliation(s)
- Rebecca J Black
- Speech Pathology Department, St Vincent's Hospital, Darlinghurst, NSW, Australia; Faculty of Medicine and Health, The University of Sydney, Australia.
| | - Daniel Novakovic
- Faculty of Medicine and Health, The University of Sydney, Australia
| | | | | | - Peter MacDonald
- Faculty of Medicine and Health, The University of Sydney, Australia
| | - Catherine Madill
- Faculty of Medicine and Health, The University of Sydney, Australia
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17
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Lung Transplantation in Systemic Sclerosis: a Practice Survey of United States Lung Transplant Centers. Transplant Direct 2021; 7:e757. [PMID: 34514112 PMCID: PMC8425834 DOI: 10.1097/txd.0000000000001209] [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: 06/01/2021] [Revised: 06/17/2021] [Accepted: 07/03/2021] [Indexed: 11/27/2022] Open
Abstract
Supplemental Digital Content is available in the text. Lung transplantation in patients with systemic sclerosis (SSc) can be complicated by extrapulmonary manifestations of the disease, leading to concerns regarding posttransplant complications and outcomes.
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18
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Luquez-Mindiola A, Atuesta AJ, Gómez-Aldana AJ. Gastrointestinal manifestations of systemic sclerosis: An updated review. World J Clin Cases 2021; 9:6201-6217. [PMID: 34434988 PMCID: PMC8362561 DOI: 10.12998/wjcc.v9.i22.6201] [Citation(s) in RCA: 6] [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: 01/18/2021] [Revised: 03/30/2021] [Accepted: 06/07/2021] [Indexed: 02/06/2023] Open
Abstract
Systemic sclerosis is an autoimmune disease characterized by vascular disease, fibrosis of the skin, and internal organ dysfunction. Gastrointestinal involvement is the most frequent complication of internal organs, impacting up to 90% of patients. Gastrointestinal involvement can affect any region of the gastrointestinal tract from the mouth to the anus, with a predominance of disorders being observed at the level of the upper digestive tract. The gastrointestinal involvement primarily involves the esophagus, small bowel, and rectum. The severity of gastrointestinal involvement affects quality of life and is a marker of worse prognosis and mortality in these patients. In this review, we describe the current findings regarding gastrointestinal involvement by this entity.
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Affiliation(s)
| | - Alexis Javier Atuesta
- Department of Internal Medicine, Universidad Nacional de Colombia, Bogota 11711, Colombia
| | - Andres Jose Gómez-Aldana
- Department of Endoscopy, Santa Fe Foundation of Bogotá (Fundación Santa Fe de Bogotá), Bogotá 11711, Colombia
- Faculty of Medicine, Universidad de los Andes, Bogota 11711, Colombia
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19
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Miles A, Barua S, McLellan N, Brkic L. Dysphagia and medicine regimes in patients following lung transplant surgery: A retrospective review. INTERNATIONAL JOURNAL OF SPEECH-LANGUAGE PATHOLOGY 2021; 23:339-348. [PMID: 32933315 DOI: 10.1080/17549507.2020.1807051] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
PURPOSE Dysphagia is reported following lung transplantation. Characteristics and trajectory for dysphagia are poorly understood. This retrospective study explored dysphagia and medicine regimes in patients following lung transplant. METHOD Medical records and endoscopic recordings of 101 patients (M:50yrs, range 20-67yrs, SD 13yrs) were reviewed. Standardised endoscopic swallowing measures were reported. Discharge reports were analysed for medicines known to cause dysphagia. RESULT All patients received bilateral sequential single-lung transplant. Prevalence of referral to speech pathology was 65% with 37 requiring more than one instrumental assessment. Twenty-nine patients were referred to otorhinolaryngology with suspected laryngeal abnormalities. Seventy-five percent of patients (n = 49/65) who received an instrumental assessment aspirated; of whom 63% aspirated silently (31/49). Diet on first day transferred from Intensive Care Unit (ICU) was significantly associated with intubation duration, ICU and hospital length of stay, tracheostomy and vocal fold paralysis (p < 0.001). In contrast, pre-operative reflux was significantly associated with diet on discharge (p < 0.05). Only three patients remained enterally fed on discharge. Polypharmacy (concurrent use of 5+ medicines) was prevalent. CONCLUSION Endoscopic, radiographic and/or manometric assessment of dysphagia in patients prior to, and following, lung transplant may allow for early management and prevention of secondary complications. Teams must consider pre-surgical reflux, length of stay in ICU and current medicine regimes when managing patients.
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Affiliation(s)
- Anna Miles
- School of Psychology, The University of Auckland, Auckland, New Zealand and
| | - Sujay Barua
- School of Psychology, The University of Auckland, Auckland, New Zealand and
| | | | - Lejla Brkic
- Auckland District Health Board, Auckland, New Zealand
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20
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Slater BJ, Dirks RC, McKinley SK, Ansari MT, Kohn GP, Thosani N, Qumseya B, Billmeier S, Daly S, Crawford C, P Ehlers A, Hollands C, Palazzo F, Rodriguez N, Train A, Wassenaar E, Walsh D, Pryor AD, Stefanidis D. SAGES guidelines for the surgical treatment of gastroesophageal reflux (GERD). Surg Endosc 2021; 35:4903-4917. [PMID: 34279710 DOI: 10.1007/s00464-021-08625-5] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 06/28/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND Gastroesophageal Reflux Disease (GERD) is an extremely common condition with several medical and surgical treatment options. A multidisciplinary expert panel was convened to develop evidence-based recommendations to support clinicians, patients, and others in decisions regarding the treatment of GERD with an emphasis on evaluating different surgical techniques. METHODS Literature reviews were conducted for 4 key questions regarding the surgical treatment of GERD in both adults and children: surgical vs. medical treatment, robotic vs. laparoscopic fundoplication, partial vs. complete fundoplication, and division vs. preservation of short gastric vessels in adults or maximal versus minimal dissection in pediatric patients. Evidence-based recommendations were formulated using the GRADE methodology by subject experts. Recommendations for future research were also proposed. RESULTS The panel provided seven recommendations for adults and children with GERD. All recommendations were conditional due to very low, low, or moderate certainty of evidence. The panel conditionally recommended surgical treatment over medical management for adults with chronic or chronic refractory GERD. There was insufficient evidence for the panel to make a recommendation regarding surgical versus medical treatment in children. The panel suggested that once the decision to pursue surgical therapy is made, adults and children with GERD may be treated with either a robotic or a laparoscopic approach, and either partial or complete fundoplication based on surgeon-patient shared decision-making and patient values. In adults, the panel suggested either division or non-division of the short gastric vessels is appropriate, and that children should undergo minimal dissection during fundoplication. CONCLUSIONS These recommendations should provide guidance with regard to surgical decision-making in the treatment of GERD and highlight the importance of shared decision-making and patient values to optimize patient outcomes. Pursuing the identified research needs may improve future versions of guidelines for the treatment of GERD.
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Affiliation(s)
- Bethany J Slater
- Department of Surgery, University of Chicago Medicine, 5841 S. Maryland Avenue, MC 4062, Chicago, IL, 606037, USA.
| | - Rebecca C Dirks
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Sophia K McKinley
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Mohammed T Ansari
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
| | - Geoffrey P Kohn
- Department of Surgery, Monash University, Eastern Health Clinical School, Melbourne, VIC, Australia
- Melbourne Upper GI Surgical Group, Melbourne, VIC, Australia
| | - Nirav Thosani
- Center for Interventional Gastroenterology at UTHealth (iGUT), McGovern Medical School, UTHealth, Houston, TX, USA
| | - Bashar Qumseya
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Fl, USA
| | - Sarah Billmeier
- Department of Surgery, Dartmouth Hitchcock Medical Center, Lebanon, NH, USA
| | - Shaun Daly
- Department of Surgery, University of California Irvine, Irvine, USA
| | - Catherine Crawford
- Department of Surgery, Cambridge Health Alliance, Cambridge Massachusetts and Milford Regional Medical Center, Milford, MA, USA
| | - Anne P Ehlers
- Department of Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Celeste Hollands
- Department of Surgery, Texas Tech University Health Sciences Center, Texas, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Noe Rodriguez
- Department of Surgery, Florida Atlantic University, Florida, USA
| | - Arianne Train
- Department of Surgery, Winn Army Community Hospital, Fort Stewart, GA, USA
| | - Eelco Wassenaar
- Department of Surgery, Gelre Hospitals, Zutphen, Netherlands
| | - Danielle Walsh
- Department of Surgery, East Carolina University, Greenville, NC, USA
| | - Aurora D Pryor
- Department of Surgery, Stony Brook University, Stony Brook, NY, USA
| | - Dimitrios Stefanidis
- Department of Surgery, Indiana University School of Medicine, Indianapolis, IN, USA
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21
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Esophageal Motility Disorders Associated With Death or Allograft Dysfunction After Lung Transplantation? Results of a Retrospective Monocentric Study. Clin Transl Gastroenterol 2021; 11:e00137. [PMID: 32352712 PMCID: PMC7145052 DOI: 10.14309/ctg.0000000000000137] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
OBJECTIVES Pathological gastroesophageal reflux (GER) is a known risk factor for bronchiolitis obliterans syndrome (BOS) after lung transplantation. This study aimed at determining whether functional esophageal evaluation might predict BOS occurrence and survival in this setting. METHODS Ninety-three patients who underwent esophageal high-resolution manometry and 24-hour pH-impedance monitoring within the first year after lung transplantation were retrospectively included. A univariable analysis was performed to evaluate the parameters associated with GER disease and BOS occurrence. The Cox regression model was used to identify the prognostic factors of death or retransplantation. RESULTS Thirteen percent of patients exhibited major esophageal motility disorders and 20% pathological GER. GER occurrence was associated with younger age, cystic fibrosis, and hypotensive esophagogastric junction. Within a median follow-up of 62 months, 10 patients (11%) developed BOS, and no predictive factors were identified. At the end of the follow-up, 10 patients died and 1 underwent retransplantation. The 5-year cumulative survival rate without retransplantation was lower in patients with major esophageal motility disorders compared with that in those without (75% vs 90%, P = 0.01) and in patients who developed BOS compared with that in those without (66% vs 91%; P = 0.005). However, in multivariable analysis, major esophageal motility disorders and BOS were no longer significant predictors of survival without retransplantation. DISCUSSION Major esophageal motility disorders and BOS were associated with allograft survival in lung transplantation in the univariable analysis. Although the causes of this association remain to be determined, this observation confirms that esophageal motor dysfunction should be evaluated in the context of lung transplantation.
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22
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Herbella FAM, Patti MG. Gastroesophageal Reflux Disease and Idiopathic Lung Fibrosis. From Heartburn to Lung Transplant, and Beyond. Am Surg 2021; 88:297-302. [PMID: 33629881 DOI: 10.1177/0003134821998686] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Idiopathic pulmonary fibrosis (IPF) and gastroesophageal reflux disease (GERD) are undoubtedly related. Even though it is not clear yet which one is the primary disease, they certainly interact increasing each other's severity. Symptoms are unreliable to diagnose GERD in patients with IPF, and objective evaluation with pH monitoring and/or bronchoalveolar lavage analysis is mandatory. Pharmacological treatment with proton pump inhibitors (PPIs) may bring control of IPF in few patients, but PPIs do not control reflux but just change the pH of the gastric refluxate. Surgical therapy based on a fundoplication is safe and effective as it controls any type of reflux, independently from the pH of the gastric refluxate. In patients waiting for lung transplantation (if they can tolerate a laparoscopic operation under general anesthesia), a fundoplication before the operation might block the progression of IPF, while after transplantation it might prevent rejection by preventing the bronchiolitis obliterans syndrome.
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Affiliation(s)
| | - Marco G Patti
- Department of Surgery, 58804Escola Paulista de Medicina, São Paulo, Brazil
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23
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Surgical treatment of recalcitrant gastroesophageal reflux disease in patients with systemic sclerosis: a systematic review. Langenbecks Arch Surg 2021; 406:1353-1361. [PMID: 33611653 PMCID: PMC8370958 DOI: 10.1007/s00423-021-02118-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Accepted: 02/03/2021] [Indexed: 12/16/2022]
Abstract
Introduction Gastroesophageal reflux disease (GERD) is frequently seen in patients with systemic sclerosis (SSc). Long-standing GERD may cause esophagitis, long-segment strictures, and Barrett’s esophagus and may worsen pre-existing pulmonary fibrosis with an increased risk of end-stage lung disease. Surgical treatment of recalcitrant GERD remains controversial. The purpose of this systematic review was to summarize the current data on surgical treatment of recalcitrant GERD in SSc patients. Materials and methods A systematic literature review according to PRISMA and MOOSE guidelines. PubMed, EMBASE, and Web of Science databases were consulted. Results A total of 101 patients were included from 7 studies. The age ranged from 34 to 61 years and the majority were females (73.5%). Commonly reported symptoms were heartburn (92%), regurgitation (77%), and dysphagia (74%). Concurrent pulmonary disease was diagnosed in 58% of patients. Overall, 63 patients (62.4%) underwent open fundoplication, 17 (16.8%) laparoscopic fundoplication, 15 (14.9%) Roux en-Y gastric bypass (RYGB), and 6 (5.9%) esophagectomy. The postoperative follow-up ranged from 12 to 65 months. Recurrent symptoms were described in up to 70% and 30% of patients undergoing fundoplication and RYGB, respectively. Various symptoms were reported postoperatively depending on the type of surgical procedures, anatomy of the valve, need for esophageal lengthening, and follow-up. Conclusions The treatment of recalcitrant GERD in SSc patients is challenging. Esophagectomy should be reserved to selected patients. Minimally invasive RYGB appears feasible and safe with promising preliminary short-term results. Current evidence is scarce while a definitive indication about the most appropriate surgical treatment is lacking. Supplementary Information The online version contains supplementary material available at 10.1007/s00423-021-02118-8.
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24
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Whitmore TJ, Yaw M, Lavender M, Musk M, Boan P, Wrobel J. A novel highly bio-available itraconazole formulation (SUBA®-Itraconazole) for anti-fungal prophylaxis in lung transplant recipients. Transpl Infect Dis 2021; 23:e13587. [PMID: 33590676 DOI: 10.1111/tid.13587] [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: 11/11/2020] [Revised: 01/28/2021] [Accepted: 02/07/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Antifungal prophylaxis remains a mainstay of lung transplantation, given invasive fungal infection is a common and serious complication after lung transplantation. Choice of systemic agent to prevent invasive fungal infection varies between centers and funding of agents remains challenging. Our center has recently changed from posaconazole to a highly bioavailable formulation of itraconazole (SUBA®-itraconazole) at substantially reduced cost, but safety and toxicity require further assessment. A retrospective study of lung transplant patients receiving systemic antifungal prophylaxis from December 2016 through December 2019 following change from posaconazole to itraconazole as standard practice. 150 patients with lung transplants were managed in this time period, with 88 (59%) receiving at least 1 mold-active triazole during the study period. 48 (58%) of these patients received SUBA®-itraconazole; 68 (82%) received posaconazole and 10 (12%) received voriconazole. The average cost per patient during the study period was significantly lower on SUBA®-itraconazole (mean $1548/patient/6 month course) than posaconazole (mean $16 921.35/patient/6 month course). Target trough concentrations for prophylaxis of itraconazole > 0.5 mg/L and posaconazole > 0.7 mg/L were achieved on empiric dosing in 49% and 68% respectively. Overall trough itraconazole (0.50 vs 1.12 mg/L, P < .001) and posaconazole (1.37 vs 2.10 mg/L P < .001) concentrations were significantly lower in patients with cystic fibrosis. Calcineurin inhibitor dose changes on introduction or cessation were similar for SUBA®-itraconazole and posaconazole. Breakthrough invasive fungal infection and toxicity were rare. SUBA®-itraconazole is well-tolerated, associated with rare breakthrough invasive fungal infection, and lower cost. Prospective studies following general introduction are required to determine long-term safety, tolerability, and efficacy.
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Affiliation(s)
- Timothy James Whitmore
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Perth, WA, Australia.,Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Meow Yaw
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Melanie Lavender
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Michael Musk
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - Peter Boan
- Department of Infectious Diseases, Fiona Stanley Hospital, Perth, WA, Australia.,Department of Microbiology, PathWest Laboratory Medicine WA, Perth, WA, Australia
| | - Jeremy Wrobel
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia.,School of Medicine, University of Notre Dame Australia, Fremantle, WA, Australia
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25
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Dugger DT, Fung M, Hays SR, Singer JP, Kleinhenz ME, Leard LE, Golden JA, Shah RJ, Lee JS, Deiter F, Greenland NY, Jones KD, Langelier CR, Greenland JR. Chronic lung allograft dysfunction small airways reveal a lymphocytic inflammation gene signature. Am J Transplant 2021; 21:362-371. [PMID: 32885581 PMCID: PMC8009189 DOI: 10.1111/ajt.16293] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/27/2020] [Accepted: 08/16/2020] [Indexed: 01/25/2023]
Abstract
Chronic lung allograft dysfunction (CLAD) is the major barrier to long-term survival following lung transplantation, and new mechanistic biomarkers are needed. Lymphocytic bronchitis (LB) precedes CLAD and has a defined molecular signature. We hypothesized that this LB molecular signature would be associated with CLAD in small airway brushings independent of infection. We quantified RNA expression from small airway brushings and transbronchial biopsies, using RNAseq and digital RNA counting, respectively, for 22 CLAD cases and 27 matched controls. LB metagene scores were compared across CLAD strata by Wilcoxon rank sum test. We performed unbiased host transcriptome pathway and microbial metagenome analysis in airway brushes and compared machine-learning classifiers between the two tissue types. This LB metagene score was increased in CLAD airway brushes (p = .002) and improved prediction of graft failure (p = .02). Gene expression classifiers based on airway brushes outperformed those using transbronchial biopsies. While infection was associated with decreased microbial alpha-diversity (p ≤ .04), neither infection nor alpha-diversity was associated with LB gene expression. In summary, CLAD was associated with small airway gene expression changes not apparent in transbronchial biopsies in this cohort. Molecular analysis of airway brushings for diagnosing CLAD merits further examination in multicenter cohorts.
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Affiliation(s)
- Daniel T. Dugger
- Department of Medicine, University of California, San Francisco, CA 94143,Veterans Affairs Health Care System, San Francisco, CA 94121
| | - Monica Fung
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Steven R. Hays
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Jonathan P. Singer
- Department of Medicine, University of California, San Francisco, CA 94143
| | | | - Lorriana E. Leard
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Jeffrey A. Golden
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Rupal J. Shah
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Joyce S. Lee
- Department of Medicine, University of Colorado, Denver, CO 80045
| | - Fred Deiter
- Department of Medicine, University of California, San Francisco, CA 94143
| | - Nancy Y. Greenland
- Veterans Affairs Health Care System, San Francisco, CA 94121,Department of Anatomic Pathology, University of California, San Francisco, CA 94143
| | - Kirk D. Jones
- Department of Anatomic Pathology, University of California, San Francisco, CA 94143
| | | | - John R. Greenland
- Department of Medicine, University of California, San Francisco, CA 94143,Veterans Affairs Health Care System, San Francisco, CA 94121
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26
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El Moussaoui I, De Pauw V, Navez J, Closset J. Roux-En-Y gastric bypass after lung transplantation: case report and literature review. Surg Obes Relat Dis 2020; 17:239-241. [PMID: 33199198 DOI: 10.1016/j.soard.2020.10.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 09/30/2020] [Accepted: 10/02/2020] [Indexed: 02/02/2023]
Affiliation(s)
- Imad El Moussaoui
- Department of Bariatric Surgery, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
| | - Vincent De Pauw
- Department of Bariatric Surgery, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Julie Navez
- Department of Bariatric Surgery, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Jean Closset
- Department of Bariatric Surgery, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
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27
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Lechien JR, Saussez S, Muls V, Barillari MR, Chiesa-Estomba CM, Hans S, Karkos PD. Laryngopharyngeal Reflux: A State-of-the-Art Algorithm Management for Primary Care Physicians. J Clin Med 2020; 9:E3618. [PMID: 33182684 PMCID: PMC7697179 DOI: 10.3390/jcm9113618] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 10/24/2020] [Accepted: 11/04/2020] [Indexed: 12/15/2022] Open
Abstract
Laryngopharyngeal reflux (LPR) is a common disease in the general population with acute or chronic symptoms. LPR is often misdiagnosed in primary care because of the lack of typical gastroesophageal reflux disease (GERD) symptoms and findings on endoscopy. Depending on the physician's specialty and experience, LPR may be over- or under-diagnosed. Management of LPR is potentially entirely feasible in primary care as long as General Practitioners (GPs) are aware of certain "red flags" that will prompt referral to a Gastroenterologist or an Otolaryngologist. The use of patient-reported outcome questionnaires and the consideration of some easy ways to diagnose LPR without special instrumentation oropharyngeal findings may help the GP to diagnose and often manage LPR. In this review, we provide a practical algorithm for LPR management for GPs and other specialists that cannot perform fiberoptic examination. In this algorithm, physicians have to exclude some confounding conditions such as allergy or other causes of pharyngolaryngitis and "red flags". They may prescribe an empirical treatment based on diet and behavioral changes with or without medication, depending on the symptom severity. Proton pump inhibitors and alginates remain a popular choice in order to protect the upper aerodigestive tract mucosa from acid, weakly acid and alkaline pharyngeal reflux events.
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Affiliation(s)
- Jerome R. Lechien
- Department of Human Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), B7000 Mons, Belgium;
- Department of Otolaryngology-Head & Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), 92150 Paris, France;
- Department of Otolaryngology-Head & Neck Surgery, Ambroise Paré Hospital, APHP, Paris Saclay University, 92150 Paris, France
- Department of Otolaryngology-Head & Neck Surgery, CHU Saint-Pierre, Faculty of Medicine, University Libre de Bruxelles, 1000 Brussels, Belgium
- Department of Otolaryngology-Head & Neck Surgery, CHU Ambroise Paré, 92150 Paris, France
| | - Sven Saussez
- Department of Human Anatomy and Experimental Oncology, Mons School of Medicine, UMONS Research Institute for Health Sciences and Technology, University of Mons (UMons), B7000 Mons, Belgium;
- Department of Otolaryngology-Head & Neck Surgery, CHU Saint-Pierre, Faculty of Medicine, University Libre de Bruxelles, 1000 Brussels, Belgium
- Department of Otolaryngology-Head & Neck Surgery, CHU Ambroise Paré, 92150 Paris, France
| | - Vinciane Muls
- Division of Gastroenterology and Endoscopy, CHU Saint-Pierre, Faculty of Medicine, University Libre de Bruxelles, 1000 Brussels, Belgium;
| | - Maria R. Barillari
- Division of Phoniatrics and Audiology, Department of Mental and Physical Health and Preventive Medicine, University of Naples SUN, 34103 Naples, Italy;
| | - Carlos M. Chiesa-Estomba
- Department of Otorhinolaryngology-Head & Neck Surgery, Hospital Universitario Donostia, 00685 San Sebastian, Spain;
| | - Stéphane Hans
- Department of Otolaryngology-Head & Neck Surgery, Foch Hospital, School of Medicine, UFR Simone Veil, Université Versailles Saint-Quentin-en-Yvelines (Paris Saclay University), 92150 Paris, France;
- Department of Otolaryngology-Head & Neck Surgery, Ambroise Paré Hospital, APHP, Paris Saclay University, 92150 Paris, France
- Department of Otolaryngology-Head & Neck Surgery, CHU Ambroise Paré, 92150 Paris, France
| | - Petros D. Karkos
- Department of Otorhinolaryngology and Head and Neck Surgery, AHEPA University Hospital, Thessaloniki Medical School, 54621 Thessaloniki, Greece;
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28
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Bell R, Lipham J, Louie BE, Williams V, Luketich J, Hill M, Richards W, Dunst C, Lister D, McDowell-Jacobs L, Reardon P, Woods K, Gould J, Buckley FP, Kothari S, Khaitan L, Smith CD, Park A, Smith C, Jacobsen G, Abbas G, Katz P. Magnetic Sphincter Augmentation Superior to Proton Pump Inhibitors for Regurgitation in a 1-Year Randomized Trial. Clin Gastroenterol Hepatol 2020; 18:1736-1743.e2. [PMID: 31518717 DOI: 10.1016/j.cgh.2019.08.056] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/19/2019] [Accepted: 08/30/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Regurgitative gastroesophageal reflux disease (GERD) refractive to medical treatment is common and caused by mechanical failure of the anti-reflux barrier. We compared the effects of magnetic sphincter augmentation (MSA) with those of proton-pump inhibitors (PPIs) in a randomized trial. METHODS Patients with moderate to severe regurgitation (assessed by the foregut symptom questionnaire) despite once-daily PPI therapy (n = 152) were randomly assigned to groups given twice-daily PPIs (n = 102) or laparoscopic MSA (n = 50) at 20 sites, from July 2015 through February 2017. Patients answered questions from the foregut-specific reflux disease questionnaire and GERD health-related quality of life survey about regurgitation, heartburn, dysphagia, bloating, diarrhea, flatulence, and medication use, at baseline and 6 and 12 months after treatment. Six months after PPI therapy, MSA was offered to patients with persistent moderate to severe regurgitation and excess reflux episodes during impedance or pH testing on medication. Regurgitation, foregut scores, esophageal acid exposure, and adverse events were evaluated at 1 year. RESULTS Patients in the MSA group and those who crossed over to the MSA group after PPI therapy (n = 75) had similar outcomes. MSA resulted in control of regurgitation in 72/75 patients (96%); regurgitation control was independent of preoperative response to PPIs. Only 8/43 patients receiving PPIs (19%) reported control of regurgitation. Among the 75 patients who received MSA, 61 (81%) had improvements in GERD health-related quality of life improvement scores (greater than 50%) and 68 patients (91%) discontinued daily PPI use. Proportions of patients with dysphagia decreased from 15% to 7% (P < .005), bloating decreased from 55% to 25%, and esophageal acid exposure time decreased from 10.7% to 1.3% (P < .001) from study entry to 1-year after MSA (Combined P < .001). Seventy percent (48/69) of patients had pH normalization at study completion. MSA was not associated with any peri-operative events, device explants, erosions, or migrations. CONCLUSIONS In a prospective study, we found MSA to reduce regurgitation in 95% of patients with moderate to severe regurgitation despite once-daily PPI therapy. MSA is superior to twice-daily PPIs therapy in reducing regurgitation. Relief of regurgitation is sustained over 12 months. ClinicalTrials.gov no: NCT02505945.
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Affiliation(s)
- Reginald Bell
- Institute of Esophageal and Reflux Surgery, Englewood, Colorado.
| | - John Lipham
- Department of Surgery, University of Southern California, Los Angeles, California
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Medical Center, Seattle, Washington
| | - Valerie Williams
- Thoracic Surgery Department, St. Elizabeth's Healthcare, Edgewood, Kentucky
| | - James Luketich
- Division of Thoracic Surgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania
| | - Michael Hill
- Department of Surgery, Adirondack Medical Center and Adirondack Surgical Group, Saranac Lake, New York
| | - William Richards
- Department of Surgery, University of South Alabama, Mobile, Alabama
| | - Christy Dunst
- Department of Surgery, Oregon Clinic, Portland, Oregon
| | - Dan Lister
- Arkansas Heartburn Treatment Center, Baptist Health Medical Center, Heber Springs, Arkansas
| | | | - Patrick Reardon
- Department of Surgery, Houston Methodist Hospital, Houston, Texas
| | - Karen Woods
- Department of Medicine, Houston Methodist Hospital, Houston, Texas
| | - Jon Gould
- Department of Surgery, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - F Paul Buckley
- Department of Surgery and Perioperative Care, University of Texas at Austin, Austin, Texas
| | - Shanu Kothari
- Department of Surgery, Prisma Health, Greenville, South Carolina
| | - Leena Khaitan
- Department of Surgery, Digestive Health Institute, University Hospitals, Cleveland Medical Center, Cleveland, Cleveland, Ohio
| | | | - Adrian Park
- Department of Surgery, Anne Arundel Health System and Johns Hopkins Medicine, Annapolis, Maryland
| | | | - Garth Jacobsen
- Department of Surgery, University of California, San Diego, San Diego, California
| | - Ghulam Abbas
- Division of Thoracic Surgery, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Philip Katz
- Department of Gastroenterology, Weill Cornell Medicine, New York, New York
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29
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Bansal S, McGilvrey M, Garcia-Mansfield K, Sharma R, Bremner RM, Smith MA, Hachem R, Pirrotte P, Mohanakumar T. Global Proteomics Analysis of Circulating Extracellular Vesicles Isolated from Lung Transplant Recipients. ACS OMEGA 2020; 5:14360-14369. [PMID: 32596573 PMCID: PMC7315412 DOI: 10.1021/acsomega.0c00859] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2020] [Accepted: 05/27/2020] [Indexed: 06/11/2023]
Abstract
Lung transplant recipients (LTxRs) with acute rejection (AR) and chronic rejection (bronchiolitis obliterans syndrome [BOS]) induce circulating exosomes known to contain donor human leukocyte antigens and lung-associated self-antigens. Here, we sought to identify proteomic signatures in circulating extracellular vesicles (EVs) that differentiate LTxRs in 4 groups: stable, AR, BOS, or respiratory viral infection (RVI). EVs were isolated from plasma from patients in each group via ultracentrifugation. EV protein cargoes were prepared for shotgun proteomics using liquid chromatography-tandem mass spectrometry. We identified 2 unique proteins for AR, 4 for RVI, 24 for BOS, and 8 for stable LTxRs. Differential analysis of AR, BOS, RVI, and stable proteins identified significantly deregulated proteins (p < 0.05, log2(fold change) > ±1) in each condition (31, 2, and 2, respectively). EVs from LTxRs with AR contained proteins involved in immunoglobulin, complement regulation, coagulation, and innate and adaptive immune response pathways. EVs from LTxRs with BOS revealed enriched immunoglobulin receptors and a carboxypeptidase N catalytic chain. EVs from LTxRs with RVI had an enriched macrophage-stimulating factor. We found unique signatures in LTxRs with AR, BOS, and RVI, highlighting complex immune mechanisms underlying lung allograft rejection. Proteomic signatures in LTxRs' circulating EVs provided insights into immunological mechanisms of graft rejection and RVI.
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Affiliation(s)
- Sandhya Bansal
- Norton Thoracic
Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona 85013, United States
| | - Marissa McGilvrey
- Collaborative Center for Translational Mass Spectrometry (CCTMS), Translational Genomics Research Institute (TGen), Phoenix, Arizona 85004, United States
| | - Krystine Garcia-Mansfield
- Collaborative Center for Translational Mass Spectrometry (CCTMS), Translational Genomics Research Institute (TGen), Phoenix, Arizona 85004, United States
| | - Ritin Sharma
- Collaborative Center for Translational Mass Spectrometry (CCTMS), Translational Genomics Research Institute (TGen), Phoenix, Arizona 85004, United States
| | - Ross M. Bremner
- Norton Thoracic
Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona 85013, United States
| | - Michael A. Smith
- Norton Thoracic
Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona 85013, United States
| | - Ramsey Hachem
- Department of Medicine, Washington University
School of Medicine, St. Louis, Missouri 63110, United States
| | - Patrick Pirrotte
- Collaborative Center for Translational Mass Spectrometry (CCTMS), Translational Genomics Research Institute (TGen), Phoenix, Arizona 85004, United States
| | - Thalachallour Mohanakumar
- Norton Thoracic
Institute, St. Joseph’s Hospital and Medical Center, Phoenix, Arizona 85013, United States
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30
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Patrucco F, Venezia L, Nicali R, Pellicano R, Bellan M, Balbo PE. Idiopathic pulmonary fibrosis and gastroesophageal reflux. ACTA ACUST UNITED AC 2020. [DOI: 10.23736/s0026-4954.20.01865-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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31
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Gualdoni J, Ritzenthaler J, Burlen J, Stocker A, Abell T, Roman J, Nunley DR. Gastroesophageal Reflux and Microaspiration in Lung Transplant Recipients: The Utility of a Single Esophageal Manometry and pH Probe Monitoring Study. Transplant Proc 2020; 52:977-981. [PMID: 32151388 DOI: 10.1016/j.transproceed.2020.01.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 01/23/2020] [Indexed: 11/18/2022]
Abstract
BACKGROUND Gastroesophageal reflux (GER) in recipients of lung transplant (LTX) is associated with chronic allograft rejection, presumably via microaspiration that damages airway epithelium. Most LTX programs perform a single post-LTX esophageal study to evaluate for GER; the efficacy of this test is unclear. METHODS Patients with 1 year of post-LTX follow-up, including routine bronchoscopies with bronchoalveolar lavage fluid (BALF) samples as well as high-resolution esophageal manometry and pH probe monitoring (HREMpH), were evaluated. BALF samples were analyzed with competitive enzyme-linked immunosorbent assay to detect bile salts, which are indicative of aspiration. These results were compared to results of HREMpH studies post LTX. RESULTS Ninety BALF samples were analyzed for bile salts and acted as disease positive for this evaluation. Of the 13 HREMpH cases, 8 were positive for GER, but only 3 were positive for bile salts via assay. Of the 5 HREMpH-negative cases, 2 experienced aspiration. A solitary HREMpH study had 60.0% sensitivity and 37.5% specificity with positive and negative likelihood ratios: 0.96 and 1.07, respectively. CONCLUSION Microaspiration appears to be an intermittent phenomenon, and HREMpH screening poorly correlates with BALF evidence of aspiration; which may not be adequate. As aspiration detection is crucial in this population, further analysis is warranted.
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Affiliation(s)
- J Gualdoni
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States.
| | - J Ritzenthaler
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - J Burlen
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - A Stocker
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - T Abell
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
| | - J Roman
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States; Robley Rex VA Medical Center, Louisville, Kentucky, United States
| | - D R Nunley
- Department of Medicine, University of Louisville School of Medicine, Louisville, Kentucky, United States
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Ghisa M, Marinelli C, Savarino V, Savarino E. Idiopathic pulmonary fibrosis and GERD: links and risks. Ther Clin Risk Manag 2019; 15:1081-1093. [PMID: 31564886 PMCID: PMC6733342 DOI: 10.2147/tcrm.s184291] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Accepted: 08/11/2019] [Indexed: 01/06/2023] Open
Abstract
Gastroesophageal reflux disease (GERD) and idiopathic pulmonary fibrosis (IPF) are two pathological conditions often strictly related, even if a clear relationship of causality has not been demonstrated. GERD is a frequent comorbidity in IPF patients, as demonstrated using combined multichannel intraluminal impedance-pH, despite being mostly clinically silent. According to that, it has been hypothesized that microaspiration of gastric material may play a fundamental role in the fibrotic transformation of pulmonary parenchyma. In contrast, it cannot be excluded that IPF may favor GERD by increasing the negative intrathoracic pressure. Therefore, this relationship is uncertain as well as not univocal. Nevertheless, the latest international guidelines recommend the use of proton pump inhibitors (PPIs) in IPF based on several data showing that PPIs can stabilize lung function, reduce disease flares and hospitalizations. On the contrary, recent studies not only question the relevance of these results, but also associate the use of PPIs with an increased risk of lung infections and a negative prognostic outcome. The aim of this review is to analyze the possible links between GERD and IPF and their possible therapeutic implications, trying to translate this scientific evidence into useful information for clinical practice.
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Affiliation(s)
- Matteo Ghisa
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Carla Marinelli
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
| | - Vincenzo Savarino
- Gastrointestinal Unit, Department of Internal Medicine and Medical Specialties, University of Genoa, Genoa, Italy
| | - Edoardo Savarino
- Gastrointestinal Unit, Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
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Chwiesko A, Kowal-Bielecka O, Sierakowski S. Perspectives on the interlinked nature of systemic sclerosis and reflux disease. Expert Rev Gastroenterol Hepatol 2019; 13:213-227. [PMID: 30791766 DOI: 10.1080/17474124.2019.1561274] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Systemic sclerosis (SSc) is a multisystem connective tissue disease, characterized by chronic inflammation and vascular changes that result in esophageal smooth muscle atrophy and fibrosis. Subsequent progressive loss of peristalsis in the distal esophagus and loss of lower esophageal sphincter function lead to problems with the protective barrier and exposure of sensitive tissues to the gastroduodenal contents, a disorder called reflux disease. Areas covered: Depending on the range, nature and symptoms of the disease, the term 'reflux disease' may refer to gastroesophageal reflux, laryngopharyngeal reflux, microaspiration into the airways and silent reflux. Despite the links between these visceral complications, this connection remains controversial. This is due to a lack of complete understanding, the asymptomatic nature of the disease and the limited diagnostic accuracy of tests, which can delay diagnosis. Such delays are problematic, given that the early detection of GERD in SSc patients, the timing of assessment, the treatment of the organs involved are critical aspects of patient prognosis and disease outcome. Expert commentary: This review summarizes the most recent knowledge about the pathophysiology, diagnosis and prospective treatment of GERD in SSc patients and highlights how innovative technologies applied through an integrative, interdisciplinary approach may soon lead to effective treatment strategies.
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Affiliation(s)
- Adam Chwiesko
- a Department of Gastroenterology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
| | - Otylia Kowal-Bielecka
- b Department of Rheumatology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
| | - Stanislaw Sierakowski
- b Department of Rheumatology and Internal Medicine , Medical University of Bialystok , Bialystok , Poland
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Drees D, Tumin D, Miller R, Kirkby S, Bhalla T, Tobias JD, Hayes D. Chronic opioid use and clinical outcomes in lung transplant recipients: A single-center cohort study. CLINICAL RESPIRATORY JOURNAL 2019; 12:2446-2453. [PMID: 30054981 DOI: 10.1111/crj.12948] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 06/09/2018] [Accepted: 07/11/2018] [Indexed: 12/23/2022]
Abstract
INTRODUCTION Chronic opioid use is common after organ transplantation, and has been associated with poor outcomes in transplantation of abdominal organs. However, little is known about possible influences of chronic opioid use on outcomes of lung transplantation (LTx). OBJECTIVES We assessed whether long-term chronic opioid use influenced clinical outcomes among LTx recipients at our program. METHODS We retrospectively evaluated chronic opioid use among bilateral LTx recipients ages 12 and older followed at our institution 1-5 years post-transplant. Chronic opioid use was defined as ≥3 months of consecutive prescribed use. Outcomes included survival, hospitalization, emergency department and urgent care visits, forced expiratory volume in one second (FEV1), and allograft rejection. RESULTS Twenty-one patients ages 15-50 years met inclusion criteria. On multivariable analysis, initiation of chronic opioid use was followed by increased mortality hazard (hazard ratio=7.1; 95% confidence interval [CI]: 1.1, 45.0, P = 0.037) and decreased FEV1 (-16%; 95% CI: -24%, -7%; P < 0.001), although no differences were observed in risk of acute care visits, inpatient admission, or chronic rejection. CONCLUSION This analysis presents the first evidence that late-onset chronic opioid use may be associated with decreased lung function and increased mortality after LTx. Therefore, evaluation of chronic opioid use should be included in the routine monitoring of transplant recipients, to better define the impact of this risk factor on LTx outcomes.
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Affiliation(s)
- David Drees
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio
| | - Dmitry Tumin
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Rebecca Miller
- Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Stephen Kirkby
- Department of Pulmonary Medicine and Critical Care, The Ohio State University College of Medicine, Columbus, Ohio.,Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Tarun Bhalla
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Joseph D Tobias
- Department of Anesthesiology and Pain Medicine, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Anesthesiology and Pain Medicine, Nationwide Children's Hospital, Columbus, Ohio
| | - Don Hayes
- Department of Pediatrics, The Ohio State University College of Medicine, Columbus, Ohio.,Department of Pulmonary Medicine and Critical Care, The Ohio State University College of Medicine, Columbus, Ohio.,Section of Pulmonary Medicine, Nationwide Children's Hospital, Columbus, Ohio
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Jo KW, Hong SB, Kim DK, Jung SH, Kim HR, Choi SH, Lee GD, Lee SO, Do KH, Chae EJ, Choi IC, Choi DK, Kim IO, Park SI, Shim TS. Long-Term Outcomes of Adult Lung Transplantation Recipients: A Single-Center Experience in South Korea. Tuberc Respir Dis (Seoul) 2019; 82:348-356. [PMID: 31583875 PMCID: PMC6778743 DOI: 10.4046/trd.2019.0016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2019] [Revised: 05/19/2019] [Accepted: 05/21/2019] [Indexed: 12/28/2022] Open
Abstract
Background Recently, the number of lung transplants in South Korea has increased. However, the long-term outcome data is limited. In this study, we aimed to investigate the long-term outcomes of adult lung transplantation recipients. Methods Among the patients that underwent lung transplantation at a tertiary referral center in South Korea between 2008 and 2017, adults patient who underwent deceased-donor lung transplantation with available follow-up data were enrolled. Their medical records were retrospectively reviewed. Results Through eligibility screening, we identified 60 adult patients that underwent lung (n=51) or heart-lung transplantation (n=9) during the observation period. Idiopathic pulmonary fibrosis (46.7%, 28/60) was the most frequent cause of lung transplantation. For all the 60 patients, the median follow-up duration for post-transplantation was 2.6 years (range, 0.01–7.6). During the post-transplantation follow-up period, 19 patients (31.7%) died at a median duration of 194 days. The survival rates were 75.5%, 67.6%, and 61.8% at 1 year, 3 years, and 5 years, respectively. Out of the 60 patients, 8 (13.3%) were diagnosed with chronic lung allograft dysfunction (CLAD), after a mean duration of 3.3±2.8 years post-transplantation. The CLAD development rate was 0%, 17.7%, and 25.8% at 1 year, 3 years, and 5 years, respectively. The most common newly developed post-transplantation comorbidity was the chronic kidney disease (CKD; 54.0%), followed by diabetes mellitus (25.9%). Conclusion Among the adult lung transplantation recipients at a South Korea tertiary referral center, the long-term survival rates were favorable. The proportion of patients who developed CLAD was not substantial. CKD was the most common post-transplantation comorbidity.
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Affiliation(s)
- Kyung Wook Jo
- Division of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Bum Hong
- Division of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Kwan Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung Ho Jung
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyeong Ryul Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Se Hoon Choi
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Geun Dong Lee
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Oh Lee
- Department of Infectious Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung Hyun Do
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Chae
- Department of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Cheol Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dae Kee Choi
- Department of Anesthesiology and Pain Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - In Ok Kim
- Organ Transplantation Center, Asan Medical Center, Seoul, Korea
| | - Seung Il Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Tae Sun Shim
- Division of Pulmonology and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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Tilak A, Ramirez AG, Turrentine FE, Sohn MW, Jones RS. Preoperative Gastroesophageal Reflux Disorder Is Associated With Increased Morbidity in Patients Undergoing Abdominal Surgery. J Surg Res 2018; 232:587-594. [PMID: 30463778 DOI: 10.1016/j.jss.2018.07.051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 06/27/2018] [Accepted: 07/13/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND In North America, the prevalence of gastroesophageal reflux disorder ranges from 18.1% to 27.8%. We measured the risk posed by preoperative esophageal disease for patients undergoing abdominal operations. METHOD American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP; 2005-2015) data were merged with institutional clinical data repository records to identify esophageal disease in surgical patients undergoing intra-abdominal procedures. Patients with esophageal disease were classified as gastroesophageal reflux disorder (GERD) or other, which included patients with esophageal stricture, spasm, ulcer, or diverticuli, achalasia, esophagitis, reflux esophagitis, Barrett's esophagus, and multiple esophageal diagnoses, excluding GERD. ACS NSQIP-targeted procedure groups included were colectomy, proctectomy, ventral hernia repair, bariatric surgery, hepatectomy, appendectomy, abdominal aortic aneurysm repair, open aortoiliac repair, hysterectomy, myomectomy, and oophorectomy. Multivariable logistic regression was used to model postoperative complication rates, adjusting for ACS NSQIP risk of morbidity, demographic factors, ACS NSQIP-targeted procedure groups, and open versus laparoscopic surgery. RESULTS Of 9172 intra-abdominal cases, 21.3% had preoperative esophageal disease (19.6% GERD and 1.7% other). After adjustment, patients with GERD were at higher risk for experiencing a number of complications, including all-cause 30-d complication (odds ratio [OR] = 1.21, 95% confidence interval [CI] 1.05-1.41, P = 0.044), renal complication (OR = 1.43, 95% CI 1.09-1.87, P = 0.036), wound complication (OR = 1.40, 95% CI 1.10-1.79, P = 0.028), and readmission within 30 d (OR = 1.66, 95% CI 1.35-2.04, P < 0.001). CONCLUSIONS Preoperative GERD is associated with increased postoperative complication rate. Surgeons should consider assessing GERD in patients undergoing abdominal operations.
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Affiliation(s)
- Ashwini Tilak
- Department of Surgery, University of Virginia, Charlottesville, Virginia
| | - Adriana G Ramirez
- Department of Surgery, University of Virginia, Charlottesville, Virginia.
| | | | - Min-Woong Sohn
- Department of Public Health Sciences, Charlottesville, Virginia
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Abstract
Gastroesophageal reflux disease pathophysiology is multifactorial and linked to a misbalance between the aggressiveness of the refluxate into the esophagus or adjacent organs and the failure of protective mechanisms associate or not to a defective valvular mechanism at the level of the esophagogastric junction incapable of dealing with a transdiaphragmatic pressure gradient. Antireflux mechanisms include the lower esophageal sphincter and abdominal esophagus, the diaphragm, the angle of His, the Gubaroff valve, and the phrenoesophageal membrane. Protective mechanisms include esophageal motility, saliva production, and epithelial protection. Disruption of this balance occurs most commonly due to the presence of a hiatal hernia, esophageal dysmotility, a rise in abdominal pressure (obesity), and decrease in thoracic pressure (chronic lung diseases).
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Affiliation(s)
- Mariano A Menezes
- Department of Surgery, State University of Londrina, Londrina, Brazil
| | - Fernando A M Herbella
- Department of Surgery, Escola Paulista de Medicina, Federal University of São Paulo, Rua Diogo de Faria 1087 cj 301, São Paulo, SP, 04037-003, Brazil.
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Siboni S, Asti E, Sozzi M, Bonitta G, Melloni M, Bonavina L. Respiratory Symptoms and Complications of Zenker Diverticulum: Effect of Trans-Oral Septum Stapling. J Gastrointest Surg 2017; 21:1391-1395. [PMID: 28470561 DOI: 10.1007/s11605-017-3435-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2017] [Accepted: 04/24/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Zenker diverticulum is a rare condition commonly associated with dysphagia and respiratory symptoms/complications, which are alarming especially in the elderly population. Aim of this study was to investigate the prevalence of respiratory symptoms/complications and the effects of minimally invasive trans-oral surgery in these patients. METHODS Consecutive adult patients who underwent trans-oral septum stapling for Zenker diverticulum were included in a retrospective, observational cohort study. Pre- and postoperative symptoms, including chronic cough and aspiration pneumonia, were evaluated using a dedicated foregut questionnaire and were recorded on a prospectively maintained database. The operation was performed under general anesthesia. A barium swallow study and an upper gastrointestinal endoscopy were performed 6 months after the operation, and the foregut questionnaire was administered yearly. RESULTS A total of 139 patients were finally included in the study. The median age was 72 years. In 62 (44.6%, CI 36.2-53.3) patients, there was a history of chronic cough and/or aspiration pneumonia. Chronic cough was associated with pneumonia (p < 0.001), while pneumonia was associated with severe regurgitation (p < 0.042) and weight loss (p = 0.001). The overall postoperative morbidity rate was 2.2% and there was no mortality. The median postoperative hospital stay was 2 days (range 0-22). The median follow-up was 38 months (range 2-105). At 3 years, a statistically significant reduction in the rate of chronic cough (36.8 vs. 7.9%, p < 0.001), recurrent episodes of pneumonia (6.6 vs. 0.0%, p = 0.031), dysphagia (78.9 vs. 6.6%, p < 0.001), and regurgitation (67.1 vs. 6.6%, p < 0.001) was recorded. The probability of remaining symptom-free at 90 months of follow-up was 0.818 (CI: 0.745-0.899). CONCLUSIONS Trans-oral septum stapling is safe and can effectively reduce the burden of respiratory symptoms and complications associated with Zenker diverticulum.
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Affiliation(s)
- Stefano Siboni
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Emanuele Asti
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Marco Sozzi
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Gianluca Bonitta
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Matteo Melloni
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy
| | - Luigi Bonavina
- Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, University of Milan, Via Morandi 30, San Donato Milanese, 20097, Milan, Italy.
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Managing Systemic Sclerosis-Related Interstitial Lung Disease in the Modern Treatment Era. JOURNAL OF SCLERODERMA AND RELATED DISORDERS 2017. [DOI: 10.5301/jsrd.5000237] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Interstitial lung disease (ILD) affects the majority of patients with systemic sclerosis (SSc) and is the leading cause of death in SSc. Traditionally, treatments for SSc-ILD have targeted broad suppression of the immune system with agents such as cyclophosphamide and mycophenolate. The recently published Scleroderma Lung Study (SLS) II demonstrated that treatment with either oral cyclophosphamide or mycophenolate led to similar improvement in lung function, dyspnea and radiographic extent of fibrosis. However, with the emergence of anti-fibrotic therapy for the treatment of idiopathic pulmonary fibrosis, the repurposing of biologic agents used to treat other connective tissue diseases, and the introduction of hematopoetic stem-cell transplantation for patients with early diffuse SSc, options for managing SSc-ILD have increased. For the first time ever, patients and physicians have choices for how to treat SSc-ILD. At the same time, the study and administration of these novel therapeutic agents have raised important clinical research questions that warrant further investigation. This review describes the current and experimental therapies available for SSc-ILD. This review also explores unanswered questions directly relevant to patient care and future research efforts in this area, including questions on indications for initiation of SSc-ILD therapy, the use of maintenance SSc-ILD therapy and the duration of SSc-ILD therapy. Conducting studies designed to answer these important questions is central to advancing SSc-ILD research and improving outcomes for patients with this devastating disease.
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Noth I. When Is It More Than Just a Spicy Meal? J Laparoendosc Adv Surg Tech A 2016; 26:499-500. [PMID: 27176108 DOI: 10.1089/lap.2016.29007.in] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Imre Noth
- Section of Pulmonary and Critical Care Medicine, University of Chicago , Chicago, Illinois
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