Extraesophageal syndrome of gastroesophageal reflux: relationships with lung disease and transplantation outcome

The impact of lung transplantation on esophageal motility and inter-relationships with reflux and lung mechanics in patients with restrictive and obstructive respiratory disease

BACKGROUND

For many patients with lung disease the only proven intervention to improve survival and quality of life is lung transplantation (LTx). Esophageal dysmotility and gastroesophageal reflux (GER) are common in patients with respiratory disease, and often associate with worse prognosis following LTx. Which, if any patients, should be excluded from LTx based on esophageal concerns remains unclear. Our aim was to understand the effect of LTx on esophageal motility diagnosis and examine how this and the other physiological and mechanical factors relate to GER and clearance of boluses swallowed.

METHODS

We prospectively recruited 62 patients with restrictive (RLD) and obstructive (OLD) lung disease (aged 33-75 years; 42 men) who underwent high resolution impedance manometry and 24-h pH-impedance before and after LTx.

KEY RESULTS

RLD patients with normal motility were more likely to remain normal (p = 0.02), or if having abnormal motility to change to normal (p = 0.07) post-LTx than OLD patients. Esophageal length (EL) was greater in OLD than RLD patients' pre-LTx (p < 0.001), reducing only in OLD patients' post-LTx (p = 0.02). Reduced EL post-LTx associated with greater contractile reserve (r = 0.735; p = 0.01) and increased likelihood of motility normalization (p = 0.10). Clearance of reflux improved (p = 0.01) and associated with increased mean nocturnal baseline impedance (p < 0.001) in RLD but not OLD. Peristaltic breaks and thoraco-abdominal pressure gradient impact both esophageal clearance of reflux and boluses swallowed (p < 0.05).

CONCLUSIONS AND INFERENCES

RLD patients are more likely to show improvement in esophageal motility than OLD patients post-LTx. However, the effect on GER is more difficult to predict and requires other GI, anatomical and pulmonary factors to be taken into consideration.

Gastroesophageal Reflux Revealed by 18 F-MFBG PET/CT

ABSTRACT

A 56-year-old woman who had a lung transplant 4 months ago presented frequent vomiting for 1 month. Barium meal and 99m Tc gastroesophageal scintigraphy showed no gastroesophageal reflux. The patient was enrolled in a clinical trial and underwent 18 F-MFBG PET/CT dynamic imaging. At the seventh minute of dynamic imaging, the images revealed reflux from the cardia into the esophagus and reached the oral cavity.

Lap. Nissen fundoplication leads to better respiratory symptom control than Toupet in the long term of 20 years

INTRODUCTION

Having performed anti-reflux surgery for thirty years, it was important to reexamine our patients in the long term to enlarge the body of evidence concerning classical and extraesophageal symptoms that are differently controlled by Nissen or Toupet fundoplication.

OBJECTIVES

We report a cohort of 155 GERD patients who underwent fundoplication within a tailored approach between 1994 and 2000. Changes in the perioperative functional outcome, GERD symptoms, and quality of life are being analyzed 10 and 20 years after the operation.

RESULTS

The operation resulted in a superior quality of life compared to a patient cohort treated with PPI therapy. We found that both surgical methods (laparoscopic Nissen fundoplication and laparoscopic Toupet fundoplication) cure classical symptoms equally (heartburn, regurgitation, and dysphagia). GERD patients receiving a Toupet fundoplication seem more likely to suffer from extraesophageal GERD symptoms 10 and 20 years after surgery than patients with a Nissen fundoplication. On the other hand, some patients with Nissen fundoplication report dysphagia even 10 and 20 years after surgery.

CONCLUSION

Both the laparoscopic Nissen and Toupet fundoplications provide excellent symptom control in the long term. Moreover, the Nissen fundoplication seems to be superior in controlling extraesophageal reflux symptoms, but at the expense of dysphagia. In summary, tailoring the operation based on symptoms seems advantageous.

Utilization of Oil Red O staining for assessing aspiration risk in lung transplant patients: A multidisciplinary prospective study with clinical practice insights

BACKGROUND

Gastroesophageal reflux disease with microaspiration has been associated with graft dysfunction in lung transplant patients. Identifying patients with aspiration is clinically important because it enables implementation of appropriate interventions like antireflux therapy. Oil Red O (ORO) staining with determination of the lipid-laden macrophage index (LLMI) has been proposed as a noninvasive surrogate marker in the detection of aspiration. The aim of this study was to prospectively evaluate clinical utilization of ORO staining in the assessment of aspiration risk.

METHODS

All transbronchial surgical pathology biopsies obtained in lung transplant patients undergoing routine surveillance from August 2020 through November 2021 were included in this study. Clinical team members prospectively ascertained the aspiration risk category (ARC) of each patient both before and after biopsy findings and recorded reasons for change in ARC.

RESULTS

A total of 132 transbronchial biopsies with concurrent LLMI were included in the study. LLMI was low in 51 cases (38.6%), including 21 of the 54 cases (38.9%) where aspiration was suggested based on the transbronchial biopsy findings. In total, 19 cases (14.4%) underwent a change in ARC post-biopsy including 10 that were upgraded and nine cases that were downgraded. Transbronchial biopsy findings were noted as the reason for change in ARC in the majority (15/19; 79%) of cases; only a minority (2/19; 10.5%) were due to the LLMI. Notably, 16 cases (12.1%) had a low LLMI with high-risk post-biopsy ARC and nine cases (6.8%) had a high LLMI with low-risk post-biopsy ARC.

CONCLUSIONS

This study observed that clinical evaluation for aspiration relied more heavily on transbronchial biopsy findings. Although LLMI may retain clinical utility in some scenarios, reevaluation of the clinical value of ORO testing would be prudent.

Esophageal Dysfunction in Post-lung Transplant: An Enigma

The prevalence of lung transplants has increased over the years, albeit with a low survival rate amongst all solid organ transplants, including liver and heart transplantation. Microaspiration is one of the primary mechanisms that has been implicated in the pathogenesis of lung injury following lung transplants. Of late, esophageal dysfunction such as gastroesophageal reflux and esophageal hypercontractility is often noted post-lung transplant. However, reflux is associated with chronic allograft lung injury such as bronchiolitis obliterans syndrome, which is one of the predictors for long-term survival in this specialized population. Its role in acute lung injury post-lung transplant is still being explored. This review critically examines the salient points which provide the current understanding of the characteristics, pathophysiology, and implications of esophageal dysfunction following lung transplant.