Antireflux surgery versus medical management of gastro-oesophageal reflux after lung transplantation

Razia, Deepika; Mittal, Sumeet K.; Fournier, Sarah; Walia, Rajat; Smith, Michael A.; Bremner, Ross M.; Huang, Jasmine

doi:10.1093/ejcts/ezad063

Cited by 7 publications

(6 citation statements)

References 23 publications

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“…This requires a multidisciplinary patient management and combined expertise across the multifaceted clinical manifestations of SSc to mitigate the triggers and to stabilize/improve the respiratory function. Alternatively, it is possible that a wellstandardized laparoscopic antireflux procedure performed in the early disease stages may provide safer and near-optimal reflux control by repairing the hiatal hernia and augmenting the LES pressure [37][38][39][40][41]. This may in turn halt the progression of interstitial lung damage and avoid later lung transplantation.…”

Section: K Original Article Discussionmentioning

confidence: 99%

Toupet fundoplication to prevent progression of scleroderma-associated interstitial lung damage: a study protocol

Aiolfi,

Bona,

Manara

et al. 2024

Eur Surg

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Summary Background Systemic sclerosis (SSc) is a rare autoimmune and multiorgan disorder. Hallmarks of the disease include inflammation, endothelial dysfunction, and dysregulation of fibroblasts leading to fibrosis of the skin and internal organs. The esophagus is often involved, with up to 80% of patients developing gastroesophageal reflux disease (GERD). Reflux can be associated with hiatal hernia and several complications such as erosive esophagitis, peptic stricture, Barrett’s esophagus, aspiration pneumonia, and chronic microaspiration. Silent aspiration can lead to interstitial lung disease (ILD) in up to 50% of patients with scleroderma and accounts for up to 40% of mortality. Treatment of GERD in patients with SSc is challenging. Proton pump inhibitors (PPI) have been shown effective in relieving typical GERD symptoms, but up to 40% of patients are non-responders. Various antireflux surgical procedures have been proposed to treat GERD and to modify the natural course of the disease by preventing lung damage in these patients. However, current algorithms consider only the degree of esophageal dilation as a marker of disease severity/progression, and results of antireflux surgery remain controversial. Methods We propose a feasibility, observational, multicenter, single-arm trial including adult patients diagnosed with SSc. Criteria for inclusion are individuals with GERD symptoms refractory to PPI, absence of peptic stricture at baseline endoscopy, high-resolution computed tomography (HRCT) scan showing no or less than 10% lung fibrosis, forced vital capacity at least 40% of the predicted value, and diffusing capacity of lung for carbon monoxide 30–89% of the predicted value. A laparoscopic partial posterior fundoplication according to the Toupet technique will be performed. Primary study outcome is the efficacy of fundoplication to reduce reflux exposure measured with a pH-impedance study or 4‑day wireless pH recording. Secondary outcomes include endoscopic, HRCT, and respiratory function tests findings as well as quality of life at 12-month follow-up. Conclusions The expected reduction of reflux burden in SSc patients selected for Toupet fundoplication may improve GERD symptoms/complications, pulmonary function, and quality of life, and may be associated with a reduced risk for lung transplant.

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Section: K Original Article Discussionmentioning

confidence: 99%

Toupet fundoplication to prevent progression of scleroderma-associated interstitial lung damage: a study protocol

Aiolfi,

Bona,

Manara

et al. 2024

Eur Surg

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“…Recent studies have demonstrated a relationship between GERD and lung transplant outcomes, including acute and chronic rejection [ 20 ]. Razia et al [ 21 ] compared outcomes between surgical and medical management of reflux in lung transplant recipients with an elevated DeMeester score and found that anti-reflux surgery in recipients with reflux improved long-term allograft function, and early surgery showed a survival benefit. In our study, we only evaluated preoperative GERD and did not assess postoperative GERD or antireflux surgery, which could have influenced the results.…”

Section: Discussionmentioning

confidence: 99%

Impact of gastro-jejunostomy tube in lung transplant patients: a propensity-matched analysis

Furukawa,

Chan,

Ryan

et al. 2023

Interdisciplinary CardioVascular and Thoracic Surgery

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Objectives During the postoperative phase of lung transplantation, the surgical creation of a gastro-jejunostomy may be deemed necessary for patients with severe esophageal dysmotility, prolonged oral intake difficulties stemming from use of a ventilator or marked malnutrition. We explored the effects of postoperative gastro-jejunostomy tube on survival and bronchiolitis obliterans syndrome in lung transplant recipients. Methods We retrospectively reviewed all lung transplants performed at our institution between 2011 and 2022. Propensity score matching was performed to match patients who required a gastro-jejunostomy tube with control patients on a 1:1 ratio. The preoperative, operative, and postoperative outcomes of the patients were evaluated. Results After propensity score matching, 193 patients with gastro-jejunostomy were compared to 193 patients without gastro-jejunostomy. Patients with gastro-jejunostomy had significantly higher rates of delayed chest closure (p = 0.007), and postoperative dialysis (p = 0.016), longer intensive care unit stays (p < 0.001), longer ventilator duration (p < 0.001), higher rates of pneumonia (p = 0.035) and higher rates of being treated for acute cellular rejection within one year of transplant (p = 0.008). Overall survival and freedom from bronchiolitis obliterans syndrome were not found to be significantly different between the matched groups (p = 0.09 and p = 0.3). Conclusions Gastro-jejunostomy tube placement during the postoperative phase of lung transplantation did not compromise patient survival or freedom from bronchiolitis obliterans syndrome although the results reflect more difficult and complicated cases. This study indicates that the gastro-jejunostomy tube may be a useful option for enteral feeding. Institutional review board number and date of approval STUDY20050181: 6/15/2020

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“…30 Lastly, anti-reflux surgery has been proven to reduce the proinflammatory effects of GRASP, reduce CLAD, and improve survival, although randomized controlled clinical trials are lacking. 31,32…”

Section: Grasp In Cf Ltxmentioning

confidence: 99%

The foregut in cystic fibrosis

Vélez,

Neuringer,

Schwarzenberg

2024

Pediatric Pulmonology

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The aerodigestive organs share a kindred embryologic origin that allows for a more complete explanation as to how the foregut can remain a barrier to normalcy in people with cystic fibrosis (pwCF). The structures of the aerodigestive tract include the nasopharynx, the oropharynx, the hypopharynx, the esophagus, the stomach, as well as the supraglottic, glottic, and subglottic tubular airways (including the trachea). Additional gastrointestinal (GI) luminal/alimentary organs of the foregut include the duodenum. Extraluminal foregut structures include the liver, the gall bladder, the biliary tree, and the pancreas. There are a variety of neurologic controls within these complicated anatomic compartments to separate the transit of food and liquid from air. These structures share the same origin from the primitive foregut/mesenchyme. The vagus nerve is a critical structure that unites respiratory and digestive functions. This article comments on the interconnected nature of cystic fibrosis and the GI tract. As it relates to the foregut, this has been typically treated as simple “reflux” as the cause of worsened lung function in pwCF. That terms like gastroesophageal reflux (GER), gastroesophageal reflux disease (GERD), heartburn, and regurgitation are used interchangeably to reflect pathology further complicates matters; we offer a more physiologically accurate term called “GI‐related aspiration” or “GRASP.” Broadly, this term reflects that aspiration of foregut contents from the duodenum through the stomach to the esophagus, into the pharynx and the respiratory tree in pwCF. As a barrier to normalcy in pwCF, GRASP is fundamentally two disease processes—GERD and gastroparesis—that likely contribute most to the deterioration of lung disease in pwCF. In the modulator era, successful GRASP management will be critical, particularly in those post‐lung transplantation (LTx), only through successful management of both GERD and gastroparesis. Standardization of clinical management algorithms for GRASP in CF‐related GRASP is a key clinical and research gap preventing normalcy in pwCF; what exists nearly exclusively addresses surgical evaluations or offers guidance for the management of GI symptoms alone (with unclear parameters for respiratory disease considerations). We begin first by describing the result of GRASP damage to the lung in various stages of lung disease. This is followed by a discussion of the mechanisms by which the digestive tract can injure the lungs. We summarize what we anticipate future research directions will be to reduce the impact of GRASP as a barrier to normalcy in pwCF.

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Antireflux surgery versus medical management of gastro-oesophageal reflux after lung transplantation

Cited by 7 publications

References 23 publications

Toupet fundoplication to prevent progression of scleroderma-associated interstitial lung damage: a study protocol

Toupet fundoplication to prevent progression of scleroderma-associated interstitial lung damage: a study protocol

Impact of gastro-jejunostomy tube in lung transplant patients: a propensity-matched analysis

The foregut in cystic fibrosis

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