Laparoscopic anti-reflux surgery for idiopathic pulmonary fibrosis at a single centre

Abstract

We sought to assess whether laparoscopic anti-reflux surgery (LARS) is associated with decreased rates of disease progression in patients with idiopathic pulmonary fibrosis (IPF).The study was a retrospective single-centre study of IPF patients with worsening symptoms and pulmonary function despite antacid treatment for abnormal acid gastro-oesophageal reflux. The period of exposure to LARS was September 1998 to December 2012. The primary end-point was a longitudinal change in forced vital capacity (FVC) % predicted in the pre- versus post-surgery periods.27 patients with progressive IPF underwent LARS. At time of surgery, the mean age was 65 years and mean FVC was 71.7% pred. Using a regression model, the estimated benefit of surgery in FVC % pred over 1 year was 5.7% (95% CI -0.9-12.2%, p=0.088) with estimated benefit in FVC of 0.22 L (95% CI -0.06-0.49 L, p=0.12). Mean DeMeester scores decreased from 42 to 4 (p<0.01). There were no deaths in the 90 days following surgery and 81.5% of participants were alive 2 years after surgery.Patients with IPF tolerated the LARS well. There were no statistically significant differences in rates of FVC decline pre- and post-LARS over 1 year; a possible trend toward stabilisation in observed FVC warrants prospective studies. The ongoing prospective randomised controlled trial will hopefully provide further insights regarding the safety and potential efficacy of LARS in IPF.

Gastroesophageal Reflux Disease in Idiopathic Pulmonary Fibrosis: Uncertainties and Controversies

“…Some previous studies have supported this hypothesis by reporting the detection of gastric contents (acids and pepsin) in the bronchoalveolar lavage fluid (BALF) of patients with IPF [9, 10]; such microaspiration may stimulate the fibroproliferative responses of the lung at molecular and cellular levels [11, 12]. Furthermore, some studies found that both antacid drugs and antireflux surgery were potentially beneficial to patients with IPF [1, 2, 13], although some other studies do not agree with this claim [14, 15]. In addition, antacid drugs are recommended by the most recent international guideline [2]; however, some recent national IPF guidelines are more hesitant on this recommendation, which reflects the controversies concerning this issue [16, 17].…”

“…Another study reported that laparoscopic antireflux surgery (LARS) did not influence 6-min walk distance, FEV 1 %, FVC%, or DL CO % as predicted, but that it may stabilize or reduce oxygen requirements over the 15-month average follow-up in patients with IPF [78]. In a more recent study, 27 patients with IPF who underwent LARS were reviewed to find that LARS was well tolerated with no perioperative death, which resulted in improved acidic reflux and stabilized, if not improved, FVC [13]. These results have mostly been derived from small-size retrospective cohort studies, which limit their collective validity.…”

Pharmacotherapy for idiopathic pulmonary fibrosis: current landscape and future potential

“…While recent perspectives on the topic discuss the potential and prospects of the antifibrotic properties of proton pump inhibitors (PPIs), several questions regarding the use of PPIs and antiacid treatment need to be answered [11,12]. In a recent retrospective study, the safety of laparoscopic antireflux surgery in patients with IPF demonstrating abnormal acid gastro-oesophageal reflux (GOR), and a trend to slow the rate of decline in FVC over a year were demonstrated [13]. It is hoped that the ongoing prospective RCT "WRAP-IPF" (ClinicalTrials.gov NCT01982968) will provide useful results and insights regarding the treatment of IPF with surgical correction of abnormal acid GOR or antiacids in patients with IPF.…”

Gastro-oesophageal reflux and idiopathic pulmonary fibrosis: in search of evidence

“…In this edition of the European Respiratory Journal, RAGHU et al [22] report their unique experience on a series of IPF patients with worsening symptoms and pulmonary function, despite antacid therapy for abnormal GOR, and treatment with laparoscopic anti-reflux surgery (LARS). First, they report that the procedure was generally safe as there were no acute exacerbations of IPF in the post-operative period and no deaths in the 90-day period after LARS; the majority (81.5%) of patients were still alive 2 years after surgery.…”