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

OBJECTIVES: Gastro-oesophageal reflux disease after lung transplantation may be associated with chronic lung allograft dysfunction. Aspiration may continue on medical management of reflux, but antireflux surgery potentially reduces all reflux. We compared outcomes between medical and surgical management of reflux in lung recipients. METHODS: Lung recipients with an elevated DeMeester score (≥14.72) on post-transplant reflux testing between 2015 and 2020 were included. Patients were divided into 2 groups: group A (underwent surgery) and group B (medically managed). Endpoints were pulmonary function, allograft dysfunction-free survival and overall survival. Further analysis included subgroups: A1 (early surgery, <6 months) and A2 (late surgery, >6 months), and B1 (DeMeester <29.9) and B2 (DeMeester ≥30). RESULTS: A total of 186 included subjects were divided into groups A [n = 46 (A1, n = 36; A2, n = 10)] and B [n = 140 (B1, n = 78; B2, n = 62)]. Compared to medically managed patients, patients who underwent surgery had a higher prevalence of hiatal hernia (P < 0.001) and a lower prevalence of oesophageal motility disorders (P = 0.036). Recipients who underwent surgery had superior pulmonary function at 5 years compared to group B (P < 0.05) and longer allograft dysfunction-free survival than subgroup B2 (P = 0.028). Furthermore, early surgery was associated with longer survival than late surgery (P = 0.021). CONCLUSIONS: Antireflux surgery in recipients with reflux improved long-term allograft function, and early surgery showed a survival benefit. Allograft dysfunction-free survival of lung recipients who underwent surgery was significantly better than that of medically managed patients with DeMeester ≥30. We present an algorithm for appropriate selection of candidates for antireflux surgery after lung transplantation.

Morbidity of antireflux surgery in lung transplant and matched nontransplant cohorts is comparable.

BACKGROUND: Safety data on perioperative outcomes of laparoscopic antireflux surgery (LARS) after lung transplantation (LT) are lacking. We compared the 30-day readmission rate and short-term morbidity after LARS between LT recipients and matched nontransplant (NT) controls. METHODS: Adult patients who underwent LARS between January 1, 2015, and October 31, 2021, were included. The participants were divided into two groups: LT recipients and NT controls. First, we compared 30-day readmission rates after LARS between the LT and NT cohorts. Next, we compared 30-day morbidity after LARS between the LT cohort and a 1-to-2 propensity score-matched NT cohort. RESULTS: A total of 1328 patients (55 LT recipients and 1273 NT controls) were included. The post-LARS 30-day readmission rate was higher in LT recipients than in the overall NT controls (14.5% vs. 2.8%, p < 0.001). Compared to matched NT controls, LT recipients had a lower prevalence of paraesophageal hernia, a smaller median hernia size, and higher peristaltic vigor. Also compared to the matched NT controls, the LT recipients had a lower median operative time but a longer median length of hospital stay. The proportion of patients with a post-LARS event within 30 postoperative days was comparable between the LT and matched NT cohorts (21.8% vs 14.5%, p = 0.24). CONCLUSIONS: Despite a higher perceived risk of comorbidity burden, LT recipients and matched NT controls had similar rates of post-LARS 30-day morbidity at our large-volume center with expertise in transplant and foregut surgery. LARS after LT is safe.

Esophageal aperistalsis and lung transplant: Recovery of peristalsis after transplant is associated with improved long-term outcomes.

OBJECTIVE: Esophageal aperistalsis has been considered a relative contraindication for lung transplant because of a higher risk of allograft dysfunction secondary to reflux and aspiration induced by poor esophageal clearance. We previously reported that esophageal motility improves in some patients after lung transplant. We reviewed the clinical course of lung transplant recipients diagnosed with an aperistaltic esophagus on pretransplant testing. METHODS: We identified patients diagnosed with pretransplant aperistaltic esophagus on high-resolution manometry who underwent lung transplant. Recipients with normal esophageal motility before lung transplant were used as the propensity score-matched control group. High-resolution manometry was repeated after lung transplant, and patients with aperistalsis were further divided into 2 subgroups: improved esophageal peristalsis and nonimproved peristalsis (ie, persistent aperistalsis after lung transplant). RESULTS: Esophageal aperistalsis was seen in 31 patients (mean age, 59.0 years; 21 men). The 1-, 3-, and 5-year post-lung transplant survivals in the aperistalsis group were 80.6%, 51.2%, and 34.9%, respectively, which was significantly lower than in the control group (90.3%, 73.4%, and 58.8%, respectively; P = .038). Post-lung transplant high-resolution manometry was performed for 29 patients in the aperistalsis group, 19 of whom demonstrated improved esophageal motility (65.5%). The 1-, 3-, and 5-year survivals after lung transplant of patients with recovery of peristalsis were similar to those of the control group (89.5%, 65.0%, and 48.8%, respectively; P = 1.000), whereas the nonimproved peristalsis group had lower survival (80.0%, 36.0%, and data unavailable, respectively; P = .012). CONCLUSIONS: Esophageal aperistalsis is not necessarily a contraindication for lung transplant. Improved peristalsis can be expected in up to two-thirds of these patients and is associated with good outcomes.

Foregut function before and after lung transplant.

BACKGROUND: Esophageal dysmotility and gastroesophageal reflux disease are common in patients with advanced lung disease and can potentially affect outcomes of lung transplant; however, the effects of lung transplant on foregut function remain unknown. We assessed foregut function before and after bilateral lung transplant. METHODS: We attempted complete foregut function testing before and after lung transplant. We compared patients with obstructive lung disease and patients with restrictive lung disease who underwent lung transplant between 2015 and 2016. RESULTS: In total, 112 patients met inclusion criteria. The mean age of patients was 62.2 years, and 62 patients were men. A total of 51 patients (45.5%) were diagnosed with obstructive lung disease, and 56 patients (50.0%) were diagnosed with restrictive lung disease. Approximately half of these patients had a change in manometric diagnosis before and after lung transplant, with most achieving increased peristaltic vigor. Pre-lung transplant gastroesophageal reflux disease was more prevalent in the restrictive lung disease cohort than in the obstructive lung disease cohort (42.9% vs 19.6%, P = .010). Thoracoabdominal pressure gradient before lung transplantation was greater in the restrictive lung disease group than in the obstructive lung disease group (23.4 vs 14.7 mm Hg, P < .001), which may explain the mechanism of increased reflux in patients with restrictive lung disease. No differences were seen in the post-lung transplant prevalence of pathological reflux and thoracoabdominal pressure gradient between groups. CONCLUSIONS: Esophageal motility and reflux parameters vary significantly between patients with obstructive lung disease and patients with restrictive lung disease, and can be explained by differences in underlying pulmonary dynamics. Restoring pulmonary physiology after lung transplant ameliorates the effects of esophageal dysmotility and reflux. Improved peristaltic vigor after lung transplant in patients with hypomotility is important, which may make them eligible for antireflux surgery if gastroesophageal reflux disease persists after lung transplant.

Successful Lung Re-transplant in a Patient with Cepacia Syndrome due to Burkholderia ambifaria.

Chronic airway inflammation and infection drive morbidity and mortality among patients with cystic fibrosis (CF). While Haemophilus influenzae and Staphylococcus aureus predominate in children, the prevalence of Pseudomonas aeruginosa increases as patients age. Other bacteria, including species within the Burkholderia cepacia complex (Bcc), are also more prevalent among adults with CF. Species within the Bcc accelerate lung function decline and can trigger development of "cepacia syndrome," both before and after lung transplantation. As a result, some centers advise against lung transplantation for Bcc-infected patients; however, little is known about the relative virulence of uncommon Bcc species. We describe a successful lung re-transplant in a patient with CF, chronic Burkholderia ambifaria airway infection, and cepacia syndrome.

Primary paraesophageal hernia repair with Gore® Bio-A® tissue reinforcement: long-term outcomes and association of BMI and recurrence.

BACKGROUND: Laparoscopic repair remains the gold-standard treatment for paraesophageal hernia (PEH). We analyzed long-term symptomatic outcomes and surgical reintervention rates after primary PEH repair with onlay synthetic bioabsorbable mesh (W. L. Gore & Associates, Inc., Flagstaff, AZ) and examined body mass index (BMI) as a possible risk factor for poor outcomes and for recurrence. METHODS: We queried a prospectively maintained database to identify patients who underwent laparoscopic primary PEH repair with onlay patch of a bioprosthetic absorbable mesh (Bio-A® Gore®) between 05/28/2009 and 12/31/2013. Electronic health records were accessed to record demographic and operative data and were reviewed up to the present to identify any repeat procedures. Patients were grouped according to preoperative BMI (A: BMI < 25; B: BMI = 25-29.9; C: BMI = 30-34.9; D: BMI ≥ 35). Patients completed standardized satisfaction and symptom surveys. RESULTS: In total, 399 patients were included. Most patients (n = 261; 65.4%) were women. Mean age was 59.6 ± 13.4 years; mean BMI was 29.9 ± 5.0 kg/m2. The patients were grouped as follows: A, 53 patients (13.3%); B, 166 (41.6%); C, 115 (28.8%); D: 65 (16.3%). Four procedures (1.0%) were converted from laparoscopy to open procedures. All patients underwent an antireflux procedure (225 Nissen, 170 Toupet, 4 Dor). A mean follow-up of 44.7 ± 22.8 months was available for 305 patients (76.4%). 24/305 patients (7.9%) underwent reoperation, and the number of reoperations did not differ among groups (P = 0.64). Long-term symptomatic outcomes were available for 217/305 patients (71.1%) at a mean follow-up of 54.0 ± 13.1  months; no significant difference was observed among groups. 194/217 patients (89.4%) reported good to excellent satisfaction, with no significant differences among the groups. CONCLUSIONS: Laparoscopic primary PEH repair with onlay Bio-A® mesh is a safe and feasible procedure with excellent long-term patient-centered outcomes and acceptable symptomatic recurrence rate. BMI does not appear to be related to the need for surgical reintervention.

Coexistent Non-Small Cell Carcinoma and Small Cell Carcinoma in a Patient Presenting with Hyponatremia.

Despite recent advances in screening methods, lung cancer remains the leading cause of cancer-related deaths worldwide. By the time lung cancer becomes symptomatic and patients seek treatment, it is often too advanced for curative measures. Low-dose computed tomography (CT) screening has been shown to reduce mortality in patients at high risk of lung cancer. We present a 66-year-old man with a 50-pack-year smoking history who had a right upper lobe (RUL) pulmonary nodule and left lower lobe (LLL) consolidation on a screening CT. He reported a weight loss of 45 pounds over 3 months, had recently been hospitalized for hyponatremia, and was notably cachectic. A CT of the chest showed a stable LLL mass-like consolidation and a 9 × 21 mm subsolid lesion in the RUL. Navigational bronchoscopy biopsy of the RUL lesion revealed squamous non-small cell lung cancer (NSCLC). Endobronchial ultrasound-guided transbronchial needle aspiration of the LLL lesion revealed small cell lung cancer (SCLC). The final diagnosis was a right-sided Stage I NSCLC (squamous) and a left-sided limited SCLC. The RUL NSCLC was treated with stereotactic radiation; the LLL SCLC was treated with concurrent chemotherapy and radiation. In patients with multiple lung nodules, a diagnosis of synchronous multiple primary lung cancers (MPLCs) is crucial, as inadvertent upstaging of patients with MPLC (to T3 and/or T4 tumors) can lead to erroneous staging, inaccurate prognosis, and improper treatment. Recent advances in the diagnosis of small pulmonary nodules via navigational bronchoscopy and management of these lesions dramatically affect a patient's overall prognosis.

Early fundoplication is associated with slower decline in lung function after lung transplantation in patients with gastroesophageal reflux disease.

OBJECTIVES: Gastroesophageal reflux disease (GERD) is prevalent after lung transplantation. Fundoplication slows lung function decline in patients with GERD, but the optimal timing of fundoplication is unknown. METHODS: We retrospectively reviewed patients who underwent fundoplication after lung transplantion at our center from April 2007 to July 2014. Patients were divided into 2 groups: early fundoplication (<6 months after lung transplantation) and late fundoplication (≥6 months after lung transplantation). Annual decline in percent predicted forced expiratory volume in 1 second (FEV1) was analyzed. RESULTS: Of the 251 patients who underwent lung transplantation during the study period with available pH data, 86 (34.3%) underwent post-transplantation fundoplication for GERD. Thirty of 86 (34.9%) had early fundoplication and 56 of 86 (65.1%) had late fundoplication. Median time from lung transplantation to fundoplication was 4.6 months (interquartile range, 2.0-5.2) and 13.8 months (interquartile range, 9.0-16.1) for the early and late groups, respectively. The median DeMeester score was comparable between groups. One-, 3-, and 5-year actuarial survival rates in the early group were 90%, 70%, and 70%, respectively; in the late group, these rates were 91%, 66%, and 66% (log rank P = .60). Three- and 5-year percent predicted FEV1 was lower in the late group by 8.9% (95% confidence interval, -30.2 to 12.38; P = .46) and 40.7% (95% confidence interval, -73.66 to -7.69; P = .019). A linear mixed model showed a 5.7% lower percent predicted FEV1 over time in the late fundoplication group (P < .001). CONCLUSIONS: In this study, patients with early fundoplication had a higher FEV1 5 years after lung transplantation. Early fundoplication might protect against GERD-induced lung damage in lung transplant recipients with GERD.

Treatment of Barrett's esophagus with early neoplasia: a comparison of endoscopic therapy and esophagectomy.

BACKGROUND: Endoscopic therapies for early neoplasia in Barrett's esophagus may be a viable alternative to esophagectomy. OBJECTIVE: Our purpose was to compare endoscopic therapy and esophagectomy. DESIGN: Retrospective review from a single institution. SETTING: A medium-sized tertiary referral center. PATIENTS AND INTERVENTIONS: All patients with Barrett's esophagus and dysplasia or intramucosal carcinoma treated by photodynamic therapy (PDT), EMR, or argon plasma coagulation (APC) or esophagectomy with curative intent from May 1998 until November 2005. MAIN OUTCOME MEASUREMENTS: Survival, progression to cancer, eradication of dysplasia and Barrett's esophagus, major and minor complications, and costs were compared. RESULTS: Sixty-two patients who underwent endoscopic therapy (2 APC alone, 18 EMR + APC, 20 PDT + APC, and 22 EMR + PDT + APC) and 32 patients who underwent esophagectomy met the inclusion criteria. The 30-day mortality rate included 1 patient in the endotherapy group (2%) and none in the surgical group (P = .49). No deaths from esophageal cancer occurred in either group. Cancer developed in 6% of endotherapy patients and in none in the surgical cohort (P < .05). Major and minor complications occurred in 8% and 31% of endotherapy patients, respectively, and 13% and 63% of surgery patients (P = .50, P < .001). Median cost to date was $40,079 for endotherapy and $66,060 for esophagectomy (P < .001). LIMITATIONS: Retrospective study, relatively short follow-up, small numbers. CONCLUSIONS: Both endotherapy and esophagectomy can effectively treat high-grade dysplasia and intramucosal carcinoma associated with Barrett's esophagus. Endotherapy is associated with a higher risk of tumor progression, although this is uncommon. Esophagectomy incurs higher initial costs and results in more frequent minor complications but is usually curative.

Outcomes after resection of cholangiocellular carcinoma.

BACKGROUND: Cholangiocellular carcinoma (CCC) is a rare primary liver malignancy that arises from intrahepatic bile duct canaliculi and presents as a liver mass. Our purpose is to report operative morbidity and mortality and to determine long-term survival after resection for CCC. METHODS: Retrospective review of 31 consecutive patients who underwent resection during a 20-year period. RESULTS: Thirty-day hospital mortality was 3%, and postoperative morbidity was 38%. Kaplan-Meier 5-year survival was 35%; mean survival was 37 months; absolute 5-year survival was 33%. Mean survival in stages I, II, IIIA, and IIIC were 57, 33, 26, and 14 months, respectively (P = 0.03 comparing I to >I). Recurrence occurred in 18 patients; 89% were in the liver. Carbohydrate antigen 19-9 >100 U/mL was found to be an indicator of poor prognosis (P = 0.009). CONCLUSIONS: Resection for CCC can be performed with acceptable morbidity and mortality rates and results in good survival and cure. Hepatic recurrence is common. Carbohydrate antigen 19-9 may be useful in determining prognosis.