Fundoplication after lung transplantation prevents the allograft dysfunction associated with reflux

Abstract

Background: Gastroesophageal reflux disease (GERD) in lung recipients is associated with decreased survival and attenuated allograft function. This study evaluates fundoplication in preventing GERD-related allograft dysfunction.

Methods: Prospectively collected data on patients who underwent transplantation between January 2001 and August 2009 were included. Lung transplant candidates underwent esophageal pH probe testing before transplantation and surveillance spirometry evaluation after transplantation. Bilateral lung transplant recipients who had pretransplant pH probe testing and posttransplant 1-year forced expiratory volume in the first second of expiration (FEV1) data were included for analysis.

Results: Of 297 patients who met study criteria, 222 (75%) had an abnormal pH probe study before or early after transplantation and 157 (53%) had a fundoplication performed within the first year after transplantation. Patients with total proximal acid contact times greater than 1.2% or total distal acid contact times greater than 7.0% demonstrated an absolute decrease of 9.4% (±4.6) or 12.0% (±5.4) in their respective mean 1-year FEV1 values. Patients with abnormal acid contact times who did not undergo fundoplication had considerably worse predicted peak and 1-year FEV1 results compared with recipients receiving fundoplication (peak percent predicted=75% vs. 84%; p=0.004 and 1-year percent predicted=68% vs. 77%; p=0.003, respectively).

Conclusions: Lung transplant recipients with abnormal esophageal pH studies attain a lower peak allograft function as well as a diminished 1-year FEV1 after transplantation. However a strategy of early fundoplication in these recipients appears to preserve lung allograft function.

Fig 1

Relationship of total proximal acid contact time to the mean percent predicted 1-year forced expiratory volume in first second of expiration (FEV₁). Notably, the mean 1-year FEV₁ decreases with total proximal acid contact times greater than 1.2%.

Fig 2

Acid contact time threshold for predicting allograft dysfunction was determined. Using 1.2% for total proximal acid contact times and 7% for total distal acid contact, clear distinctions were noted in both 1-year and peak forced expiratory volume in first second of expiration (FEV₁) values.

Fig 3

One-way analysis of variance demonstrating a significant difference between the GERD and No GERD and GERD and FUNDO groups for 1-year (A) and peak (B) FEV₁. In neither instance was a difference noted between the No GERD and FUNDO groups.(FUNDO = fundoplicaion; GERD = gastroesophaeal reflux disease.)