Early Fundoplication is Associated With Slower Decline in Lung Function After Lung Transplantation in Patients With Gastroesophageal Reflux Disease
Sreeja Biswas Roy1, Cassandra Haworth2, Shaimaa Elnahas1, Rosemarie Serrone3, Michael T Olson4, Paul Kang5, *A. Samad Hashimi1, *Michael A Smith1, *Ross M Bremner1, *JASMINE HUANG1
1Norton Thoracic Institute, PHOENIX, AZ;2A.T. Still University, PHOENIX, AZ;3St. Joseph's Hospital and Medical Center, PHOENIX, AZ;4Grand Canyon University, PHOENIX, AZ;5University of Arizona College of Public Health, PHOENIX, AZ
OBJECTIVES: Gastroesophageal reflux disease (GERD) is prevalent after lung transplantation in patients with end-stage lung disease. Fundoplication is known to slow decline in lung function in patients with GERD, but the optimal timing of fundoplication is unknown. METHODS: We retrospectively reviewed patients who underwent fundoplication after lung transplantation at our center between April 2007 and July 2014. Patients were divided into two groups: early fundoplication (within six months of lung transplantation) and late fundoplication. Wilcoxon rank sum and Fisher's exact tests were used for continuous and categorical variables, respectively. Actuarial survival at one, three, and five years was estimated using the Kaplan-Meier method. A linear mixed model was used to analyze decline in % predicted forced expiratory volume in one second (FEV1) yearly after lung transplantation. RESULTS: In total, 84 of 273 (30.8%) patients underwent fundoplication for GERD after lung transplantation; 29 patients (34.5%) had early fundoplication; 55 patients (65.5%) had late fundoplication. The median time from lung transplantation to fundoplication was 4.7 months (2.2, 5.2) and 13.8 months (9, 16.1) for the early and late groups, respectively. The early fundoplication group had higher lung allocation scores (p=0.006) and lower body mass indexes (p=0.027) compared to the late fundoplication group. Age, sex, and type of fundoplication were comparable for both groups. Median acid exposure time in the distal pH channel increased from 101 minutes (52.7, 147.7) pre-transplant to 144.9 minutes (87.5, 173.9) pre-fundoplication in the early group, and from 58.6 minutes (12.9, 125.6) to 147 minutes (86, 244.8) in the late group. The late fundoplication group had a higher median DeMeester score (111 versus 62; p=0.004). One-year, three-year, and five-year survival rates in the early group were 93%, 65%, and 44%; in the late group, these rates were 90%, 70%, and 46% (log-rank p=0.60). A higher proportion of patients in the late group had one or more episodes of acute rejection after fundoplication (30.9% versus 13.8%; p=0.085). Three-year and five-year % predicted FEV1 was lower in the late group by 7.5% (95% CI [-27.6, 12.58], p=0.46) and 40.7 % (95% CI [-68.5, -12.8], p=0.004; Figure 1). A linear mixed model showed a 3.6% lower % predicted FEV1 over time in the late fundoplication group (p=0.587). CONCLUSIONS: The severity of GERD appears to increase after lung transplantation. Early fundoplication may slow the rate of lung function decline after transplantation. In this study, patients with early fundoplication had a higher FEV1 five years after transplantation and fewer episodes of acute rejection. Early fundoplication may protect against GERD-induced lung damage in transplant recipients with GERD.
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