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GERDing Against Poor Lung Transplant Outcomes
Gastroesophageal reflux disease (GERD) is a chronic digestive disorder describing the flow of stomach contents back into the esophagus. This happens when the muscle at the bottom of the esophagus doesn't close properly. Fundoplication—a surgical procedure that treats GERD by wrapping the upper part of the stomach around the esophagus —tightens the connection between the stomach and esophagus thereby preventing stomach acid from coming back up.
One population at increased risk of GERD is lung transplant recipients. Studies show that up to 75% of lung transplant patients have GERD, which can lead to microaspiration and decreased overall allograft function and survival. Studies also show that a history of lung transplantation doesn’t bode well for recovery from fundoplication. Therein lies the dilemma.
Min Peter Kim, MD
Historically, laparoscopic fundoplication in patients with a history of lung transplantation has an average length of stay of three days with a 30-day readmission rate of 25%, which is significantly poorer than that in non-lung transplant populations. Houston Methodist researchers led by Min Peter Kim, MD, David M. Underwood Distinguished Professor of Surgery in Digestive Health, wanted to determine whether enhanced recovery after a robotic-assisted surgery program would mitigate these risks.
“In a practice setting with full implementation of enhanced recovery after robotic-assisted laparoscopic surgery and with a high volume of both lung transplant and foregut surgery, we wanted to explore whether a history of lung transplantation is still a risk factor for poor short-term surgical outcomes,” said Kim.
The study was a single-center retrospective analysis of the Society of Thoracic Surgery database for patients who underwent elective antireflux procedures, from January 1, 2018 to February 2, 2021, under the enhanced recovery after surgery program using robotic assistance. Among 386 patients who underwent fundoplication, 41 had history of either a bilateral (n=28) or single (n=13) lung transplant.
The results indicate there were no significant differences in postoperative complications, median hospital length-of-stay or 30-day readmission. While bivariate analysis showed that advanced age, history of deep vein thrombosis/pulmonary embolism, history of cerebrovascular events, opioid dependence, neurocognitive dysfunction, and dependent functional status were associated with postoperative complications, lung transplantation had no such association.
Patients with a history of lung transplantation have significantly more comorbidities, which would be expected to lead to a higher post-operative complication rate as seen historically in the absence of enhanced recovery after surgery (ERAS). The results are promising and merit further investigation. Studies with statistically powerful sample sizes are needed to confirm that there is no significant difference between these groups as well as to assign correlation between implementation of the ERAS protocol and improved post-surgical outcomes.