High prevalence of gastroesophageal reflux in children after lung transplantation

Bronchiolitis obliterans and its clinical correlate bronchiolitis obliterans syndrome (BOS) are a major cause of morbidity and mortality following lung transplantation. Gastroesophageal reflux disease (GERD) may be a contributing factor for the development of BOS. Since 2002, all recipients of lung and heart-lung transplantation at our institution have been routinely investigated for GERD. In this observational study, we report on the prevalence of GERD in this population, including all pediatric patients undergoing single (SLTx) or double (DLTx) lung transplantation or heart-lung (HLTx) transplantation from January 2003-May 2004. GERD was assessed 3-6 months after transplantation by 24-hr pH testing. The fraction time (Ft) with a pH < 4 within a 24-hr period was recorded. Spirometry data, episodes of confirmed acute rejection, and demographic data were also collected. Ten transplant operations were performed: 4 DLTx, 1 SLTx, and 5 HLTx. Nine patients had cystic fibrosis. One patient had end-stage pulmonary disease secondary to chronic aspiration pneumonia and postadenovirus lung damage. Of 10 patients tested, 2 had severe GERD (Ft > 20%), 5 had moderate GERD (Ft 10-20%), 2 had mild GERD (Ft 5-10%), and 1 had no GERD. The only patient in this group with no GERD had a Nissen fundoplication pretransplant. All study patients were asymptomatic for GERD. All patients with episodes of rejection had moderate to severe GERD posttransplant. There was no association between severity of GERD and peak spirometry results posttransplant. Moderate to severe GERD is common following lung transplantation in children.     

Lung transplantation in patients with connective tissue disorders and esophageal dysmotility

SUMMARY. Lung and esophageal dysfunction are common in patients with connective tissue disease (CTD). Recent reports have suggested a link between pathologic gastroesophageal reflux and bronchiolitis obliterans syndrome (BOS) after lung transplant. Because patients with CTD have a high incidence of esophageal dysmotility and reflux, this group may be at increased risk of allograft dysfunction after lung transplantation. Little is known about antireflux surgery in these patients. Our aims were to describe: (i) the esophageal motility and reflux profile of patients with CTD referred for lung transplantation; and (ii) the safety and outcomes of laparoscopic fundoplication in this group. A retrospective review of 26 patients with CTD referred for lung transplantation between July 2003 and June 2007 at a single center. Esophageal studies included manometry and ambulatory 24‐h pH monitoring. Twenty‐three patients had esophageal manometry and ambulatory 24‐h pH monitoring. Nineteen patients (83%) had pathologic distal reflux and 7 (30%) also had pathologic proximal reflux. Eighteen patients (78%) had impaired or absent peristalsis. Eleven of 26 patients underwent lung transplantation. Ten patients are alive at a median follow‐up of 26 months (range 3–45) and one has bronchiolitis obliterans syndrome‐1. Six patients had a laparoscopic fundoplication, 1 before transplantation and 5 after. All fundoplication patients are alive at median follow‐up of 25 months (range 19–45). In conclusion, esophageal dysmotility and reflux are common in CTD patients referred for lung transplant. For this group, laparoscopic fundoplication is safe in experienced hands.     

Feasibility of esophagogastric junction distensibility measurement during Nissen fundoplication

Increased esophagogastric junction distensibility has been implicated in the development of gastroesophageal reflux disease (GERD). Previous authors have demonstrated a reduction in distensibility following anti‐reflux surgery, but the changes during the operation are not clear. Our study aimed to ascertain the feasibility of measuring intraoperative distensibility changes and to assess if this would have potential to modify the operation. Seventeen patients with GERD were managed in a standardized manner consisting of preoperative assessment with symptom scoring, endoscopy, 24 hours pH studies, and manometry. Patients then underwent laparoscopic Nissen fundoplication with intraoperative distensibility measurement using an EndoFLIP EF‐325 functional luminal imaging probe (Crospon Ltd, Galway, Ireland). This device utilizes impedance planimetry technology to measure cross‐sectional area and distensibility within a balloon‐tipped catheter. This is inflated at the esophagogastric junction to fixed distension volumes. Thirty‐second median cross‐sectional area and intraballoon pressure measurements were recorded at 30 and 40 mL balloon distensions. Measurement time points were initially after induction of anesthesia, after pneumoperitoneum, after hiatal mobilization, after hiatal repair, after fundoplication, and finally pre‐extubation. Postoperatively, patients continued on protocol and were discharged after a two‐night stay tolerating a sloppy diet. Patients with a hiatus hernia on high‐resolution manometry had a significantly higher initial esophagogastric junction distensibility index (DI) than those without. Hiatus repair and fundoplication resulted in a significant overall reduction in the median DI from the initial to final recordings (30 mL balloon distension reduction of 3.26 mm²/mmHg (P = 0.0087), 40 mL balloon distension reduction of 2.39 mm²/mmHg [P = 0.0039]). There was also a significant reduction in the DI after pneumoperitoneum, hiatus repair, and fundoplication at 40 mL balloon distension. Two individual cases in the series highlight the utility of the system in potentially changing the operation. After fundoplication, patient 7 recorded a DI of 0.47 mm²/mmHg, the lowest in our series, and subsequently required reoperation because of significant symptoms of dysphagia. Patient 12 had a fundoplication that appeared visually too tight and was converted intraoperatively to a Lind 270° wrap resulting in a change in the DI from 0.65 to 0.89 mm²/mmHg. Laparoscopic Nissen fundoplication results in a significant reduction in the distensibility of the esophagogastric junction. The EndoFLIP system is able to demonstrate significant changes during the operation and may help guide intraoperative modification. Larger multicenter studies with long‐term follow up would be beneficial to develop a target range of distensibility associated with good outcome.     

Tobramycin pharmacokinetics in patients with cystic fibrosis before and after bilateral lung transplantation

K.A. Walsh, G.A. Davis, D. Jr Hayes, R.J. Kuhn, K.A. Weant, J.D. Flynn. Tobramycin pharmacokinetics in patients with cystic fibrosis before and after bilateral lung transplantation.
Transpl Infect Dis 2011: 13: 616–621. All rights reserved Study objectives. To compare the pharmacokinetics (PK) of tobramycin in patients with cystic fibrosis (CF) before and after bilateral lung transplantation, in order to evaluate optimal dosing practices post transplant. Design. Retrospective, single‐center, chart review study, in which tobramycin concentrations from CF patients were used to calculate PK parameters, including elimination rate constant, half‐life, volume of distribution (Vd), area under the curve (AUC), and clearance before and after lung transplantation. Setting. Medical school‐affiliated teaching hospital. Patients. Eight patients with CF, who received a bilateral lung transplant from January 1, 2005 through August 1, 2009 (4 males, 4 females; mean age 26.3 years). Interventions. None. Main results. Sixty‐nine sets of pre‐ (n=52) and post transplant (n=17) tobramycin concentrations were available. PK parameters were significantly altered post transplant. Elimination rate constant decreased 38% from 0.26±0.1 to 0.16±0.1 h^‐1 (P<0.001), with a related increase of 200% in half‐life from 2.8±0.8 to 8.4±8.7 h (P<0.001). Clearance decreased 25% post transplant from 67.3±32.3 to 50.2±15.9 mL/min (P=0.04). No statistically significant change occurred in AUC or Vd after transplant, although a trend was seen toward increased Vd. Dosage requirements after transplantation were significantly lower, 10.7±2.5 and 7.6±1.6 mg/kg/day, pre and post transplant, respectively (P<0.001). Concentrations were also evaluated in 2 time periods: 0–3 weeks and ≥6 weeks post transplant, based on available data. Clearance and Vd ≥6 weeks post transplant did not significantly differ from pre‐transplant values (P=0.28 and 0.54, respectively), suggesting that these changes may be temporary. Conclusions. The results suggest that tobramycin PK are altered in patients with CF after bilateral lung transplantation, although no clear trend was seen owing to inter‐patient variability. We propose that PK parameters should be reassessed during each treatment course post transplant.     

Epidemiological investigation in outpatients with symptomatic gastroesophageal reflux from the Department of Medicine in Zhejiang Province, east China

Background and Aim: To elucidate the epidemiology of gastroesophageal reflux disease (GERD) symptoms in outpatients from the Department of Medicine in 10 hospitals in Zhejiang Province, east China. Methods: A cross‐sectional survey in the cluster random sample was conducted from November 2004 to June 2005 using a validated Chinese version of the reflux disease questionnaire and other items recording the demographic characteristics for GERD symptoms. The statistical analysis was performed with SPSS 13.0 programs. Results: A total of 15 283 outpatients from the Department of Medicine were investigated. The prevalence of GERD symptoms was 7.28% (95% confidence interval [CI], 6.87%, and 7.69%) with the prevalence rate increasing with age (P < 0.001), which was higher in men (7.79%, 95% CI: 7.20%, 8.38%) than in women (6.73%, 95% CI: 6.18%, 7.28%; χ² = 5.81, P < 0.05). The prevalence rate of the gastrointestinal symptoms in GERD symptoms, including epigastric discomfort, nausea, retrosternal pain, belching, globus sensation, loss of appetite, excessive salivation, vomiting, wheezing cough, weight loss, and dysphagia were all higher than the non‐GERD patients (P < 0.0001). In the GERD patients, the prevalence of diseases, such as pharyngolaryngitis, snoring, bronchitis, liver disease, and gallbladder disease were all higher than the non‐GERD patients (P < 0.01). The multiple logistic regression analysis showed that old age, night‐shift work, heavy work burdens, single or divorced people, increase intake of greasy or sweet foods, excessive eating, and constipation were independent risk factors associated with GERD symptoms. Conclusion: GERD has a high prevalence in China and its main associated factors include respiratory, laryngopharyngeal and dental disorders, sex, anthropometrical variables, and social–psychological characteristics.     

The effect of fundoplication on proliferative and anti-apoptotic activity of esophageal mucosa in gastroesophageal reflux disease: 4-year follow-up study

OBJECTIVE: The capacity of fundoplication to prevent esophageal adenocarcinoma is controversial. Development of cancer is associated with proliferation and anti‐apoptosis, for which little data exist as to their response to fundoplication. Therefore, we wanted to clarify the effect of fundoplication on the magnitude of Ki‐67 and B‐cell lymphoma 2 (Bcl‐2) during 48 months of follow up. METHODS: Ki‐67 and Bcl‐2 were assessed quantitatively from biopsies of the esophagogastric junction (EGJ) and from the distal and proximal esophagus of 20 patients with gastroesophageal reflux disease (GERD) treated by fundoplication. An upper gastrointestinal endoscopy was performed preoperatively and postoperatively at 6 months for 20 patients and 48 months for 16 patients, respectively. Ki‐67 and Bcl‐2 were compared to those of 7 controls. RESULTS: Compared to the preoperative level, Ki‐67 was elevated in the distal (P = 0.012) and proximal (P = 0.007) esophagus at 48 months. Compared to control values, Ki‐67 was lower at 6 months in the EGJ (P = 0.037) and the proximal esophagus (P = 0.003) and higher at 48 months in the distal esophagus (P = 0.002). Compared to control values, Bcl‐2 was lower at 6 months in the EGJ (P = 0.038). Correlations between Ki‐67 and Bcl‐2 were positive in the EGJ (P > 0.001) and in the distal (P = 0.001) and proximal esophagus (P = 0.013). CONCLUSION: Proliferative activity after fundoplication increased during long‐term follow up in the distal esophagus despite a normal fundic wrap and objective healing of GERD.     

Gastroesophageal Reflux in Cystic Fibrosis: Current Understandings of Mechanisms and Management

Cystic fibrosis (CF) is an inherited disease that affects both the lungs and the digestive system in children and adults. Thick mucus fills the gut and blocks lumens of the pancreas and hepatobiliary systems, creating insufficient pancreas function and liver disease. Chronic gastrointestinal (GI) complications, including intestinal obstruction, occur in neonates, and poor digestion and gastroesophageal reflux disease (GERD) in children. Although GI symptoms tend to improve with age, CF and associated GERD eventually create respiratory insufficiency; the only available treatment option at this stage is a bilateral lung transplant, which carries considerable morbidity and mortality. While GERD may reoccur as a complication of lung transplantation, GERD symptoms are often reduced following a fundoplication.     

Variation of health‐care resource utilization according to GERD‐associated complications

Complications associated with gastroesophageal reflux disease (GERD) can include esophageal stricture, Barrett's esophagus, gastrointestinal hemorrhage, and extraesophageal symptoms. The impact of GERD‐associated complications on health‐care utilization deserves further evaluation. We identified commercial enrollees 18–75 years old with claims for GERD (International Classification of Diseases, Ninth Revision, Clinical Modification Codes: 530.81 or 530.11) and subsequent usage of proton pump inhibitors from 01/01/05 to 06/30/09. The initial GERD diagnosis date was designated as the index date, and patients were studied for 6 months preindex and postindex. Eligible patients were subsequently stratified based on medical claims for GERD‐associated complications as follows: stage A (GERD diagnosis, no other symptoms), stage B (GERD + extraesophageal symptoms), stage C (GERD + Barrett's esophagus), stage D (GERD + esophageal stricture), and stage E (GERD + iron‐deficiency anemia or acute upper gastrointestinal hemorrhage). Patient characteristics, health‐care utilization, and costs were compared between stage A and each stage with complicated GERD (B–D). Of the 174,597 patients who were eligible for analysis, 74% were classified as stage A, 20% stage B, 1% stage C, 2% stage D, and 3% stage E. Relative to stage A, patients in stages C, D, and E were significantly more likely to visit a gastroenterologist (13% vs. 68%, 71%, and 38%, respectively) and had higher rates of esophageal ulcers (0.3% vs. 8%, 5%, and 3%, respectively) and Nissen fundoplication (0.05% vs. 0.6%, 0.3%, and 0.2%, respectively). Six‐month GERD‐related costs ranged from $615/patient (stage A) to $1714/patient (stage D); all‐cause costs ranged from $4195/patient (stage A) to $11,340/patient (stage E). Compared with stage A, all other cohorts had significantly higher all‐cause and GERD‐related costs (P < 0.0001 for all comparisons). While patients with more severe GERD represented a relatively small portion of the GERD cohort, they demonstrated significantly greater health‐care costs and overall utilization than patients with uncomplicated GERD.     

Endoluminal gastroplication for treatment of patients with classic gastroesophageal reflux symptoms and borderline 24‐h pH studies

Background: Patients with classic gastroesophageal reflux disease (GERD) symptoms and borderline 24‐h pH studies are not considered to be good candidates for surgical fundoplication. Endoluminal gastroplication (ELGP) is a new endoscopic treatment for patients with GERD. The aim of this study was to evaluate the efficacy of ELGP in these patients. Methods: Patients with heartburn, regurgitation symptoms and a DeMeester score of less than 30 were studied. ELGP involved placement of two or three plications within 2?cm of the gastroesophageal junction. Clinical outcomes measured were heartburn symptom score (HSS), regurgitation frequency score (RFS) and medication use. Results: Twenty‐five patients (11 M, 14 F, mean age of 51 years) had a medication use of 11.5 doses of proton‐pump inhibitors per week prior to ELGP. Average lower esophageal sphincter pressure measured 15?±?8?mmHg, and average DeMeester score was 18?±?8. Nine patients had hiatal hernias and 11 had esophagitis. Twenty‐four patients were available for a mean follow‐up of 12 months. HSS significantly decreased from 48 to 17 (P?P?P?Conclusions: Endoluminal gastroplication provides symptomatic relief for patients with classic GERD symptoms despite medical therapy and borderline 24‐h pH studies.     

Gastroesophageal reflux disease in children: efficacy of Nissen fundoplication in treating digestive and respiratory symptoms. Experience of a single center

Fundoplication has been commonly performed in neurologically impaired and normal children with complicated gastroesophageal reflux disease. The relationship between gastroesophageal reflux disease and respiratory diseases is still unclear. We aimed to compare results of open and laparoscopic procedures, as well as the impact of fundoplication over digestive and respiratory symptoms. From January 2000 to June 2007, 151 children underwent Nissen fundoplication. Data were prospectively collected regarding age at surgery, presence of neurologic handicap, symptoms related to reflux (digestive or respiratory, including recurrent lung infections and reactive airways disease), surgical approach, concomitant procedures, complications, and results. Mean age was 6 years and 9 months. Eighty‐two children (54.3%) had neurological handicaps. The surgical approach was laparoscopy in 118 cases and laparotomy in 33. Dysphagia occurred in 23 patients submitted to laparoscopic and none to open procedure (P = 0.01). A total of 86.6% of patients with digestive symptoms had complete resolution or significant improvement of the problems after the surgery. A total of 62.2% of children with recurrent lung infections showed any reduction in the frequency of pneumonias. Only 45.2% of patients with reactive airway disease had any relief from bronchospasm episodes after fundoplication. The comparisons demonstrated that Nissen fundoplication was more effective for the resolution of digestive symptoms than to respiratory manifestations (P = 0.04). Open or laparoscopic fundoplication are safe procedures with acceptable complication indices and the results of the surgery are better for digestive than for respiratory symptoms.     

Clinically distinct characteristics in patients younger than 40 years old with non-cardiac chest pain

Background and Aim: Little is known about non‐cardiac chest pain (NCCP) in young patients. We aimed to examine the proportion of gastroesophageal reflux disease (GERD) in young patients with NCCP compared to the average‐aged NCCP patients and to evaluate their symptomatic characteristics and the clinical efficacy of a 2‐week proton pump inhibitor (PPI) trial. Methods: Ninety‐six patients with NCCP ≥ 1/week were classified into the young‐aged (≤ 40 years, n = 38) and the average‐aged groups (> 40 years, n = 58). Typical reflux symptoms were assessed. The patients were defined into a GERD group and non‐GERD group according to reflux esophagitis on esophagogastroduodenoscopy and/or pathologic acid exposure on 24‐h esophageal pH monitoring. Then the patients were treated with 30 mg of lansoprazole bid for 14 days. Results: Nine patients (23%) in the young‐aged group and 22 patients (38%) in average‐aged group were diagnosed with GERD‐related NCCP (P = 0.144). The proportion of typical reflux symptoms was higher in the GERD group compared with the non‐GERD group in both age groups. A PPI test improved symptoms in the GERD group irrespective of age, but this improvement was not observed in non‐GERD group. Conclusions: In young NCCP patients, the prevalence of GERD was relatively low compared to average‐aged NCCP, but the difference was insignificant. The PPI test was very effective in diagnosing GERD in the NCCP patients in both age groups. Therefore, in young NCCP patients, if there is a negative response to a 2‐week PPI trial, the possibility of extra‐esophageal disease origin needs to be considered.     

Effect of acid‐suppressive therapy on narrow band imaging findings in gastroesophageal reflux disease: a pilot study

Standard endoscopy is an insensitive test for gastroesophageal reflux disease (GERD). Narrow band imaging (NBI) endoscopy enhances visualization of the distal esophagus. NBI patterns like intrapapillary capillary loop (IPCL) dilatation, tortuosity, and increased number; microerosions; increased vascularity at the squamocolumnar junction (SCJ); ridge‐villous pattern below the SCJ; and presence of columnar islands in the distal esophagus have been suggested as features of GERD. We evaluated the effect of proton pump inhibitor (PPI) therapy on NBI findings in GERD patients. Patients prospectively underwent NBI upper endoscopy before and after PPI therapy. NBI findings were recorded at each endoscopy. Twenty‐one patients with GERD symptoms (mean age 60.0 years; males 90.5%; white 90.5%) were studied. After PPI therapy, there was a significant reduction in the proportion of patients with the following NBI features: IPCL tortuosity (90% vs. 4.8%, P < 0.0001), dilated IPCLs (86% vs. 9.5%, P < 0.0001), and increased vascularity at the SCJ (43% vs. 9.5%, P= 0.0082). PPI led to healing of all microerosions (71% vs. 0%, P < 0.0001) and disappearance of ridge‐villous patterns below the SCJ (14% vs. 0%, P < 0.0001). There was no significant change in the proportion of patients with increased numbers of IPCLs pre‐ and post‐PPI therapy (71% vs. 48%, P= 0.09) or columnar islands in the distal esophagus (38% vs. 29%, P= 0.31). In patients with GERD symptoms, NBI features suggestive of GERD respond to PPI; suggesting these features are truly acid‐mediated. These findings need to be confirmed by randomized controlled trials.     

Short‐term and long‐term effect of diaphragm biofeedback training in gastroesophageal reflux disease: an open‐label,pilot, randomized trial

This study investigated the effectiveness of diaphragm biofeedback training (DBT) for patients with gastroesophageal reflux disease (GERD). A total of 40 patients with GERD treated at the Peking Union Medical College Hospital between September 2004 and July 2006 were randomized to receive DBT and rabeprazole proton pump inhibitor (PPI) or rabeprazole alone. The DBT + rabeprazole group received DBT during the 8‐week initial treatment; the rabeprazole group did not. During the 6‐month follow up, all patients took acid suppression according to their reflux symptoms, and the patients in the DBT + rabeprazole group were required to continue DBT. The primary outcome (used for power analysis) was the amount of acid suppression used at 6 months. Secondary outcomes were reflux symptoms, health‐related quality of life (HRQL), and esophageal motility differences after the 8‐week treatment compared with baseline. Acid suppression usage significantly decreased in the DBT + rabeprazole group compared with the rabeprazole group at 6 months (P < 0.05). At 8 weeks, reflux s ymptoms and GERD‐HRQL were significantly improved in both groups (P < 0.05), without difference between them. Crural diaphragm tension (CDT) and gastroesophageal junction pressure (GEJP) significantly increased in the DBT + rabeprazole group (P < 0.05), but without change in lower esophageal sphincter (LES) pressure. There was no significant change in CDT, GEJP, and LES pressure compared with baseline in the rabeprazole group. In conclusion, long‐term DBT could reduce acid suppression usage by enhancing the anti‐reflux barrier, providing a non‐pharmacological maintenance therapy and reducing medical costs for patients with GERD.     

Twice‐daily proton pump inhibitor therapy does not decrease the frequency of reflux episodes during nocturnal recumbency in patients with refractory GERD: analysis of 200 patients using multichannel intraluminal impedance–pH testing

Over half of patients with gastroesophageal reflux disease (GERD) report nocturnal symptoms. Proton pump inhibitors (PPIs) are the main medications used to treat GERD. Multichannel intraluminal impedance with pH (MII‐pH) monitoring is the most sensitive method for detection and characterization of GERD. The aim of this study was to assess and compare reflux frequency in patients with refractory GERD symptoms on and off PPI therapy during the nocturnal recumbent period, as assessed by MII‐pH testing. We analyzed 24‐hour MII‐pH studies performed in 200 patients monitored either on twice‐daily (n = 100) or off (n = 100) PPI therapy. Demographic analysis of the on‐therapy group revealed a mean age of 52 years (24–78 years) with 37% males, and the off‐therapy group revealed a mean age of 49 years (18–84 years) with 40% males. All studies were interpreted to assess and characterize the number of acid and nonacid reflux episodes in the nocturnal recumbent period identified by each patient on an overnight recorder (Zephyr, Sandhill Scientific, Inc., Highlands Ranch, CO, USA). The nocturnal recumbent period was the period documented by patients during which they lie in the recumbent period at night to sleep with average periods lasting 456 and 453 minutes for patients on and off PPI therapy. There were more mean recumbent reflux episodes in the on‐therapy group in comparison with the off‐therapy group (3.76 mean reflux episodes [mre] per patient in the recumbent vs. 2.82 mre); the difference was not statistically significant (P = 0.187). When the reflux events are classified into acid and non‐acid reflux episodes, the relative occurrence of acid reflux events is less in the on‐therapy group (P = 0.047), while the off‐therapy group have fewer nonacid reflux episodes (P = 0.003). PPIs decrease the acidity of esophageal refluxate but do not decrease the relative frequency of reflux episodes in the recumbent position in patients with refractory GERD despite twice‐a‐day treatment with PPI therapy. The explanation for the finding of numerically increased, although not statistically significant, amount of reflux episodes in the PPI treatment group in this study, and previous studies is unclear and warrants further evaluation.     

Safety and efficacy of an implantable device for management of gastroesophageal reflux in lung transplant recipients

BackgroundMagnetic sphincter augmentation (MSA) is a promising minimally invasive surgical technique for management of gastroesophageal reflux disease (GERD); however, device implantation after transplantation has not been studied and may be concerning in these immunosuppressed patients. We explored the safety of the LINX Reflux Management System (MSA device) for management of GERD following lung transplantation (LTx).MethodsLung transplant recipients who underwent LINX implantation at our institution between 2017 and 2019 were followed prospectively in the Reflux Following Lung Transplantation and Associated Treatment Registry. Ambulatory pH testing and acid-suppressing medication use were compared before and after LINX implantation. One-year outcomes and change in pulmonary function were compared between matched LINX and fundoplication groups.ResultsOf 17 patients who underwent post-lung transplant LINX implantation, 8 (47.1%) agreed to undergo post-LINX pH testing. Three/eight (37.5%) patients achieved normal esophageal acid exposure time; 14 (82.4%) remained on acid-suppressing medication at one-year under the direction of their transplant teams. One-year patient survival and change in pulmonary function were similar between groups. LINX patients experienced more early side effects.ConclusionsUse of the LINX MSA device in a cohort of lung transplant recipients at our institution was associated with similar short-term safety compared to traditional fundoplication, however assessment of efficacy was limited. Further investigation is needed to characterize the long-term efficacy of LINX implantation after LTx.     

Lung transplantation in IIP: A review

The idiopathic interstitial pneumonias (IIP) encompass a large and diverse subtype of interstitial lung disease (ILD) with idiopathic pulmonary fibrosis (IPF) and non‐specific interstitial pneumonia (NSIP) being the most common types. Although pharmacologic treatments are available for most types of IIP, many patients progress to advanced lung disease and require lung transplantation. Close monitoring with serial functional and radiographic tests for disease progression coupled with early referral for lung transplantation are of great importance in the management of patients with IIP. Both single and bilateral lung transplantation are acceptable procedures for IIP. Procedure selection is a complex decision influenced by multiple factors related to patient, donor and transplant centre. While single lung transplant may reduce waitlist time and mortality, the long‐term outcomes after bilateral lung transplantation may be slightly superior. There are numerous complications following lung transplantation including primary graft dysfunction, chronic lung allograft dysfunction (CLAD), infections, gastroesophageal reflux disease (GERD) and airway disease that limit post‐transplant longevity. The median survival after lung transplantation is 4.7 years in patients with ILD, which is less than in patients with other underlying lung diseases. Although long‐term survival is limited, this intervention still conveys a survival benefit and improved quality of life in suitable IIP patients with advanced lung disease and chronic hypoxemic respiratory failure.     

The influence of gastroesophageal reflux in the lung: A case–control study

Background and objective: Many researchers have investigated the pH of exhaled breath condensate but direct measurement of pH in the lung has not been performed in vivo in humans. We hypothesized that the pH measured directly in the lung would differ between healthy subjects and patients with gastroesophageal reflux disease (GERD). We also wished to determine whether an acidic environment in the lung influences pulmonary function and DL_CO, and whether microaspiration of gastric contents directly influences non‐specific inflammation in the lung. Methods: The patients were otherwise healthy individuals who had been newly diagnosed with GERD. The control subjects were mostly volunteers who underwent bronchoscopy for different reasons. For all subjects (n = 63) a medical history was taken, and physical examination, oesophagogastroduodenoscopy, fibre‐optic bronchoscopy and pulmonary function testing were performed. Results: In patients with GERD the average pH in the lung was 5.13 ± 0.43; this was significantly lower than the pH in the lung of controls 6.08 ± 0.39 (P = 0.001). Patients with GERD had lower FEV₁% (P = 0.035), PEF (P = 0.001), FEF_50% (P = 0.002) and FEF_25% (P = 0.003), while the differences in FVC% and FEF_75% were not significant. DL_CO (P = 0.003), as well as transfer coefficient of the lung (P = 0.001), was lower in patients with GERD. LDH levels in bronchoalveolar aspirate were higher in the patients with GERD (P = 0.001). Conclusions: This study found evidence of cell and tissue injury in the lung, a lowering of pH and higher bronchoalveolar aspirate LDH levels in patients with GERD compared with healthy subjects. These findings suggest that pulmonary function, and especially DL_CO, should be evaluated in patients presenting with GERD.     

Laparoscopic Heller's cardiomyotomy achieved lesser recurrent dysphagia with better quality of life when compared with endoscopic balloon dilatation for treatment of achalasia

Achalasia is a rare primary motility disorder of esophagus; treatments include endoscopic balloon dilatation (EBD) and laparoscopic Heller's cardiomyotomy (LC). This study compared EBD versus LC for treatment of achalasia with focus on quality of life (QoL) and prevalence of post‐treatment gastroesophageal reflux disease. This was a retrospective cohort study of all patients diagnosed with achalasia older than 16 treated with either EBD or LC from January 1998 to April 2008. Patients' demographic data, comorbidities, postintervention GERD symptoms, QoL, recurrence of dysphagia, reintervention rate, hospital stay, and time to resumption of diet were collected. Sixty‐eight patients were recruited into the study (EBD n= 50; LC n= 18). A significant improvement in QoL was found in patients undergoing LC (0.917 vs. 0.807, P= 0.006). A higher proportion of patients treated with EBD developed post‐treatment gastroesophageal reflux symptoms (60.5% vs. 43.8%) when compared with LC, although statistically insignificant (P= 0.34). Patients treated with balloon dilatation had a greater percentage of recurrence of dysphagia (55.1% vs. 26.7%; P= 0.235) and need of reintervention (42.1% vs. 9.1%; P= 0.045). However, these patients had a shorter median hospital stay (1d [range 0–4]) and earlier resumption of diet (0d [range 0–3]). Although EBD is associated with a quicker perioperative recovery, LC accomplished a better QoL, lower incidence of recurrence of dysphagia, and need of reintervention after treatment for achalasia.     

Diagnostic value of dilated intercellular space and histopathologic scores in gastroesophageal reflux disease

The aim of this paper is to investigate the diagnostic value of histopathologic score and the dilated intercellular space (DIS) in patients with gastroesophageal reflux disease (GERD) and functional heartburn (FH). Participants with GERD symptoms including reflux esophagitis, non‐erosive reflux disease (NERD), Barrett's esophagus (BE), functional heartburn (FH), along with a control group with atypical GERD‐like symptom (Sym‐C), and asymptomatic healthy volunteers (H‐C) were administered GERD questionnaire, and subjected to endoscopy and biopsies, as well as 24‐hour pH‐impedance monitoring. Biopsies were evaluated using standards from the 2011 Esohisto Project after Hematoxylin‐Eosin staining. DIS was measured quantitatively under light microscopy. Among the total of 565 participants with qualified biopsy specimens, the mean DIS of the reflux esophagitis (RE) group was significantly wider compared with the other five groups. DIS in patients with GERD‐like symptoms was significantly wider compared with the H‐C. No significant differences were observed between NERD and FH. Results from 24‐hour pH‐impedance monitoring indicated that only the DIS of patients with acid reflux or the amount of acid reflux episodes in patients with DIS was significantly wider compared with patients with nonacid reflux or patients without DIS (P < 0.001). With DIS = 0.9 μm as the cutoff value, the sensitivity and specificity were 62.6% and 54.1%, respectively. Using the total histopathologic score > 3 as the diagnostic criterion, the sensitivity and specificity were 71.7% and 47.4%. DIS is closely associated with GERD and acid reflux. The diagnostic value of histological scores in lower esophagus in GERD is very similar to that of the quantitative measurement of DIS.     

Esophageal pH and bile monitoring for detecting duodenogastroesophageal reflux and evaluating the effectiveness of treatment

OBJECTIVE: To study methods of diagnosing duo­denogastroesophageal reflux (DGER) and to evaluate the role of bile reflux in gastroesophageal reflux disease (GERD). METHODS: Simultaneous 24‐h esophageal mucosal bilirubin level and pH monitoring were performed in 20 healthy subjects and 52 patients with symptoms suggesting gastroesophageal reflux. Data were gathered by using an ambulatory duodenogastric reflux monitoring system (Bilitec 2000) and an ambulatory pH recorder (Digitrapper MKIII). An absorbance value of ≥0.14 was designated as the threshold value for the presence of bile reflux. Patients suffering from mixed pathological reflux of acid and bile were treated with hydrotalcite and cisapride for 4 weeks, then the monitoring was repeated. RESULTS: No pathological acid reflux was found in the 20 healthy subjects. Based on findings from 24‐h esophageal pH monitoring, 47 of 52 patients (including 12 with esophagitis) were found to have patho­logical reflux. The total fraction of time with bile reflux was greater in the patients (n = 52) than in the healthy subjects (n = 20; 2.67 ± 3.23%vs 0.47 ± 0.71%; P < 0.05) and was greater in the patients with esophagitis (n = 12) than in the patients without esophagitis (n = 35; 5.41 ± 4.93%vs 1.68 ± 1.76%; P < 0.05). Of the 47 patients with GERD, 15 (32%) had abnormal mixed acid and bile reflux. Eight of the 15 patients with esophagitis were found to have mixed reflux and only four of 32 had acid reflux only (P < 0.05). After treatment with hydrotalcite and cisapride, the total fraction of time with acid and bile reflux in the 15 patients with mixed reflux decreased significantly (P < 0.05). Esophagitis was cured in seven of eight patients. CONCLUSION: The ambulatory duodenogastric reflux monitoring system is a useful tool for detecting DGER and evaluating the efficacy of treatment. Approximately 32% (15/47 cases) of patients with GERD were found to have DGER. Bile reflux may play a significant role in causing esophageal mucosal damage in patients suffering from GERD.