Introduction
For many patients with restrictive and obstructive lung disease the only proven intervention to improve survival and quality of life is lung transplantation (LTx). Esophageal dysmotility and gastroesophageal reflux (GER) are common in patients with respiratory disease, and often associate with worse prognosis following LTx (1,2). Which, if any patients, should be excluded from transplantation due to GER remains unclear.
Aims & Methods
Aim: To examine the changes in esophageal motor function (Chicago Classification v4.0) and association with GER following LTx in patients based on pre-LTx restrictive or obstructive lung disease.
Methods: High-resolution impedance esophageal manometry (HRIM) and 24hr impedance-pH (MII-pH) were performed in 57 respiratory patients (40 restrictive disease, 17 obstructive disease) before and after LTx (mean age 60 yrs (range 33-75 yrs), 39 males) between November 2016 and October 2022.
Results
Restrictive disease: Before LTx, 15 (38%) patients exhibited abnormal motility, with the majority presenting with either ineffective esophageal motility (IEM) (8, 53%) or esophagogastric junction outflow obstruction (EGJOO) (6, 40%). One patient had distal esophageal spasm and the rest (25, 63%) normal motility. Following LTx, approximately half of patients (21, 53%) retained the same diagnosis as pre-LTx. Patients with normal motility pre-LTx were more likely to retain the same diagnosis (i.e. normal) post-LTx (17/25, 68%) than those with an abnormal motility diagnoses (4/15, 27%)(p=0.021), particularly those with EGJOO(1/6, 17%)(p=0.059). Nine of 15 (60%) patients with abnormal motility pre-LTx changed to normal motility post-LTx.
Obstructive disease: Before LTx, 8 (47%) patients exhibited abnormal motility, with the majority exhibiting EGJOO (4, 50%). The rest exhibited either IEM (2, 25%), absent motility (1, 12.5%) or hypercontractility (1, 12.5%). Nine (53%) exhibited normal motility. Following LTx, about half (10, 59%) retained the same diagnoses, but patients with normal motility (5/9, 56%) were no more likely to retain the same diagnoses as those with abnormal motility (5/8, 63%). Only one of eight (12.5%) patients with abnormal motility changed to normal motility post-LTx, which is lower than that seen in patients with restrictive disease (p=0.07). Examination of the pH findings revealed that although acid exposure time (AET) was similar pre-LTx (restrictive 2.4(0.7-7.0) v obstructive 2.0(0.5-3.4); p=0.53), there was a decrease in AET in restrictive patients (1.7(0.3-3.5);p=0.05) but no change in patients with obstructive disease (3.7(0.6-10.1)p=0.31) post-LTx. Of note, mean nocturnal baseline impedance (5cm above the LES) was similar pre-LTx (1750(1139-2705)ohms v 1799(1058-2540)ohms) and increased in restrictive patients (2480(1511-4413)ohms; p=0.002) but not in those with obstructive disease (1732(1173-2293)ohms; p=0.82), mirroring changes in AET.
Conclusion
Patients with restrictive lung disease are more likely to retain a diagnosis of normal motility or change to normal motility post-LTx than patients with obstructive lung disease. This appears to associate with improved acid exposure time and mean nocturnal baseline impedance. Further data are required on long-term outcome.
References
- Houghton LA, Lee AS, Badri H, DeVault KR, Smith JA. Respiratory disease and the oesophagus: reflux, reflexes and microaspiration. Nat Rev Gastroenterol Hepatol 2016; 13(8); 445-60
- Chan WW, Ahuja N, Fisichella PM, Gavini S, Rangan V, Vela MF. Extraesophageal syndrome of gastroesophageal reflux: relationships with lung disease and transplantation outcome. Ann N Y Acad Sci 2020; 1482: 95-105