The protective role of laparoscopic antireflux surgery against aspiration of pepsin after lung transplantation

Abstract

Background The goal of this study was to determine, in lung transplant patients, if laparoscopic antireflux surgery (LARS) is an effective means to prevent aspiration as defined by the presence of pepsin in the bronchoalveolar lavage fluid (BALF). Methods Between September 2009 and November 2010, we collected BALF from 64 lung transplant patients at multiple routine surveillance assessments for acute cellular rejection, or when clinically indicated for diagnostic purposes. The BALF was tested for pepsin by enzyme-linked immunosorbent assay (ELISA). We then compared pepsin concentrations in the BALF of healthy controls (n = 11) and lung transplant patients with and without gastroesophageal reflux disease (GERD) on pH-monitoring (n = 8 and n = 12, respectively), and after treatment of GERD by LARS (n = 19). Time to the development of bronchiolitis obliterans syndrome was contrasted between groups based on GERD status or the presence of pepsin in the BALF. Results We found that lung transplant patients with GERD had more pepsin in their BALF than lung transplant patients who underwent LARS (P = .029), and that pepsin was undetectable in the BALF of controls. Moreover, those with more pepsin had quicker progression to BOS and more acute rejection episodes. Conclusion This study compared pepsin in the BALF from lung transplant patients with and without LARS. Our data show that: (1) the detection of pepsin in the BALF proves aspiration because it is not present in healthy volunteers, and (2) LARS appears effective as a measure to prevent the aspiration of gastroesophageal refluxate in the lung transplant population. We believe that these findings provide a mechanism for those studies suggesting that LARS may prevent nonallogenic injury to the transplanted lungs from aspiration of gastroesophageal contents.

An international ISHLT/ATS/ERS clinical practice guideline: diagnosis and management of bronchiolitis obliterans syndrome

“…Nissen fundoplication and Toupet fundoplication) can be performed safely on lung transplant candidates with advanced lung disease or lung transplant recipients with documented abnormal GOR [123,124,[127][128][129][132][133][134][135][136][137][138], thereby preventing reflux, aspiration of gastric secretions and related sequelae.…”

The Intersection of GERD, Aspiration, and Lung Transplantation

“…They categorized those who had aspiration as those who had any pepsin in their BALF (pepsin was undetectable in the BALF of controls) and found that lung transplant patients with LARS had minimal pepsin levels in their BALF. 23 Davis et al studied 128 patients who had esophageal function tests after lung transplantation. 24 Among these, 43 patients underwent LARS, while the other patients served as controls.…”

Silent gastro-oesophageal reflux and microaspiration in IPF: mounting evidence for anti-reflux therapy?

“…Indeed, pepsin in BAL fluid may well be considered a biomarker of microaspiration and may be useful to assess the efficacy of anti-reflux therapy. Pepsin or bile salts could be monitored in BAL fluid to determine the efficacy of anti-reflux surgical interventions such as fundoplication, as has been reported in lung transplant recipients with lung allograft dysfunction [31].…”