Treatment of Gastroesophageal Reflux Disease After Lung Transplant Using Radiofrequency Ablation to the Lower Esophageal Sphincter (Stretta Procedure)

Abstract

Background

Gastroesophageal reflux disease (GERD) is associated with chronic lung allograft dysfunction after lung transplant. Treating GERD after lung transplant has been shown to improve lung allograft function. This case series describes the efficacy of the Stretta procedure to control GERD after lung transplant at our institution.

Methods

Eleven patients underwent the Stretta procedure at our institution for GERD after lung transplant during the years 2016-2017. Pre- and post-Stretta reflux parameters were gathered. Pulmonary function was followed up until subsequent fundoplication surgery, death, or end of study observation.

Results

Reflux on esophagram was noted in 9 patients before Stretta and 8 patients after Stretta. The median number of acid reflux events was 31.5 vs. 26 after Stretta (P = .95), and median percent time in reflux was 17.7% before vs. 14.5% after Stretta (P = .76). Median DeMeester score before Stretta was 65.5 (range: 33.2-169.8) vs. 42.5 (range: 19.2-109.8) after the procedure (P = .14). Median lower esophageal resting pressure was 20.7 mm Hg (n = 7) compared to 25.9 mm Hg (n = 9) on post-Stretta follow-up (P = .99). Median FEV₁% predicted was 84% (41-97%) before compared to 71% (23-108%) at 1 year after the procedure (P = .14). Seven patients required fundoplication surgery for continued reflux. All patients were on triple immunosuppression, most commonly prednisone, tacrolimus, and mycophenolate (n = 9).

Discussion

The Stretta procedure did not provide expected results at our institution after lung transplant surgery. Based on our limited series, we do not recommend routine use of the Stretta procedure for management of GERD in lung transplant patients.

Keywords

endoscopy lungs gastrointestinal

Get full access to this article

View all access options for this article.

References

Christie

Edwards

Kucheryavaya

, et al. The registry of the international society for heart and lung transplantation: 29th adult lung and heart-lung transplant report-2012. J Heart Lung Transplant. 2012;31(10):1073-1086. doi:10.1016/j.healun.2012.08.004

Verleden

Glanville

Lease

, et al. Chronic lung allograft dysfunction: Definition, diagnostic criteria, and approaches to treatment―A consensus report from the pulmonary council of the ISHLT. J Heart Lung Transplant. 2019;38(5):493-503. doi:10.1016/j.healun.2019.03.009

Sweet

Herbella

FAM

Leard

, et al. The prevalence of distal and proximal gastroesophageal reflux in patients awaiting lung transplantation. Ann Surg. 2006;124(4):156-162. doi:10.1097/01.sla.0000237757.49687.03

Blondeau

Mertens

Vanaudenaerde

, et al. Gastro-oesophageal reflux and gastric aspiration in lung transplant patients with or without chronic rejection. Eur Respir J. 2008;31(4):707-713. doi:10.1183/09031936.00064807

Mertens

Dupont

Sifrim

. Relevance of GERD in lung transplant patients. Curr Gastroenterol Rep. 2010;12(3):160-166. doi:10.1007/s11894-010-0106-3

W-K

Goldberg

Boukedes

Burakoff

Chan

. Proton pump inhibitors independently protect against early allograft injury or chronic rejection after lung transplantation. Dig Dis Sci. 2018;63(2):403-410. doi:10.1007/s10620-017-4827-0

Hartwig

Anderson

Onaitis

, et al. Fundoplication after lung transplantation prevents the allograft dysfunction associated with reflux. Ann Thorac Surg. 2011;92(2):462-469. doi:10.1016/j.athoracsur.2011.04.035

Hoppo

Jarido

Pennathur

, et al. Antireflux surgery preserves lung function in patients with gastroesophageal reflux disease and end-stage lung disease before and after lung transplantation. Arch Surg. 2011;146(9):1041-1047. doi:10.1001/archsurg.2011.216

Pearl

Pauli

Dunkin

Stefanidis

. SAGES endoluminal treatments for GERD. Surg Endosc. 2017;31(10):3783-3790. doi:10.1007/s00464-017-5639-1

10.

Lipka

Kumar

Richter

. No evidence for efficacy of radiofrequency ablation for treatment of gastroesophageal reflux disease: A systematic review and meta-analysis. Clin Gastroenterol Hepatol. 2015;13(6):1058-1067. doi:10.1016/j.cgh.2014.10.013

11.

Fass

Cahn

Scotti

Gregory

. Systematic review and meta-analysis of controlled and prospective cohort efficacy studies of endoscopic radiofrequency for treatment of gastroesophageal reflux disease. Surg Endosc. 2017;31(12):4865-4882. doi:10.1007/s00464-017-5431-2

12.

Perry

Banerjee

Melvin

. Radiofrequency energy delivery to the lower esophageal sphincter reduces esophageal acid exposure and improves GERD symptoms. Surg Laparosc Endosc Percutan Tech. 2012;22(4):283-288.

13.

Harris

Taylor

Thielke

Payne

Gonzalez

Conde

. Research electronic data capture (REDCap)-A metadata-driven methodology and workflow process for providing translational research informatics support. J Biomed Inf. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010

14.

Noar

Lotfi-Emran

. Sustained improvement in symptoms of GERD and antisecretory drug use: 4-year follow-up of the stretta procedure. Gastrointest Endosc. 2007;65(3):367-372. doi:10.1016/j.gie.2006.11.015

15.

Dughera

Navino

Cassolino

, et al. Long-term results of radiofrequency energy delivery for the treatment of GERD: Results of a prospective 48-month study. Diagn Ther Endosc. 2011;2011:507157. doi:10.1155/2011/507157

16.

Noar

Squires

Noar

Lee

. Long-term maintenance effect of radiofrequency energy delivery for refractory GERD: A decade later. Surg Endosc. 2014;28(8):2323-2333. doi:10.1007/s00464-014-3461-6

17.

Wang

Armstrong

. Corticosteroids and wound healing: clinical considerations in the perioperative period. Am J Surg. 2013;206(3):410-417. doi:10.1016/j.amjsurg.2012.11.018

18.

Houston

Khaitan

Holzman

Richards

. First year experience of patients undergoing the stretta procedure. Surg Endosc. 2003;17(3):401-404. doi:10.1007/s00464-002-8923-6

19.

Dundon

Karlowicz

Domingo

Muscarella II

Melvin

. Delivery of radiofrequency energy to the lower esophageal sphincter improves symptoms of gastroesophageal reflux. Surgery. 2004;136(4):786-794. doi:10.1016/j.surg.2004.07.006

20.

Kilic

Shah

Merlo

Gourin

Lidor

. Early outcomes of antireflux surgery for United States lung transplant recipients. Surg Endosc. 2013;27(5):1754-1760. doi:10.1007/s00464-012-2674-9

21.

Tian

Wang

Shan

Zhang

Jiang

Qiu

. A meta-analysis of randomized controlled trials to compare long-term outcomes of Nissen and Toupet fundoplication for gastroesophageal reflux disease. PloS One. 2015;10(6):e0127627. doi:10.1371/journal.pone.0127627