Division of Thoracic Surgery and Lung Transplant, Columbia University Medical Center, New York, New York.
Division of Pulmonary, Allergy, and Critical Care Medicine, Columbia University Medical Center, New York, New York.
Ann Thorac Surg. 2022 Jun;113(6):1801-1810. doi: 10.1016/j.athoracsur.2021.05.098. Epub 2021 Jul 16.
Gastroesophageal reflux disease (GERD) and aspiration of enteric contents are associated with worse outcomes after lung transplantation. The purpose of this study was to elucidate populations of patients who benefit the most from fundoplication after lung transplantation.
Lung transplantations from 2001 to 2019 (n = 971) were retrospectively reviewed and stratified by fundoplication before (n = 128) or after (n = 24) chronic lung allograft dysfunction (CLAD) development vs patients who did not undergo fundoplication. Patients with a fundoplication before CLAD were propensity matched to patients without a fundoplication. The primary outcome of interest was posttransplant survival. Time-to-event rates were calculated using a multivariable Cox proportional hazards model and Kaplan-Meier functions.
Fundoplication before CLAD improved posttransplant survival before and after propensity matching, and it remained a significant predictor after adjusting for baseline characteristics (hazard ratio [HR],0.57; 95 % confidence interval [CI], 0.4 to 0.8; P = .001). Transplant recipients with a restrictive disorder (HR, 0.46; 95 % CI, 0.3 to 0.73; P = .001), age younger than 65 years (HR, 0.48; 95 % CI, 0.32 to 0.71; P < ;0.001), and with both single (HR, 0.47; 95 % CI, 0.28 to 0.79; P = .005) and double (HR, 0.55; 95 % CI, 0.32 to 0.93; P = .027) lung transplants had a significant decrease in mortality after fundoplication. The effect was present after excluding early deaths and CLAD diagnoses. Gastroesophageal reflux disease diagnosed by pH, impedance, or esophagogastroduodenoscopy was not associated with worse outcomes. Among patients with CLAD, a fundoplication was an independent predictor of post-CLAD survival (HR, 0.27; 95 % CI; 0.12 to 0.61; P = .002).
Fundoplication before or after CLAD development is an independent predictor of survival. Younger patients with restrictive disease, independent of the type of transplant, have a survival benefit. Gastroesophageal reflux disease diagnosed by conventional methods was not associated with worse survival.
胃食管反流病（GERD）和肠内容物吸入与肺移植后预后较差有关。本研究旨在阐明哪些患者从肺移植后胃底折叠术（fundoplication）中获益最多。
回顾性分析了 2001 年至 2019 年的肺移植患者（n=971），根据慢性肺移植物功能障碍（CLAD）发展前（n=128）或发展后（n=24）接受 fundoplication 以及未接受 fundoplication 进行分层。CLAD 前接受 fundoplication 的患者与未接受 fundoplication 的患者进行倾向匹配。主要观察指标为移植后生存情况。使用多变量 Cox 比例风险模型和 Kaplan-Meier 函数计算时间事件率。
CLAD 前的 fundoplication 改善了移植前和移植后的生存，并且在调整基线特征后仍然是一个显著的预测因素（风险比 [HR]，0.57；95%置信区间 [CI]，0.4 至 0.8；P=0.001）。限制性疾病（HR，0.46；95%CI，0.3 至 0.73；P=0.001）、年龄小于 65 岁（HR，0.48；95%CI，0.32 至 0.71；P<0.001）、单肺（HR，0.47；95%CI，0.28 至 0.79；P=0.005）和双肺（HR，0.55；95%CI，0.32 至 0.93；P=0.027）移植的患者，在接受 fundoplication 后死亡率显著降低。在排除早期死亡和 CLAD 诊断后，该效果仍然存在。通过 pH、阻抗或食管胃十二指肠镜检查诊断的胃食管反流病与不良结局无关。在 CLAD 患者中，fundoplication 是 CLAD 后生存的独立预测因素（HR，0.27；95%CI，0.12 至 0.61；P=0.002）。
CLAD 前后的 fundoplication 是生存的独立预测因素。患有限制性疾病的年轻患者，无论移植类型如何，都有生存获益。通过常规方法诊断的胃食管反流病与生存不良无关。
