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Ann Thorac Surg 2006;82:1570-1571
© 2006 The Society of Thoracic Surgeons
Toronto Lung Transplant Program, Toronto General Hospital, 200 Elizabeth St 9N-946, Toronto, ON, Canada M5G 2C4
(Email: shaf.keshavjee{at}uhn.on.ca).
We agree with the statement by Sweet and colleagues [1] that the pathogenesis of gastroesophageal reflux (GER) in patients with end-stage lung disease remains unclear.
With regard to the specific question from Sweet we did not observe any significant correlation or association between the data related to gastric emptying and that from pH testing. Although it should be noted that the tests were not done concomitantly, and ideally, to obtain the appropriate answers a timed investigation should be undertaken. Posttransplant we have noted a prevalence of abnormally delayed gastric emptying for solids in 90% of patients at 3 months after transplantation (nonpublished data). This obviously supports the role of lung transplantation as one of the causes of gastroparesis as indicated by the recent American Gastroenterology Association classification [2]. In general we use prokinetic agents as part of the postoperative drug regimen for our transplant patients, and we are currently investigating the role of gastric pacing to improve gastric emptying in severe cases.
As to the lower prevalence of GER in our patients compared with the data published by the Duke University group, a possible explanation may relate the fact that their report is a retrospective analysis of a smaller and nonconsecutive case series [3, 4]. We do not have an explanation regarding the prevalence in the 25 patients with pulmonary fibrosis patients in our series, which we recognize is definitely lower than what has been recently reported by Raghu and colleagues in a prospective study on 133 patients [3, 5].
Our routine washout from anti-acid medications is 7 days for proton pump inhibitors. The patients are covered with H-2 blockers for 5 days and left with no treatment for the last 2 days [6]. The Duke University group also suggests a washout period before pH studies of at least 5 days for proton pump inhibitor and 24 hours for H-blockers while Raghu and colleagues allowed their patients to remain on their ongoing medical therapy during the pH testing [4, 5].
Our observations in chronic obstructive pulmonary disease (COPD) patients documented a greater prevalence of proximal abnormal pH values compared with idiopathic pulmonary fibrosis (IPF), and we did not specifically discuss a correlation analysis in the article. In general we did note a significant acid pH correlation between distal supine acid time percent (T%) and proximal supine T% and between distal upright T% with proximal upright T% (Spearman rank correlation r = 0.67 and r = 0.57; p < 0.0001 for both). Although, as shown in Table 1, the positive predictive value of distal pH findings for proximal pH findings is only 46% for the supine testing and 36% for the upright testing.
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Supportive evidence for our findings with regard to the different prevalence in COPD and IPF is shown in Table 2. The positive predictive value of distal findings for proximal supine pH findings in patients with COPD was 67%, whereas it was only 40% for patients with IPF. Therefore, as commented on in the Discussion of the article, there seems to be a greater likelihood of proximal reflux in patients with an elongated esophagus.
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