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Ann Thorac Surg 2010;90:1630-1636. doi:10.1016/j.athoracsur.2010.06.104
© 2010 The Society of Thoracic Surgeons
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Right arrow Lung - transplantation

Original Articles: General Thoracic

Esophageal Motor Dysfunction and Gastroesophageal Reflux Are Prevalent in Lung Transplant Candidates

Benjamin Basseri, MDa, Jeffrey L. Conklin, MDa, Mark Pimentel, MDa, Robert Tabrizi, MDa, Edward H. Phillips, MDb, Sinan A. Simsir, MDc, George E. Chaux, MDc, Jeremy A. Falk, MDc, Sara Ghandehari, MDc, Harmik J. Soukiasian, MDb,*

a GI Motility Program, Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, California
b Esophageal and Thoracic/Foregut Program, Division of Cardiothoracic Surgery, Cedars-Sinai Medical Center, Los Angeles, California
c Lung Transplant Center, Pulmonary Medicine, Cedars-Sinai Medical Center, Los Angeles, California

Accepted for publication June 22, 2010.

* Address correspondence to Dr Soukiasian, 8730 Alden Dr, Ste 229E, Los Angeles, CA 90048 (Email: soukiasianh{at}cshs.org).


   Abstract
Top
 Abstract
Introduction
 Material and Methods
 Results
 Comment
 References
 
Background: Gastroesophageal reflux and aspiration contribute to the development of bronchiolitis obliterans and accelerate graft deterioration after lung transplantation (LTx). We evaluated LTx candidates for esophageal motor abnormalities and gastroesophageal reflux.

Methods: Consecutive patients evaluated for LTx underwent 24-hour pH monitoring using a dual-channel pH probe and high-resolution esophageal manometry. High-resolution manometry was also performed in healthy control subjects. The prevalence of abnormal acid exposure was noted in the LTx candidates.

Results: Thirty LTx candidates and 10 control subjects were evaluated. Lung transplantation candidates had higher residual upper and lower esophageal sphincter pressures. The mean proportion of peristaltic swallows was 21% lower in LTx candidates. Both hypotensive and aperistaltic swallows were sixfold more prevalent in LTx candidates than in control subjects. All control subjects had normal high-resolution manometry whereas 23 LTx candidates (76.7%) had esophageal peristaltic dysfunction. Abnormal acid exposure time was seen in the proximal and distal esophagus in 25% and 36% of LTx candidates, respectively. Lung transplantation candidates with idiopathic pulmonary fibrosis had more aperistaltic contractions, more negative minimum intrathoracic pressure, and a higher frequency of abnormal distal esophagus acid exposure. The majority of patients with complications after LTx demonstrated motor, anatomic, or pH abnormalities.

Conclusions: Disordered esophageal motor function and gastroesophageal reflux are common in LTx candidates. We believe high-resolution esophageal manometry is a valid tool to use and the abnormalities we identified may be representative of this unique patient population. The role of this study in predicting a worse outcome should be further studied in patients after LTx.


   Introduction
Top
 Abstract
 Introduction
Material and Methods
 Results
 Comment
 References
 

Dr Conklin discloses that he has a financial relationship with Sierra Scientific Instruments.

 

Lung transplantation (LTx) is an effective treatment for severe pulmonary disease, with 1-year survival greater than 80%. Unfortunately, bronchiolitis obliterans remains a common and devastating complication threatening long-term graft survival after LTx. Half of LTx patients exhibit bronchiolitis obliterans within 5 years of transplant, and the 5-year survival after diagnosing bronchiolitis obliterans is only 30% to 40% [1–3]. It accounts for 30% of all deaths in the 3 years after transplantation. Bronchiolitis obliterans syndrome (BOS), the clinical correlate of bronchiolitis obliterans, is a surrogate marker for chronic rejection and is characterized clinically by a persistent decline in forced expiratory volume in 1 second. It is typically progressive and inadequately responsive to immunosuppression—treatments with corticosteroids, cyclosporine, tacrolimus, methotrexate, and mycophenolate mofetil, have proven disappointing [4–12].

Risk factors associated with the development of BOS include cytomegalovirus infection, antibodies to class I HLA, and mismatches at HLA loci [13–16]. Gastroesophageal reflux is associated with a number of other pulmonary diseases including bronchitis, asthma, cystic fibrosis, pulmonary fibrosis, emphysema, and obstructive sleep apnea [17–20]. A growing body of literature also implicates gastroesophageal reflux (GER) in the pathogenesis of BOS [21–24].

We do not know whether pharyngoesophageal motor abnormalities, other than GER, also contribute to LTx failure, but there is reason to think that they may. Oropharyngeal dysphagia rates have been shown to be very high after LTx [25]. Pharyngeal motor dysfunction or compromised upper esophageal sphincter (UES) opening causes pharyngeal stasis and predisposes to aspiration. An incompetent UES or esophageal motor patterns associated with intraesophageal stasis may increase the risk of laryngopharyngeal reflux, aspiration, and lung injury. In this study, we explored the incidence of GER and esophageal motor abnormalities in LTx candidates.


   Material and Methods
Top
 Abstract
 Introduction
 Material and Methods
Results
 Comment
 References
 
Subjects
Consecutive patients presenting beginning August 2008 for LTx evaluation were eligible for inclusion in the study. It is standard practice at our institution to perform 24-hour esophageal pH monitoring and high-resolution manometry (HRM) studies as a part of the evaluation before lung transplantation. A group of healthy subjects also underwent HRM (control subjects). All patients signed an informed consent to be placed in our esophageal database. The institutional review board approved this study.

High-Resolution Manometry
All subjects presented for HRM after a minimum 8-hour fast. Medications known to inhibit or affect esophageal motility were discontinued 5 days before HRM or 24-hour pH monitoring. A solid-state manometry catheter with 36 circumferential pressure transducers spaced at 1-cm intervals (Manoscan; Sierra Scientific Instruments, Los Angeles, CA) was used for all studies. The catheter was calibrated from 0 to 300 mm Hg using externally applied pressure immediately before use. It was then inserted transnasally and positioned to record from the pharynx to the stomach, allowing simultaneous pressure recording from the UES, esophageal body, and lower esophageal sphincter (LES).

Patients were placed in a 30-degree semirecumbent position and allowed to accommodate to the catheter. Once comfortable, a 30-second recording was made with the patient at rest, and not swallowing, to measure the resting LES and UES pressures. Immediately after resting pressure measurement, subjects were given 5-mL room temperature water swallows in a sequence of 10 swallows. Double swallows and swallows including pressure artifacts associated with coughing or belching were not counted in the 10 swallows. A computer algorithm that functions somewhat like a Dent sleeve estimates residual LES pressure. This electronic or "E" sleeve determines the lowest mean pressure over the course of 3 seconds in a 6-cm segment centered on the LES. Published normative data for the analysis of HRM were used to classify esophageal motor function and dysfunction [26, 27]. An example of normal esophageal motor function seen with HRM is depicted in Figure 1.


Figure 1
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  		Fig 1. Normal high-resolution manometry color contour after a wet swallow. Pressure is represented by color (color bar), sensor location in distance from the nares (y axis), and time is on the x axis. Resting upper (UES) and lower esophageal sphincter (LES) pressures are seen as horizontal bands of color indicating higher pressures than in the adjacent pharynx, esophagus, or stomach. Opening of the UES and LES relaxation are depicted as color changes that indicate lower pressure: UES pressure approximates that in the esophagus (*), and LES pressure approximates that in the stomach (**). Peristaltic pressure wave is portrayed as a diagonal band of color from the UES to the LES; higher pressure in striated muscle segment diminishes over the transition zone and increases in amplitude in the smooth muscle esophagus. Pressure in the swallowed bolus (intrabolus pressure) is small, a simultaneous rise in intraesophageal pressure (arrow) that occurs shortly after initiation of a wet swallow. It remains elevated ahead of the peristaltic pressure wave.

 
24-Hour pH Esophageal Monitoring
Esophageal pH monitoring was conducted using a dual-chamber pH probe (AccuView pH, Sierra Scientific Instruments). Sensors were 15 cm apart and positioned 5 and 20 cm above the LES. Continuous pH recording was performed for 24 hours. The DeMeester score was calculated according to the following distal pH variables; percentage of total time pH was less than 4, percentage supine time pH was less than 4, percentage upright time pH was less than 4, longest reflux event, number of reflux events longer than 5 minutes, and number of reflux episodes in 24 hours. A DeMeester score of greater than 14.72 was considered abnormal.

Statistical Analysis
The Mann-Whitney U test was used to assess significant differences between mean values. Statistical relationships between proportions and percentages were evaluated by Fisher analysis. Probability values of 0.05 or less were deemed statistically significant. Standard error of the mean was calculated for all continuous variables.


   Results
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 Abstract
 Introduction
 Material and Methods
 Results
Comment
 References
 
Primary Characteristics
High-resolution manometry and esophageal pH monitoring studies of 30 consecutive subjects presenting for lung transplant evaluation were reviewed. Two subjects had only HRM without a pH study. The average age of subjects within the LTx group was 64.0 ± 1.8 years (range, 25 to 76 years; Table 1). Eighteen (60%) were male and 12 (40%) female. The most common causes of advanced lung disease were chronic obstructive pulmonary disease (COPD; n = 16) and idiopathic pulmonary fibrosis (IPF; n = 11; 1 also carried a diagnosis of scleroderma). The control group was composed of 10 healthy subjects (5 female) with a mean age of 53.4 ± 3.4 years (range, 34 to 69 years). There were no significant differences between the LTx and control groups in regard to height, weight, or ethnicity.


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  		Table 1 Primary Characteristics
 
Upper and Lower Esophageal Sphincter Pressure and Anatomy
The mean basal UES pressure was 18 mm Hg lower in the LTx candidates than in the control subjects (Table 2). Twenty percent of LTx candidates had a hypotensive UES (resting UES pressure <30 mm Hg), compared with no control subjects (Fig 2, Table 3). Residual UES pressure, the pressure during UES opening, was elevated (>8 mm Hg) in 4 (13%) LTx candidates, but in no control subjects (Fig 3). Three of these patients had fluoroscopic swallowing studies or barium swallows as part of their evaluation. In all 3, abnormalities of the pharynx or UES were found. Abnormalities included (1) unilateral pharyngeal palsy and impaired pharyngeal clearance, (2) cricopharyngeal bar with aspiration, and (3) cricopharyngeal bar. Transient UES openings were seen in 3 (10%) LTx candidates and no control subjects (p = 0.299). In 2 of the 3, there was also severe motor dysfunction of the smooth muscle esophagus, and in the other, UES openings were associated with transient LES relaxations.


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  		Table 2 Upper and Lower Esophageal Sphincter Pressures a
 

Figure 2
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  		Fig 2. High-resolution manometry color contour in a lung transplantation candidate with a hypotensive upper esophageal sphincter (UES). Wet swallow timing is indicated by WS. Pressure changes caused by inspiration (I) and expiration (E) are easily identified. Pressure becomes more negative in the esophagus during inspiration and more positive during expiration, indicating the sensors are intrathoracic. Notice that the resting pressure in the upper esophageal sphincter varies with the respiratory cycle and drops below 20 mm Hg with inspiration (*). (LES = lower esophageal sphincter.)

 

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  		Table 3 Manometric Abnormalities
 

Figure 3
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  		Fig 3. High-resolution manometry color contour from a lung transplantation candidate with elevated residual pressure in the upper esophageal sphincter (UES) and elevated bolus pressure in the pharynx. The time base is expanded to get a clear look at pressure events in the UES and pharynx (*). Normally, pressure in the UES and pharynx approximate adjacent esophagus when the UES is open. Pharyngeal and UES pressures are elevated during UES opening (*), indicating a pharyngeal motor abnormality or obstruction at the UES. Fluoroscopic swallowing study identified a cricopharyngeal bar. (LES = lower esophageal sphincter.)

 
A significantly higher proportion of LTx candidates had a hypotensive LES compared with control subjects (Fig 4, Table 3). The mean overall basal LES pressure was lower in the LTx group, but the difference did not reach statistical significance. Residual LES pressure was significantly higher in the LTx group, and 27% had elevated residual pressure (>15 mm Hg, eSleeve 3-second nadir) compared with no control subjects (p = 0.068). Transient LES relaxation was appreciated in 27% of LTx candidates and no control subjects (p = 0.068). Hiatal hernia was detected in 40% of LTx candidates and 20% of control subjects (p = 0.251; Fig 4).


Figure 4
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  		Fig 4. Esophageal motor dysfunction, hypotensive lower esophageal sphincter (LES) and upper esophageal sphincter (UES) "microburps." In this high-resolution manometry color contour from a lung transplantation candidate, wet swallows (WS) do not produce normal peristalsis in the smooth muscle esophagus. At the gastroesophageal (GE) junction, contraction of the diaphragm is seen as pressure increases in association with inspiration. During expiration, pressure at the GE junction drops to approximate intragastric pressure, indicating that LES resting pressure is low. Notice that there are very short duration openings of the UES that are not associated with swallowing (*). This patient had small burps coinciding with these opening events.

 
Esophageal Motor Activity
The percentage of wet swallows that initiated normal peristalsis was significantly lower in LTx candidates than in control subjects (Fig 5). Rapidly propagated pressurization—pressurization front velocity (PVF) greater than 8 cm/s in greater than 20% of wet swallows—was diagnosed in 3 (10%) LTx candidates, but in no control subjects. In 2 of these patients, the rapid PVF resulted from rapid propagation of the contractile wave front, consistent with the diagnosis of diffuse esophageal spasm. In the other, it was from pressurization of the bolus (>15 mm Hg) ahead of a peristaltic wave, consistent with functional esophagogastric junction obstruction [27]. Twenty-three (77%) LTx candidates had some form of peristaltic dysfunction. Ten had intermittent peristaltic dysfunction (>3 and <7 swallows with either failed peristalsis or a >3-cm defect in 30-mm Hg isobaric contour of distal esophageal segment), and 10 had frequent peristaltic dysfunction (>7 swallows with either failed peristalsis or a >3-cm defect in 30-mm Hg isobaric contour of distal esophageal segment) (Fig 4). Eighty percent with frequent peristaltic dysfunction also had a hypotensive LES. Two had striated muscle dysfunction with peristaltic pressure less than 30 mm Hg, and 1 had segmental nutcracker esophagus (peristaltic pressure greater than 180 mm Hg in only one segment of the distal esophagus). Abnormalities of esophageal motor function were not identified in any control subjects (p < 0.001).


Figure 5
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  		Fig 5. Mean proportion of peristaltic, hypotensive, and aperistaltic swallows in lung transplantation (LTx) candidates and control subjects.

 
The mean minimum intrathoracic pressure was significantly more negative in LTx candidates than in control subjects (–9.8 ± 1.3 versus –4.2 ± 1.1 mm Hg; p = 0.031).

Esophageal Acidification
Thirty-six percent of LTx candidates had abnormal acid exposure in the distal esophagus (pH <4 at least 5.0% of the time; Table 4). In this group, the acid exposure time ranged from 5.0% to 25.9%. They had more negative mean minimum thoracic pressure than LTx candidates with normal distal acid exposure (–13.2 ± 3.1 versus –8.0 ± 1.0 mm Hg; p = 0.003). One in 4 LTx candidates undergoing 24-hour ambulatory intraesophageal pH studies had abnormal acid exposure in the proximal esophagus (pH <4 at least 1.0% of the time). In these patients, the exposure time ranged from 1.0% to 3.8%. They had a lower resting LES pressure than LTx candidates with normal proximal acid exposure (9.0 ± 1.2 mm Hg versus 15.1 ± 1.8 mm Hg; p = 0.029). Mean DeMeester score in LTx candidates was 18.3 ± 4.8 (range, 0.3 to 96.2); 36% (n = 11) had an elevated DeMeester score. Lung transplantation candidates with abnormal proximal or distal acid exposure, or those with an elevated DeMeester score, did not have an increased prevalence of peristaltic dysfunction.


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  		Table 4 pH-Monitoring Findings in Lung Transplantation Candidates
 
Type of Lung Disease
The majority of the study population was composed of patients with COPD (n = 16) and IPF (n = 10). In a comparison of these two subclasses of patients within the LTx candidates, the COPD group had higher residual LES pressure whereas the IPF group had a higher mean proportion of aperistaltic contractions (Table 5). Idiopathic pulmonary fibrosis patients were more likely to have increased distal esophageal acid exposure (p = 0.025) and increased DeMeester score (p = 0.025). This group also demonstrated significantly higher respiratory rate and more negative intrathoracic pressure.


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  		Table 5 Chronic Obstructive Pulmonary Disease and Idiopathic Pulmonary Fibrosis Patient Comparisons a
 
Lung Transplantation
Sixteen of the 30 (53.3%) LTx candidates received LTx, with a follow-up ranging from 1 to 21 months after surgery. Nine and 7 patients received bilateral sequential and single-lung transplantation, respectively. Death occurred in 1 LTx recipient (respiratory failure associated with pneumonia and refractory septic shock), and 4 other recipients had complications postoperatively: acute rejection (n = 1), bilateral anastomotic strictures (n = 2), and decline in respiratory status (n = 1). Four of these patients had significant abnormalities, including mild peristaltic dysfunction, hiatal hernia, severe LES dysfunction, transient LES relaxations, and abnormal proximal and distal esophagus acid exposure. Patients with GER were started on a proton pump inhibitor with a plan for reevaluation for surgery (ie, Nissen fundoplication) during the posttransplant course. No patients in the study group received antireflux surgery.


   Comment
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
References
 
Bronchiolitis obliterans syndrome is a major contributor to graft failure in LTx recipients and has been associated with GER. Although the role played in this process by abnormalities of esophageal function is not clear, esophageal dysmotility may be associated with advanced pulmonary disease. High-resolution manometry provides an unprecedented opportunity to explore esophageal motor function in much greater detail than previously possible, with new insights into esophageal function and dysfunction. We therefore sought to evaluate esophageal motor and pH abnormalities in candidates evaluated for LTx. Overall, esophageal motor abnormalities were appreciated in LTx candidates out of proportion to a control population.

One of the great advantages of solid-state HRM is spatial and temporal resolution that makes studying the striated muscle components of the swallowing mechanism reliable for the first time. The pathologic processes that disrupt striated muscle motor function differ from those affecting the smooth muscle esophagus. In fact, neuromuscular abnormalities of the pharynx and UES are likely to worsen LTx graft survival because they cause pharyngeal stasis and aspiration. Atkins and colleagues [25] detected a laryngeal penetration or tracheal aspiration in 70% of LTx patients who had a postoperative swallow evaluation. We found a surprising number of LTx candidates with striated muscle dysfunction. The low resting UES pressure present in 20% of our patients may compromise UES barrier function and predispose to pharyngeal reflux of gastroesophageal contents. Elevated residual UES pressure was seen in 13% of LTx candidates. This finding is associated with cricopharyngeal bar or abnormal pharyngeal motor function. This was the case in all 3 patients with elevated UES pressure who had radiographic evaluation of their swallowing mechanism. Thus, HRM may be a useful tool for identifying pharyngeal motor or structural abnormalities that are deleterious to LTx.

Low resting LES pressure, hiatal hernia, and transient LES relaxations were more common in LTx candidates. All three are known risk factors for GER, and should forewarn the clinician that GER may be present in the LTx candidate. However, in our LTx candidates, transient LES relaxations and hiatal hernia were not associated with elevated acid exposure in the proximal or distal esophagus. Nonetheless, such abnormalities were present in the majority of LTx recipients who experienced complications.

Esophageal peristaltic dysfunction was quite common in LTx candidates, with 77% having abnormalities not seen in control subjects. Motor dysfunction was more common than previously reported in LTx candidates (33% to 47%) [28, 29]. In nearly half of those with motor dysfunction, it was classified as frequent, ie, greater than 70% swallows producing no or hypotensive peristalsis. Such abnormalities are associated with poor or failed bolus transit, and occasionally retrograde bolus movement. All may predispose to laryngeal reflux of esophageal contents. Eighty percent of LTx candidates with frequent motor dysfunction also had a hypotensive LES. This combination of abnormalities may be problematic because any refluxate is likely to be poorly cleared from the esophagus. This hypothesis is corroborated by the prevalence of these abnormalities in LTx recipients with postoperative complications.

Reflux disease is common in the general US population, with up to 11% reporting daily symptoms of heartburn [30]. It appears to be even more common in patients with pulmonary disease. Abnormal esophageal pH monitoring is reported in 32% to 84% of the asthma population [31]. Gastroesophageal reflux symptoms are more common in COPD patients than healthy control subjects, and more prominent in those with more severe COPD [32]. Furthermore, within the COPD population, those with GER have a higher frequency of COPD exacerbations and hospitalizations [33]. Gastroesophageal reflux may also be responsible for up to 40% of cases of chronic cough [34] and is associated with obstructive sleep apnea [35]. Our population of LTx candidates was composed mostly of patients with COPD and IPF. The underlying source of pulmonary disease may be associated with different phenotypes of esophageal disease within the LTx population, eg, in COPD compared with scleroderma. In a direct comparison of patients with COPD and IPF, the latter group demonstrated a higher prevalence of aperistaltic contractions, higher respiratory rate, and more negative intrathoracic pressure. These abnormalities contributed to the higher prevalence of abnormal distal esophageal acid exposure in the IPF subgroup.

Abnormal esophageal acid exposure was common in LTx candidates, corroborating previous reports of a high prevalence of GER in patients with advanced lung disease [10, 11, 28, 29]. One in 3 LTx candidates had abnormal acid exposure in the distal esophagus. Twenty-five percent had abnormal proximal esophageal acid exposure, predisposing to microaspiration, parenchymal injury, and loss of lung function [36]. These observations were very similar to those by D'Ovidio and associates [29], who reported abnormal overall pH testing and abnormal proximal pH in 38% and 20% of LTx candidates, respectively, but less frequently appreciated than in an LTx candidate population evaluated by Sweet and colleagues [28]. Abnormal esophageal acid exposure correlated with lower resting LES pressure and more negative mean minimum thoracic pressure, both of which predispose to GER; low resting LES pressure presents a diminished barrier to reflux, and lower thoracic pressure increases the pressure gradient across the gastroesophageal junction. Hypotensive LES was common in LTx candidates (63%) and in between the frequencies previously observed by Sweet and coworkers (55%) [28] and D'Ovidio and associates (72%) [29]. Abnormal acid exposure was present in 2 of the 5 LTx recipients with posttransplantation complications, and GER was directly associated with decline in respiratory status in at least 1 LTx recipient.

A number of pathophysiologic mechanisms linking reflux and pulmonary disease have been hypothesized [34, 37]. One possibility is microaspiration of refluxed gastric contents, causing direct injury. Another is reflux of gastric contents into the esophagus, triggering a vagal reflex that provokes airway inflammation or constriction. A third, GER may make the airway hypersensitive to other stimuli, like allergens, cold, or viral infections. Furthermore, medications used in the treatment of pulmonary disease—such as β-agonists and methylxanthine bronchodilators—may decrease LES tone. These underlying pathophysiologic processes may invoke a vicious cycle continuously exacerbating pulmonary disease.

The impact of GER on advanced lung disease may be propagated by physiologic consequences of LTx and side effects of medical therapy. Gastric emptying may be prolonged by immunosuppression, or from vagal injury at the time of surgery [21, 24, 38–40]. Moreover, pulmonary defense mechanisms—ie, mucociliary clearance and cough reflex—are impaired after LTx, potentially worsening reflux-induced injury [23, 24, 39, 41]. Young and colleagues [40] reported an increase in abnormal esophageal acid exposure from 35% before to 65% after transplantation.

Unfortunately, treatment of GER with proton pump inhibitors has not improved LTx outcomes [42]. This is not surprising as proton pump inhibitors do not block the pathophysiologic mechanisms of GER; they only decrease the pH of the refluxate. The refluxate may remain weakly acid, and contain injurious substances like pepsins and bile acids [43]. Proton pump inhibitor therapy therefore does not prevent microaspiration. Fundoplication decreases the risk of developing BOS, reduces oxygen requirements, improves pulmonary function, and may improve overall survival in the LTx population [21].

It should be noted that the LTx population was significantly older than our control population and was composed of a handful of patients in their 70s. This was a limitation of the study, but we do not believe it should underscore the disparate manometric profiles between these two populations. Another limitation of our study was the lack of esophageal pH monitoring data in our control population. However, we speculate that the actual prevalence of abnormal acid exposure was uncommon in this population given our past experiences and the lack of HRM abnormalities in these patients. Our short follow-up period after LTx (1 to 21 months) limited our ability to predict postoperative complications associated with motor dysfunction or GER, although we were able to identify such abnormalities in the majority of LTx recipients with complications. Finally, it should be clarified that the observation of a greater residual pressure than resting LES pressure in the LTx population is not of any particular significance given that basal—and therefore residual—LES pressure may increase during the course of an HRM study.

In conclusion, we present a case-control analysis of esophageal pH-monitoring and HRM studies in which esophageal acidification and dysmotility were significantly more prevalent in LTx candidates. Furthermore, there was a direct association between motor abnormalities and prolonged esophageal acid exposure, and such abnormalities were prevalent in LTx candidates who received transplantation. Given the high likelihood of these abnormalities and the detrimental effects of GER after LTx—including BOS and decreased survival—we recommend all LTx candidates receive pH monitoring and HRM during transplantation evaluation. Antireflux surgery should be considered in candidates with GER and appropriate esophageal motor function. Further study is necessary to investigate the relationship between abnormalities of esophageal motor function and long-term allograft survival after LTx.


   References
Top
 Abstract
 Introduction
 Material and Methods
 Results
 Comment
 References
 

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