Vanderbilt University Medical Center Nashville, Tennessee
Introduction: There is evidence of an association between abnormal esophageal motility, GERD, and poor lung transplant outcomes. Our group has previously showed pre-operative manometric evaluation is critical for lung-transplant selection. A similar focus on post-lung transplant manometric evaluation to help prevent rejection and its common mediator chronic lung allograft dysfunction (CLAD). We hypothesized that there is increase esophageal dysmotility post-lung transplant associated with worsened CLAD.
Methods: In this retrospective 10-year cohort study, we analyzed all patients who underwent lung transplantation from 2009-2019. Time-to-event analysis using Cox proportional hazards model was utilized for mortality, acute rejection by biopsy, and the development of CLAD, testing pre- and post-transplant motility as a predictor for the above adjusted for age, gender, BMI, and transplant status (single vs. double lung). Manometric diagnosis was done using Chicago Classification 4.0. Pre-transplant GERD was defined based on > 6% time pH < 4, abnormal DeMeester score, evidence of Barrett’s esophagus, peptic strictures, and/or esophagitis.
Results: 227 patients who underwent lung transplantation were analyzed in this study. 79 patients underwent pre-operative manometry (as per guidelines at the time of their pre-transplant evaluation) with the most common diagnosis being normal (87%, n=66), Ineffective Motility (11%, n=8), and Jackhammer (3%, n=2). Post-lung transplant manometry (n=166) demonstrated an increases risk of hypercontractile esophagus (Jackhammer esophagus 11% (p< 0.01), Diffuse Esophageal Spasm 3% (p< 0.01, Type III achalasia 1%, EGJ Outflow obstruction 2%) (Table 1). This was associated with an increase rate of CLAD (37% vs 25%, p< 0.01). There was no difference with Type I or Type II Achalasia nor absent contractility. There were similar covariates including BMI, acid exposure time, and rates of Nissen fundoplication. Patients who had pre and post-lung transplant manometry (n=60), there is a similar increase in hypercontractile esophageal motility (Jackhammer 11%, DES 4%).
Discussion: We found increasing rates of hypercontractile esophageal motility independent of underlying demographics, pulmonary pathology, or surgical intervention. In this cohort, there was an associated increase risk of CLAD who have esophageal dysmotility. Effective post-transplant esophageal dysfunction management can potentially decrease CLAD which would improve overall post-transplant survivorship
