Fundoplication after lung transplantation in patients with systemic sclerosis-related end-stage lung disease

Interventional anti-reflux management for gastro-oesophageal reflux disease in lung transplant recipients: a systematic review and meta-analysis

INTRODUCTION

Gastroesophageal reflux disease (GORD) and aspiration are risk factors in the development of bronchiolitis obliterans syndrome (BOS) in the lung transplant population. The aim of this study was to investigate if allograft function and survival improved after anti-reflux surgery (ARS) in lung transplant recipients.

METHODS

In accordance with PRISMA guidelines, we conducted a systematic search of MEDLINE, Embase, and the Cochrane library databases from inception until 13/01/2024. Articles reporting outcomes of ARS following lung transplantation were included. A random effects model was used for meta-analysis.

RESULTS

The search identified 20 which were used for quantitative analysis. Overall, FEV1 and rate of change of FEV1 had improved following ARS by 0.141 L/s (95% CI; -02.82, -0.001) and -1.153 mL/d (95% CI; -12.117, -0.188), respectively. Survival hazard ratio post-ARS was 0.39 (95% CI; 0.19, 0.60). Nissen fundoplication was the most effective anti-reflux procedure with the greatest effect on reduction in the rate of change of FEV1, with an improvement of -2.353 mL/d (95% CI; -3.058, -1.649).

CONCLUSION

ARS in lung transplant recipients improves allograft function and survival. Given the increased incidence of GORD in lung transplant recipients, there should be a low threshold for investigation of GORD and subsequent ARS.

Lung Transplantation in Patients With Systemic Scleroderma-Description of the First Consecutive Cases in Poland: Case Series Report and a Short Literature Review

Pulmonary complications of systemic scleroderma (SSc), such as interstitial lung disease and pulmonary hypertension (PH), are responsible for up to 60% of deaths among patients. For many years, most centers considered SSc a contraindication to lung transplantation (LTx); however, recent publications show that appropriately selected SSc candidates for LTx give results comparable to patients with idiopathic PH or idiopathic pulmonary fibrosis. This paper presents the cases of a 60-year-old male patient (patient 1) and a 42-year-old female patient (patient 2) diagnosed with SSc in 2019 and 2013, respectively. In both patients, interstitial-fibrotic changes in the lungs leading to respiratory failure were confirmed by high-resolution computed tomography as well as pulmonary hypertension (WHO group 3), which was also diagnosed during right heart catheterization. In both cases, despite pharmacotherapy, pulmonary fibrosis progressed, leading to severe respiratory failure. The patients were referred for LTx qualification. LTx was possible to consider in patients due to the lack of significant changes in other internal organs. Double LTx was successfully performed in both patients (patient 1-July 19, 2022; patient 2-September 14, 2022). They were discharged from the hospital in good condition on the 22nd and 20th postoperative day, respectively. LTx is a last-chance therapy that saves lives among patients with extreme respiratory failure in the course of SSc. It prolongs and improves the quality of life. The selection of appropriate patients is key to the success of the procedure.

Usual interstitial pneumonia is the predominant histopathology in patients with systemic sclerosis receiving a lung transplant

OBJECTIVES

Studies identifying nonspecific interstitial pneumonia (NSIP) as the predominant histopathology in systemic sclerosis-associated interstitial lung disease (SSc-ILD) have primarily utilised surgical lung biopsies in early disease. These case series may only reflect the histopathology of early disease and differ from the histopathology of advanced disease in those with respiratory failure.

METHODS

Patients receiving a lung transplant for a diagnosis of SSc at a single centre from 2000-2021 were included for retrospective analysis. All explanted lungs underwent histopathology review as part of routine care.

RESULTS

127 patients with SSc received a native lung transplant during the study period. Usual interstitial pneumonia (UIP) was identified in 111 explants (87.4%), NSIP in 45 (35.4%) explants, organising pneumonia in 11 explants (8.7%), and lymphocytic bronchitis in 2 explants (1.6%). Areas of both UIP and NSIP were identified in 37 explants (29.1%), with only 9 explants (7.1%) showing neither UIP nor NSIP. Aspiration was identified on histology in 49 (38.6%) explants. Pathology results were available from a prior surgical lung biopsy for 19 patients, with 11 patients maintaining the same primary pathology on biopsy and explant (2 NSIP, 9 UIP) and 8 patients showing different pathology at the timepoints, all of whom had UIP on explant. Most patients (101, 79.5%) had evidence of pulmonary hypertension and vasculopathy on explant.

CONCLUSIONS

UIP is the predominant histopathology in patients with SSc receiving a lung transplant, with many patients concurrently having both NSIP and UIP or showing progression from NSIP to UIP over time before transplant.

Proton pump inhibitors in systemic sclerosis: a reappraisal to optimise treatment of gastro-oesophageal reflux disease

Gastroesophageal reflux disease (GERD) is associated with significant morbidity in patients with systemic sclerosis (SSc). Although the introduction of proton pump inhibitors (PPIs) into clinical care have represented a major achievement in the management of oesophago-gastric problems in SSc, PPIs are seldom fully effective in SSc patients, and the utilization of maximum PPI dosages is a very frequent clinical practice. However, currently there is little evidence currently to support the empiric use of PPIs in SSc which is especially relevant in regard to safety concerns of long-term exposure with have been raised in the general population. The purpose of this viewpoint is to highlight the significant beneficial impact of PPIs on GERD in SSc, while considering the potential adverse effects in this patient population. Furthermore, we highlight the unmet needs of SSc patients with GERD, and also propose an agenda for future research to optimise the safe and effective use of PPIs in SSc.