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Laparoscopic Toupet fundoplication: a safe and effective anti-reflux option in lung transplant recipients

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Abstract

Background

Fundoplication is known to improve allograft outcomes in lung transplant recipients by reducing retrograde aspiration secondary to gastroesophageal reflux disease, a modifiable risk factor for chronic allograft dysfunction. Laparoscopic Nissen fundoplication has historically been the anti-reflux procedure of choice, but the procedure is associated with discernable rates of postoperative dysphagia and gas-bloat syndrome. Laparoscopic Toupet fundoplication, an alternate anti-reflux surgery with lower rates of foregut complications in the general population, is the procedure of choice on our institution’s lung transplant protocol. In this work, we evaluated the efficacy and safety of laparoscopic Toupet fundoplication in our lung transplant recipients.

Methods

A prospective case series of 44 lung transplant recipients who underwent laparoscopic Toupet fundoplication by a single surgeon between September 2018 and November 2020 was performed. Preoperative and postoperative results from 24-h pH, esophageal manometry, gastric emptying, and pulmonary function studies were collected alongside severity of gastroesophageal reflux disease and other gastrointestinal symptoms.

Results

Median DeMeester score decreased from 25.9 to 5.4 after fundoplication (p < 0.0001), while percentage of time pH < 4 decreased from 7 to 1.1% (p < 0.0001). The severity of heartburn and regurgitation were also reduced (p < 0.0001 and p = 0.0029 respectively). Overall, pulmonary function, esophageal motility, gastric emptying, severity of bloating, and dysphagia were not significantly different post-fundoplication than pre-fundoplication. Patients with decreasing rates of FEV1 pre-fundoplication saw improvement in their rate of change of FEV1 post-fundoplication (p = 0.011). Median follow-up was 32.2 months post-fundoplication.

Conclusions

Laparoscopic Toupet fundoplication provides objective pathologic acid reflux control and symptomatic gastroesophageal reflux improvement in lung transplant recipients while preserving lung function and foregut motility. Thus, laparoscopic Toupet fundoplication is a safe and effective antireflux surgery alternative in lung transplant recipients.

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Abbreviations

A1AT:

Alpha-1 anti-trypsin

ARS:

Anti-reflux surgery

ASA:

American Society of Anesthesiology

BOS:

Bronchiolitis obliterans syndrome

CLAD:

Chronic lung allograft dysfunction

COPD:

Chronic obstructive pulmonary disease

CF:

Cystic fibrosis

CI:

Confidence interval

DCI:

Distal contractile integral

FEV1:

Forced expiratory volume in 1 s

FVC:

Forced vital capacity

GERD:

Gastroesophageal reflux disease

GES:

Gastric emptying study

GI:

Gastrointestinal

HREM:

High-resolution esophageal manometry

ILD:

Interstitial lung disease

IQR:

Interquartile range

IRP:

Integrated relaxation pressure

ISHLT:

International Society for Heart and Lung Transplantation

LARS:

Laparoscopic anti-reflux surgery

LES:

Lower esophageal sphincter

LESP:

Lower esophageal sphincter pressure

LNF:

Laparoscopic Nissen fundoplication

LTF:

Laparoscopic Toupet fundoplication

LTx:

Lung transplant

PFT:

Pulmonary function test

PPI:

Proton pump inhibitor

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Acknowledgements

The authors would like to thank Sara H. Gray, Candice L. Rogers, and Stefanie L. Wright for their help with this project.

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Authors and Affiliations

  1. University of Florida College of Medicine, Gainesville, FL, USA

    Celeste G. Yergin, Kelly M. Herremans, Sheetal Patel & Manuel A. Amaris

  2. Department of Surgery, University of Florida College of Medicine, Gainesville, FL, USA

    Kelly M. Herremans

  3. Department of Medicine, University of Florida College of Medicine, PO Box 100214, Gainesville, FL, 3261, USA

    Sheetal Patel & Manuel A. Amaris

  4. Department of Medicine, University of Miami Miller School of Medicine, Miami, FL, USA

    Andres Pelaez

  5. Department of Surgery, University of Miami Miller School of Medicine, Miami, FL, USA

    Tiago N. Machuca

  6. Affiliate Community Faculty, University of Nevada, Reno, NV, USA

    Alexander L. Ayzengart

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Correspondence to Manuel A. Amaris.

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Disclosures

Dr. Kelly M. Herremans is funded by NHGRI T32 HG008958, but has no financial relationships with any pharmaceutical or device company. Drs. Celeste G. Yergin, Sheetal Patel, Andres Pelaez, Tiago Machuca, Alexander L. Ayzengart, and Manuel A. Amaris, MD have no conflicts of interest or financial ties to disclose.

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Yergin, C.G., Herremans, K.M., Patel, S. et al. Laparoscopic Toupet fundoplication: a safe and effective anti-reflux option in lung transplant recipients. Surg Endosc 37, 8429–8437 (2023). https://doi.org/10.1007/s00464-023-10245-0

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