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15. Laparoscopic Nissen Fundoplication in Patients with End-Stage Lung Disease Awaiting Transplantation
Philip Linden, Richard Gilbert, Kathleen Boyle, Aaron Deykin, Raphael Bueno; Boston, MA

Objective: An association exists between GERD and end stage lung disease, especially idiopathic pulmonary fibrosis (IPF). Recently, it has been noted that the presence of GERD may predispose to the development of bronchiolitis obliterans following lung transplantation. It is presently unclear what effect surgical correction of GERD may have in the progression of underlying native lung disease. We evaluated the feasibility and efficacy of fundoplication in patients with documented GERD awaiting lung transplantation.
Methods: One hundred thirty seven patients on the lung transplant waitlist at a single institution between March 2001 and August 2004 were evaluated as part of their pre-transplant work-up for GERD. Seventeen patients (12.4%) were found to have a history of GERD, continued symptoms, and severe reflux by pH and manometry studies. All seventeen patients elected to undergo surgery to control their symptoms and decrease the risk of complications post transplant. The postoperative course of these patients, including lung function, was retrospectively reviewed.
Results: Thirty nine of the 137 (28.5%) waitlist patients had IPF. Thirteen of these patients (33%) had significant reflux and underwent fundoplication. Additionally there were 2 COPD patients, one with cystic fibrosis and one with immotile cilia syndrome. Eleven were on immunosuppression at the time of surgery. The average Demeester score was 92, the average mean LES pressure was 4.1 mmHg. All patients underwent laparoscopic Nissen fundoplication by a single surgeon without complication; one patient required conversion to an open procedure. Mean follow up was 11.5 months. Lung function, as assessed by percent predicted FEV1, showed a 10% improvement following the procedure in the 9 patients for whom post-op FEV1 data was available, although the difference was not statistically significant possibly due to small numbers (54%+/- 23% vs. 59%+/-28%, p = 0.65). There was no significant change in six-minute walk distance (1281 ft +/-340 vs. 1254 +/-139, p = 0.82) for the 9 patients for whom this data was available. Overall, there was no change in oxygen dependence. Four patients underwent lung transplantation at later dates, while four other patients died of respiratory failure unrelated to the operative procedure prior to receiving lung transplantation. Two patients with IPF developed substantial symptomatic improvement and elected to defer lung transplantation.
Conclusions: Laparoscopic fundoplication can safely be performed in patients with end stage lung disease awaiting lung transplantation. Analysis of a small patient cohort suggests that there may be an improvement in lung function in a subset of patients. Pre-transplant fundoplication may serve to delay transplantation in some patients.

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