Skip to main content
SpringerLink
Log in

Feasibility of laparoscopic Nissen fundoplication after pediatric lung or heart–lung transplantation: should this be the standard?

  • Published:
Surgical Endoscopy Aims and scope Submit manuscript

Abstract

Background

Five-year graft survival in the pediatric lung transplant (LTxp) population is less than 50%, with obliterative bronchiolitis (OB) the leading cause of death at 1, 3, and 5 years post-transplant. Bronchiolitis obliterans syndrome (BOS), defined using spirometry values, is the clinical surrogate for the histological diagnosis of obliterative bronchiolitis. Surgical correction of documented gastroesophageal reflux disease (GERD) has been proposed as a means to potentially delay the onset of BOS and prolong allograft survival in adults before or after lung transplantation but only one such study exists in children. We have examined the safety and possible benefits of laparoscopic antireflux surgery in pediatric patients following lung (LTxp) and heart–lung transplantation (HLTxp).

Methods

An Institutional Review Board (IRB)-approved retrospective chart review was performed to evaluate the outcomes and complications of laparoscopic antireflux surgery in pediatric lung and heart–lung transplant patients. Spirometry data were collected for BOS staging using BOS criteria for children.

Results

Twenty-five lung and heart–lung transplants were performed between January 2003 and July 2009. Eleven transplant recipients, including six double-lung and five heart–lung (HLTxp), with a median age of 11.7 years (range 5.1–18.4 years), underwent a total of 12 laparoscopic Nissen fundoplications at a median of 427 days after transplant (range 51–2310 days). GERD was determined based upon clinical impression, pH probe study, gastric emptying study, and/or esophagram in all patients. Three patients already had a gastrostomy tube in place and two had one placed at the time of fundoplication. There were no conversions to open surgery, 30-day readmissions, or 30-day mortalities. Complications included one exploratory laparoscopy for free air 6 days after laparoscopic Nissen fundoplication for a gastric perforation that had spontaneously sealed. Another patient required a revision laparoscopic Nissen 822 days following the initial fundoplication for a paraesophageal hernia and recurrent GERD. The average length of hospital stay was 4.4 ± 1.7 days. Nine of the 12 fundoplications were performed in patients with baseline spirometry values prior to fundoplication and who could also complete spirometry reliably. One of these nine operations was associated with improvement in BOS stage 6 months after fundoplication; seven were associated with no change in BOS stage; and one was associated with a decline in BOS stage.

Conclusion

It is feasible to perform laparoscopic Nissen fundoplication in pediatric lung and heart–lung transplant recipients without mortality or significant morbidity for the treatment of GERD. The real effect on pulmonary function cannot be assessed due to our small sample size and lack of reproducible spirometry in our younger patients. Additional studies are needed to elucidate the relationship between antireflux surgery and the potential for improving pulmonary allograft function and survival in children which has been previously observed in adult patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Similar content being viewed by others

References

  1. United Network for Organ Sharing (2007) Annual report of the U.S. organ procurement and transplantation network and the scientific registry of transplant recipients: transplant data 1997–2006. Available at http://www.ustransplant.org/annual_reports/current/default.htm. Accessed March 2009

  2. Aurora P, Edwards LB, Christie J, Dobbels F, Kirk R, Kucheryavaya AY, Rahmel AO, Taylor DO, Hertz MI (2008) Registry of the international society for heart, lung transplantation: eleventh official pediatric lung, heart/lung transplantation report 2008. J Heart Lung Transplant 27(9):978–983

    Article  PubMed  Google Scholar 

  3. Estenne M, Maurer JR, Boehler A, Egan JJ, Frost A, Hertz M, Mallory GB, Snell GI, Yousem S (2002) Bronchiolitis obliterans syndrome 2001: an update of the diagnostic criteria. J Heart Lung Transplant 21(3):297–310

    Article  PubMed  Google Scholar 

  4. Verleden GM, Dupont LJ, Van Raemdonck DE (2005) Is it bronchiolitis obliterans syndrome or is it chronic rejection: a reappraisal? Eur Respir J 25(2):221–224

    Article  CAS  PubMed  Google Scholar 

  5. Hartwig MG, Appel JZ, Davis RD (2005) Antireflux surgery in the setting of lung transplantation: strategies for treating gastroesophageal reflux disease. Thorac Surg Clin 15(3):417–427

    Article  PubMed  Google Scholar 

  6. Benden C, Aurora P, Curry J, Whitmore P, Priestly L, Elliott MJ (2005) High prevalence of gastroesophageal reflux in children after lung transplantation. Pediatr Pulmonol 40(1):68–71

    Article  PubMed  Google Scholar 

  7. Young LR, Hadjiliadis D, Davis RD, Palmer SM (2003) Lung transplantation exacerbates gastroesophageal reflux disease. Chest 124(5):1689–1693

    Article  PubMed  Google Scholar 

  8. Lau CL, Palmer SM, Howell DN, McMahon R, Hadjiliadis D, Gaca J, Pappas TN, Davis RD, Eubanks S (2002) Laparoscopic antireflux surgery in the lung transplant population. Surg Endosc 16(12):1674–1678

    Article  CAS  PubMed  Google Scholar 

  9. Davis RD, Lau CL, Eubanks S, Messier RH, Hadjiliadis D, Steele MP, Palmer SM (2003) Improved lung allograft function after fundoplication in patients with gastroesophageal reflux disease undergoing lung transplantation. J Thorac Cardiovasc Surg 125(3):533–542

    Article  PubMed  Google Scholar 

  10. Kurland G, Michaelson P (2005) Bronchiolitis obliterans in children. Pediatr Pulmonol 39(3):193–208

    Article  PubMed  Google Scholar 

  11. Perrin-Fayolle M (1990) Gastroesophageal reflux and chronic respiratory disease in adults: influence and results of surgical therapy. Clin Rev Allergy 8(4):457–469

    CAS  PubMed  Google Scholar 

  12. Harding SM, Richter JE (1997) The role of gastroesophageal reflux in chronic cough and asthma. Chest 111(5):1289–1402

    Article  Google Scholar 

  13. Ledson MJ, Tran J, Walshaw MJ (1998) Prevalence and mechanisms of gastroesophageal reflux in adult cystic fibrosis patients. J R Soc Med 91(1):7–9

    CAS  PubMed  Google Scholar 

  14. Tobin RW, Pope CE II, Pelligrini CA, Emond MJ, Sillery J, Raghu G (1998) Increased prevalence of gastroesophageal reflux in patients with idiopathic pulmonary fibrosis. Am J Respir Crit Care Med 158(6):1804–1808

    CAS  PubMed  Google Scholar 

  15. DeMeester TR, Bonavina L, Iascone C, Courtney JV, Skinner DB (1990) Chronic respiratory symptoms and occult gastroesophageal reflux. A prospective clinical study and results of surgical therapy. Ann Surg 211(3):337–345

    Article  CAS  PubMed  Google Scholar 

  16. Linden PA, Gilbert RJ, Yeap BY, Boyle K, Deykin A, Jaklitsch MT, Sugarbaker DJ (2006) Laparoscopic fundoplication in patients with end-stage lung disease awaiting transplantation. J Thorac Cardiovasc Surg 131(2):438–446

    Article  PubMed  Google Scholar 

  17. Sweet MP, Herbella FAM, Leard L, Hoopes C, Golden J, Hays S, Patti MG (2006) The prevalence of distal and proximal gastroesophageal reflux in patients awaiting lung transplantation. Ann Surg 244(4):491–497

    PubMed  Google Scholar 

  18. Lubetkin EI, Lipson DA, Palevsky HI, Kotloff R, Morris J, Berry GT, Tino G, Rosato ER, Berlin JA, Wurster AB, Kaiser LR, Lichtenstein GR (1996) GI complications alter orthotopic lung transplantation. Am J Gastroenterol 91(11):2382–2390

    CAS  PubMed  Google Scholar 

  19. Au J, Hawkins T, Venables C, Marritt G, Scott CD, Gascoigne AD, Corris PA, Hilton CJ, Dark JH (1993) Upper gastrointestinal dysmotility in heart–lung transplant recipients. Ann Thorac Surg 55(1):94–97

    Article  CAS  PubMed  Google Scholar 

  20. Bowery DJ, Peters JH, DeMeester TR (2000) Gastroesophageal reflux disease in asthma: effects of surgical antireflux surgery on asthma control. Ann Surg 231(2):161–172

    Article  Google Scholar 

  21. Field SK, Gelfand GA, McFadden SD (1999) The effects of antireflux surgery on asthmatics with gastroesophageal reflux. Chest 111(3):766–774

    Article  Google Scholar 

  22. O’Halloran EK, Reynolds JD, Lau CL, Manson RJ, Davis RD, Palmer SM, Pappas TN, Clary EM, Eubanks S (2004) Laparoscopic Nissen fundoplication for treating reflux in lung transplant recipients. J Gastrointest Surg 8(1):132–137

    Article  PubMed  Google Scholar 

  23. Cantu E III, Appel JZ, Hartwig MG, Woreta H, Green C, Messier R, Palmer SM, Davis RD (2004) Early fundoplication prevents chronic allograft dysfunction in patients with gastroesophageal reflux disease. Ann Thorac Surg 78(4):1142–1151

    Article  PubMed  Google Scholar 

  24. Tsai P, Peters J, Johnson W, Cohen R, Starnes V (1996) Laparoscopic fundoplication 1 month prior to lung transplantation. Surg Endosc 10(6):668–670

    CAS  PubMed  Google Scholar 

  25. Wells A, Faro A (2006) Special considerations in pediatric lung transplantation. Semin Respir Crit Care Med 27(5):552–560

    Article  PubMed  Google Scholar 

  26. Faro A, Mallory GB, Visner GA, Elidemir O, Magayzel PJ, Danziger-Isakov L, Michaels M, Sweet S, Michaelson P, Paranjape S, Conrad C, Waltz DA (2007) American Society of Transplantation executive summary on pediatric lung transplantation. Am J Transpl 7(2):285–292

    Article  CAS  Google Scholar 

  27. Gasper WJ, Sweet MP, Hoopes C, Leard LE, Kleinhenz ME, Hays SR, Golden JA, Patti MG (2008) Antireflux surgery for patients with end-stage lung disease before and after lung transplantation. Surg Endosc 22:495

    Article  CAS  PubMed  Google Scholar 

  28. Robertson AGN, Shenfine J, Ward C, Pearson JP, Dark JH, Corris PA, Griffin SM (2009) A call for standardization of antireflux surgery in the lung transplantation population. Transplantation 87(8):1112–1114

    Article  PubMed  Google Scholar 

  29. Sweet MP, Patti MG, Hoopes C, Hays SR, Golden JA (2009) Gastro-esophageal reflux and aspiration in patients with advanced lung disease. Thorax 69:167–173

    Article  Google Scholar 

Download references

Disclosures

Mr. Zheng, Ms. Iurlano, Drs. Kane, Kurland, Spahr, Potoka, Weardon, and Morell have no conflicts of interest or financial ties to disclose.

Author information

Authors and Affiliations

  1. Division of Pediatric General and Thoracic Surgery, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA

    Chi Zheng, Timothy D. Kane & Douglas A. Potoka

  2. Division of Pediatric Pulmonary Medicine, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA

    Geoffrey Kurland, Kathy Irlano & Jonathan Spahr

  3. Division of Pediatric Cardiothoracic Surgery, University of Pittsburgh Medical Center, Children’s Hospital of Pittsburgh of UPMC, One Children’s Hospital Drive, 4401 Penn Avenue, Pittsburgh, PA, 15224, USA

    Peter D. Weardon & Victor O. Morell

Authors
  1. Chi Zheng
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Timothy D. Kane
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Geoffrey Kurland
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Kathy Irlano
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Jonathan Spahr
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Douglas A. Potoka
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Peter D. Weardon
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Victor O. Morell
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Timothy D. Kane.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Zheng, C., Kane, T.D., Kurland, G. et al. Feasibility of laparoscopic Nissen fundoplication after pediatric lung or heart–lung transplantation: should this be the standard?. Surg Endosc 25, 249–254 (2011). https://doi.org/10.1007/s00464-010-1167-y

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00464-010-1167-y

Keywords

Search

Navigation