Should Pre-Transplant Esophageal Dysmotility Preclude Candidacy for Lung Transplantation?

Abstract

Esophageal dysmotility can decrease luminal clearance and increase the risk of aspiration and GERD and contribute to allograft dysfunction. We sought to determine the impact of pre-transplant esophageal dysmotility on allograft function, GERD, rejection and survival after lung transplantation. From 2012 to 2018, 699 patients underwent lung transplantation at our institution. Gastroesophageal physiological testing included esophageal manomentry, 24 hour pH measurement and gastric emptying tests before and after transplantation. High resolution manometry (HRM) was available in 337 patients including 120 patients with abnormal HRM (20-aperistalsis, 10-Distal Esophageal Spasms, 8-Jackhammer Esophagus and 82-Ineffective Motility). Allograft function was assessed by Forced Expiratory Volume in 1-second (FEV1) over time. Long-term risk of mortality was assessed non-parametrically by Kaplan-Meier method and parametrically by a multiphase hazard model. Pre-transplant esophageal dysmotility was not associated with worse survival after lung transplantation (P= .7). One year overall survival was 95%, 92% and 90% respectively for patients with aperistalsis, dysmotility and normal motility while 5-year OS was 67%, 69% and 65% respectively. On univariate analysis, patients with non-caucasian ethnicity and group B disease were more likely to have dysmotility. On post-transplant pH testing, patients with abnormal motility had greater acid exposure time and higher Demeester scores along with lower residual LES pressure. Abnormal HRM prior to lung transplantation was not significantly associated with biopsy proven acute lung rejection (P= .5) or allograft function (P= .5). Esophageal dysmotility is not associated with poor allograft function or worse post-transplant survival. Favorable outcomes can be achieved with careful selection and post-transplant management. Such patients should not be disqualified solely on the basis of esophageal dysmotility.