Electrical Stimulation of the LES – an Emerging Therapy for Lung Transplanted Patients with GERD

Cecilia Zubieta, Md, Mauricio Ramirez, Md, Juan M Riganti, Md, Franco F Ciotola, Md, Andres DiTaranto, Md, Claudio Bilder, Md, Adolfo Badaloni, Md, Alejandro Nieponice, Md, Phd. Fundacion Favaloro

Introduction: GERD is often associated with lung transplantand it can  be one of the failure mechanisms. Due to the extended dissection during the procedure, post-operative failed esophageal peristalsis is more common and can be a challenge. Traditional antireflux surgery such as Nissen fundoplication isassociated with high rates of dysphagia while Roux-en-y reconstruction is a significantly more invasive procedure. Electrical stimulationof the LES (LES-EST) has emerged as a new alternative for the treatment of GERD. Briefly, the technology involves alaparoscopicallyimplantable neurostimulator with two electrodes implanted at the LES that provide programmed electrical stimuli to improve  LES function. Open-label trials report successful control of symptoms, near elimination of dependence on acid suppression medications and significant improvement   of esophageal acid exposure up to three-year follow-up. Manometric studies reveal no negative effect on LES relaxation, making it an attractive treatment option for GERDpatients with failed peristalsis. We report the outcome of LES-ESTin 2 lung transplant patients with GERD.

Methods: Two patients (mean age = 55;men = 2) diagnosed with severe GERD and failed peristalsis after lung transplant,were found eligible for LES-EST and agreed to undergo the procedure. Peristalsis was assessed with high resolutionmanometry and reflux disease was diagnosed with Multichannel Intraluminal Impedance-pH testing (MII-pH). The LES Stimulation system (EndoStim, BV, The Hague, The Netherlands)was implanted using standard technique (SurgEndosc. 2013;27:1083-92)and stimulation was delivered in 12, 30 minute sessions of5mA, 215usec, at 20Hz. Postop follow-up endpoints included clinical symptoms, PPI intake, MII-pH , EGD, and Barium Swallow. Mean follow-up was 12 months (4-19.5)
Results: Surgical implant was completed successfully and LES-EST was initiated in both cases. At their last follow-up, both patients were free of GERD symptoms and had reduced medication use to the minimum dose required as protector for the immunosuppressant drugs. There was no dysphagia associated with LES-EST. First patient showed normalization of his barium swallow with no emptying delay and no spontaneous reflux . He did not agree to undergo MII-pH, The second patient showed normal EGD withno signs of esophagitis and there was an improvement greater than 50% in MII-Ph with total time Ph<4 of 9% for a previous of 53.8% and a DeMeester Score of 27.5 for a previous of 204.8.

Conclusions: Our small case-series represents the first report of successful use of LES-EST in patients with GERDassociated with lung trasnplant.Early   results  confirmthat LES-EST is a safe and effective treatment modality in such patients without any associated dysphagia in this particular patient population.  The lack of dysphagia is particularly encouraging. Further experience is required to fully assess the role of LES-EST in this difficult group of patients


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