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Overcoming Gastrointestinal Complications After Lung Transplant
Andres Pelaez, MD, discusses overcoming gastrointestinal complications after a lung transplant. In this podcast, we will examine how diseases of the esophagus can impact outcomes after lung transplant, and how gastric reflux and allograft dysfunction affect esophageal motility.
Featuring:
Dr. Pelaez received his medical degree from Centro de Estudios de la Salud in Medellin, Colombia, South America. He then completed an internship and residency in internal medicine at the University of Texas Health Science Center. Following this training, he completed a pulmonary disease and critical care medicine fellowship at Emory University School of Medicine. Dr. Pelaez continued his training at the University of Texas Health Science Center to complete two additional fellowships in interventional bronchoscopy and lung transplantation.
Prior to joining UF Health in 2016, Dr. Pelaez previously served on a number of lung transplant teams, including the Tampa General Hospital Lung Transplant Program, the McKlevey Lung Transplant Program at Emory University, and at Florida Hospital in Orlando, where he acted as medical director for the lung transplant program. He has published and presented widely on pulmonary and critical care medicine, with a special interest in lung transplantation and pulmonary hypertension.
Board-certified in internal medicine with subspecialties in pulmonary medicine and critical care, Dr. Pelaez’s clinical work focuses on respiratory failure, extra-corporeal membrane oxygenation (ECMO), pulmonary hypertension, evaluation of patients with end-stage lung diseases and lung transplantation.
Andres Pelaez, MD
Andres Pelaez, MD, is an associate professor of medicine, medical director of the UF Health Shands Transplant Center Lung Transplant Program and co-director of the adult respiratory ECMO program in the division of pulmonary, critical care and sleep medicine at the University of Florida College of Medicine.Dr. Pelaez received his medical degree from Centro de Estudios de la Salud in Medellin, Colombia, South America. He then completed an internship and residency in internal medicine at the University of Texas Health Science Center. Following this training, he completed a pulmonary disease and critical care medicine fellowship at Emory University School of Medicine. Dr. Pelaez continued his training at the University of Texas Health Science Center to complete two additional fellowships in interventional bronchoscopy and lung transplantation.
Prior to joining UF Health in 2016, Dr. Pelaez previously served on a number of lung transplant teams, including the Tampa General Hospital Lung Transplant Program, the McKlevey Lung Transplant Program at Emory University, and at Florida Hospital in Orlando, where he acted as medical director for the lung transplant program. He has published and presented widely on pulmonary and critical care medicine, with a special interest in lung transplantation and pulmonary hypertension.
Board-certified in internal medicine with subspecialties in pulmonary medicine and critical care, Dr. Pelaez’s clinical work focuses on respiratory failure, extra-corporeal membrane oxygenation (ECMO), pulmonary hypertension, evaluation of patients with end-stage lung diseases and lung transplantation.
Transcription:
Introduction: The University of Florida, College of Medicine is accredited by the accreditation council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida, College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category one credit. Position should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole: Welcome to UF Health Med Ed Cast with UF Health Shans Hospital. I'm Melanie Cole. And today we're discussing overcoming gastrointestinal complications after lung transplant. In this podcast, we will learn how diseases of the esophagus can impact outcomes after lung transplant and how gastric reflux and allograft dysfunction can affect esophageal motility. Joining me is Dr. Andres Pelaez. He's the Medical Director at UF Health Shan's Lung Transplant Program and Advanced Lung Failure Pulmonologist at UF Health Shans hospital, and an Associate Professor at the University of Florida, College of Medicine. Dr. Pelaez, it's such a pleasure to have you with us today. Post-Transplant please help us to understand lung allograft dysfunction. How common is this in patients and what is the most common cause of this type of dysfunction?
Dr. Pelaez: Yes. So chronic lung allograft dysfunction is a permanent loss of the lung function after lung transplant. And fortunately, this is something that doesn't present early on after lung transplant. Just to give you an idea currently, more than 4,000 lung transplants that are performed each year around the world, and there is a significant growing interest and also the commitment to this highly complex and problematic feeling solely organ transplant. Now we can see that lung transplant recipients will have more than 90% survival at one year or with time, the chronic allograft dysfunction unfortunately, will start developing and is this progressive loss of lung function, that is that producing this carving [inaudible 02:20] of the airway or the lung itself. And by the end of five years, we expect that almost 50% of the patients will end up having the chronic allograft dysfunction. That unfortunately is the main cause of reducing the long-term survival. And also unfortunately reducing the quality of life of the lung transplant recipient.
Host: Well then explain for us how diseases of the esophagus impact outcomes after lung transplant kind of tie this together for us and help us to understand the connection between gastric reflux and allograft dysfunction.
Dr. Pelaez: Yeah, I mean, that's an excellent question because the lung transplant recipient itself is going to be exposed to the immune system, trying to identify the new allograft. And that only tone is that trying to attack the lung. And that's why we use the transplant medications to try to suppress that immune response. At the same time, we have no immune factors that can lead to the progressive development of allograft dysfunction, gastroesophageal reflux, and problems of the esophagus has been suggested to be one of those important known immune contributors to the development of allograft dysfunction. So if we look at it from, if the esophagus and the long are closely interconnected, the esophagus, misleading for the person to constantly aspirate, that leads to an injury. So it's a constant injury that the lung is having to deal day after day, that over time leads to development of allograft dysfunction. As I mentioned before, either because you start developing some scarring and more fibrosis in an attempt to try to defend against that injury, but at the same time leads the immune system to be regulated. So that's why we think there is a close connection between the esophagus, and esophageal problems with patients who undergo lung transplant.
Host: Have you found Doctor, that early surgical intervention may decrease the mortality of some of these complications? Tell us about the safety of fundoplication in lung transplant recipients, its effect on their quality of life, which obviously is a big part of all of this kind of tell us a little bit about some of the treatment options or if there are things that you can do to prophylactically stave this off.
Dr. Pelaez: Yes. So it's important to them to find what things we can do to minimize that ongoing injury that is coming from recurrent aspiration. So normally how we defend from aspirating is by having different mechanisms and some of those might be the cause, and also might be also how the esophagus clears the food. So after lung transplant, not only the cough mechanism that is protecting us is impaired, but also how esophagus moves is impaired. If we look, lung transplant recipients almost 60 to 70% of them can have silent aspiration. So what's happening is that even though they might be aspirating, they might not be aware. And the only way we start noticing that that's happening to the patient is because over time we see that either they start developing more rejection or we see the lung function is starting to decline. And that's what leads for us to look for a possible gas reflux or problems with the esophagus.
So, if we look at the general population, more than 20% or 30% of the general population is going to have reflux, but that's not so problematic for the general population. After lung transplant, we see that that incidence of reflux significantly increases on almost a 60 to 70% of the patients might have gastric reflux. So imagine these patients that after lung transplant, the incidence of reflux is significantly increased. And now the patient is dealing with that ongoing injury, make us think what interventions can we do to minimize that ongoing injury? And some of the things that you alluded or you’re asked me is fundoplication. And that's a surgery that is done to try to minimize the reflux. But at the same time, we have seen that not only the reflux is what is leading to a problem. What about if it's closer and the esophagus is not moving very well, even though we stopped the reflux by undergoing fundoplication, the esophageal motility might not be completely taken care off.
And the person might still be having esophageal reflux, and they still continue to have the injury. So while I'm trying to tell you, is that being aware being a looking for, how the esophagus might be impacting the lung allograph is very important. At the same time, trying to identify what is the appropriate convention is also relevant. Today we feel that every patient who goes lung transplant is important to have some sort of assessment [inaudible 08:42] you know, the esophagus that we've identified down the road, if that patient is going to be at risk and also to determine if early interventions might make sense like doing fundoplication, for example.
Host: Well, thank you for explaining about esophageal motility and allograft dysfunction and how those are connected. So Dr. Pelaez, how have been your outcomes when you are looking at all of these factors for allograft dysfunction and the mortality rate? And tell us a little bit about your outcomes and what you've seen, what you'd like other providers to know?
Dr. Pelaez: Yes. So the most important thing is to have a multidisciplinary team approach where you closely work, not only with the pulmonologist and the gastroenterologist who has expertise in esophageal motility disorders, but at the same time with a surgeon who is very knowledgeable and is skilled in undergoing any surgical interventions of the esophagus, if it's necessary. Because when the patient is identified to have a problem and an early intervention is done, that definitely can help the patient to prevent from having a progressive allograft dysfunction. But at the same time, when that procedure is done in the wrong time, when the wrong patient, also can lead to development of other complications that not only are not going to help prevent the progressive allograft dysfunction, but at the same time might lead to all the issues that the patient was not having before.
So, some of the things that we have done is early on evaluate those patients and be very aware before going into the transplant, what risk they bring into the surgery. And immediately after surgery being aware that they are at increased risk of aspiration or gastric reflux helps the team to be in tune and be acting early on rather than waiting for a patient to aspirate or developing complications. So by having that multidisciplinary approach, our outcomes have been very successful. Our one year survival currently is 95%. And despite of dealing with challenging patients, particularly these that have esophageal motility.
Host: What a fascinating topic. And if we wrap up, what do you see on the horizon for overcoming gastrointestinal complications after lung transplant? What would you like other providers to take away from this?
Dr. Pelaez: Yeah, I think the transplant community continues to explore what interventions are necessary to minimize the complications related to esophageal problems. We know mechanistically that this is leading to an ongoing injury also to up regulation of the immune system. What we don't know as a transplant community yet is how soon the procedures need to be done or what additional procedures are necessary to minimize the problem. I think the most important is being aware that those are there and likely, I think what I see in the future is studying very early mechanical interventions to prevent and protect the esophagus from leading to aspiration. And also exploring and looking at ways of how we can overcome and improve the motility that we know is going to be impaired after lung transplant. So I think those are the things that I see down the road, as an add into the potential options beyond the surgical intervention.
Host: Thank you so much, Dr. Pelaez for joining us today. What a fascinating topic, thank you for sharing your expertise. And that concludes today's episode of UF Health Med Ed Cast with UF Health Shans Hospital. To learn more about this and other healthcare topics at UF Health Shans Hospital, please visit UFhealth.org/medmatters to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other UF Health Shan's Hospitals podcasts. I'm Melanie.
Introduction: The University of Florida, College of Medicine is accredited by the accreditation council for continuing medical education, ACCME to provide continuing medical education for physicians. The University of Florida, College of Medicine designates this enduring material for a maximum of 0.25 AMA PRA category one credit. Position should claim only the credit commensurate with the extent of their participation in this activity.
Melanie Cole: Welcome to UF Health Med Ed Cast with UF Health Shans Hospital. I'm Melanie Cole. And today we're discussing overcoming gastrointestinal complications after lung transplant. In this podcast, we will learn how diseases of the esophagus can impact outcomes after lung transplant and how gastric reflux and allograft dysfunction can affect esophageal motility. Joining me is Dr. Andres Pelaez. He's the Medical Director at UF Health Shan's Lung Transplant Program and Advanced Lung Failure Pulmonologist at UF Health Shans hospital, and an Associate Professor at the University of Florida, College of Medicine. Dr. Pelaez, it's such a pleasure to have you with us today. Post-Transplant please help us to understand lung allograft dysfunction. How common is this in patients and what is the most common cause of this type of dysfunction?
Dr. Pelaez: Yes. So chronic lung allograft dysfunction is a permanent loss of the lung function after lung transplant. And fortunately, this is something that doesn't present early on after lung transplant. Just to give you an idea currently, more than 4,000 lung transplants that are performed each year around the world, and there is a significant growing interest and also the commitment to this highly complex and problematic feeling solely organ transplant. Now we can see that lung transplant recipients will have more than 90% survival at one year or with time, the chronic allograft dysfunction unfortunately, will start developing and is this progressive loss of lung function, that is that producing this carving [inaudible 02:20] of the airway or the lung itself. And by the end of five years, we expect that almost 50% of the patients will end up having the chronic allograft dysfunction. That unfortunately is the main cause of reducing the long-term survival. And also unfortunately reducing the quality of life of the lung transplant recipient.
Host: Well then explain for us how diseases of the esophagus impact outcomes after lung transplant kind of tie this together for us and help us to understand the connection between gastric reflux and allograft dysfunction.
Dr. Pelaez: Yeah, I mean, that's an excellent question because the lung transplant recipient itself is going to be exposed to the immune system, trying to identify the new allograft. And that only tone is that trying to attack the lung. And that's why we use the transplant medications to try to suppress that immune response. At the same time, we have no immune factors that can lead to the progressive development of allograft dysfunction, gastroesophageal reflux, and problems of the esophagus has been suggested to be one of those important known immune contributors to the development of allograft dysfunction. So if we look at it from, if the esophagus and the long are closely interconnected, the esophagus, misleading for the person to constantly aspirate, that leads to an injury. So it's a constant injury that the lung is having to deal day after day, that over time leads to development of allograft dysfunction. As I mentioned before, either because you start developing some scarring and more fibrosis in an attempt to try to defend against that injury, but at the same time leads the immune system to be regulated. So that's why we think there is a close connection between the esophagus, and esophageal problems with patients who undergo lung transplant.
Host: Have you found Doctor, that early surgical intervention may decrease the mortality of some of these complications? Tell us about the safety of fundoplication in lung transplant recipients, its effect on their quality of life, which obviously is a big part of all of this kind of tell us a little bit about some of the treatment options or if there are things that you can do to prophylactically stave this off.
Dr. Pelaez: Yes. So it's important to them to find what things we can do to minimize that ongoing injury that is coming from recurrent aspiration. So normally how we defend from aspirating is by having different mechanisms and some of those might be the cause, and also might be also how the esophagus clears the food. So after lung transplant, not only the cough mechanism that is protecting us is impaired, but also how esophagus moves is impaired. If we look, lung transplant recipients almost 60 to 70% of them can have silent aspiration. So what's happening is that even though they might be aspirating, they might not be aware. And the only way we start noticing that that's happening to the patient is because over time we see that either they start developing more rejection or we see the lung function is starting to decline. And that's what leads for us to look for a possible gas reflux or problems with the esophagus.
So, if we look at the general population, more than 20% or 30% of the general population is going to have reflux, but that's not so problematic for the general population. After lung transplant, we see that that incidence of reflux significantly increases on almost a 60 to 70% of the patients might have gastric reflux. So imagine these patients that after lung transplant, the incidence of reflux is significantly increased. And now the patient is dealing with that ongoing injury, make us think what interventions can we do to minimize that ongoing injury? And some of the things that you alluded or you’re asked me is fundoplication. And that's a surgery that is done to try to minimize the reflux. But at the same time, we have seen that not only the reflux is what is leading to a problem. What about if it's closer and the esophagus is not moving very well, even though we stopped the reflux by undergoing fundoplication, the esophageal motility might not be completely taken care off.
And the person might still be having esophageal reflux, and they still continue to have the injury. So while I'm trying to tell you, is that being aware being a looking for, how the esophagus might be impacting the lung allograph is very important. At the same time, trying to identify what is the appropriate convention is also relevant. Today we feel that every patient who goes lung transplant is important to have some sort of assessment [inaudible 08:42] you know, the esophagus that we've identified down the road, if that patient is going to be at risk and also to determine if early interventions might make sense like doing fundoplication, for example.
Host: Well, thank you for explaining about esophageal motility and allograft dysfunction and how those are connected. So Dr. Pelaez, how have been your outcomes when you are looking at all of these factors for allograft dysfunction and the mortality rate? And tell us a little bit about your outcomes and what you've seen, what you'd like other providers to know?
Dr. Pelaez: Yes. So the most important thing is to have a multidisciplinary team approach where you closely work, not only with the pulmonologist and the gastroenterologist who has expertise in esophageal motility disorders, but at the same time with a surgeon who is very knowledgeable and is skilled in undergoing any surgical interventions of the esophagus, if it's necessary. Because when the patient is identified to have a problem and an early intervention is done, that definitely can help the patient to prevent from having a progressive allograft dysfunction. But at the same time, when that procedure is done in the wrong time, when the wrong patient, also can lead to development of other complications that not only are not going to help prevent the progressive allograft dysfunction, but at the same time might lead to all the issues that the patient was not having before.
So, some of the things that we have done is early on evaluate those patients and be very aware before going into the transplant, what risk they bring into the surgery. And immediately after surgery being aware that they are at increased risk of aspiration or gastric reflux helps the team to be in tune and be acting early on rather than waiting for a patient to aspirate or developing complications. So by having that multidisciplinary approach, our outcomes have been very successful. Our one year survival currently is 95%. And despite of dealing with challenging patients, particularly these that have esophageal motility.
Host: What a fascinating topic. And if we wrap up, what do you see on the horizon for overcoming gastrointestinal complications after lung transplant? What would you like other providers to take away from this?
Dr. Pelaez: Yeah, I think the transplant community continues to explore what interventions are necessary to minimize the complications related to esophageal problems. We know mechanistically that this is leading to an ongoing injury also to up regulation of the immune system. What we don't know as a transplant community yet is how soon the procedures need to be done or what additional procedures are necessary to minimize the problem. I think the most important is being aware that those are there and likely, I think what I see in the future is studying very early mechanical interventions to prevent and protect the esophagus from leading to aspiration. And also exploring and looking at ways of how we can overcome and improve the motility that we know is going to be impaired after lung transplant. So I think those are the things that I see down the road, as an add into the potential options beyond the surgical intervention.
Host: Thank you so much, Dr. Pelaez for joining us today. What a fascinating topic, thank you for sharing your expertise. And that concludes today's episode of UF Health Med Ed Cast with UF Health Shans Hospital. To learn more about this and other healthcare topics at UF Health Shans Hospital, please visit UFhealth.org/medmatters to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other UF Health Shan's Hospitals podcasts. I'm Melanie.