Heart burn surgery reverses chronic rejection in transplant patient

Apr 1 2009

Acid reflux is thought to be - at most - an irritating condition easily controlled with medication, diet and weight loss.

Mary Prucha thought so too. But that was before she woke up struggling for air one night last September, nearly two years after undergoing a rare double-lung re-transplant.

"I remember waking up, gasping for breath," said Prucha, a Chicago resident who underwent transplants to treat her cystic fibrosis at Loyola University Hospital in 1996 and again in March 2006. "I checked my lung function, and sure enough, it was down. I thought, 'I can't believe that we are here again.'"

Prucha thought she was undergoing a second round of chronic rejection, an unpredictable decline in lung function that destroyed her first set of transplanted lungs. The cause of the condition is largely unknown and can shave months and years from a transplant patient's life expectancy.

She made an appointment with Dr. Daniel Dilling, assistant professor of medicine, pulmonary and critical care medicine, Loyola University Chicago Stritch School of Medicine. Dilling ran a series of tests, including a bronchoscopy with biopsy, but couldn't pinpoint a cause for Prucha's declining lung function.

That's when Dilling considered the growing recognition in medical literature about the link between acid reflux disease and chronic rejection.

"Chronic rejection is the most common cause of death for patients who are three years or more out of transplant," Dilling said. "I told her that there is a belief in lung transplant circles that acid reflux disease is sometimes a contributor to chronic rejection."

Though heartened, Prucha, a wife and mother of 11-year-old twins, had a difficult time accepting that something so seemingly innocuous could be causing so much havoc in her body and life.

"I thought, 'Are you kidding me?' I honestly didn't believe that," Prucha said.

Dr. Dilling referred Prucha to Dr. P. Marco Fisichella, director of Loyola's Swallowing Center, a multi-disciplinary specialty clinic of skilled surgeons, gastroenterologists, otolaryngologists, speech pathologists and pulmonologists who use a full range of leading-edge technologies and therapies to diagnose and treat disorders of the esophagus.

Diagnostic tests offered at the Swallowing Center to detect acid reflux disease include 24-hour pH monitoring and multichannel intraluminal impedance monitoring, which measures the flow of liquid and gas through the esophagus.

Fisichella performed an esophageal function test and determined that Prucha had severe reflux disease. He also determined that she was among a group of patients whose reflux exhibited no symptoms.

"Reflux is acidic and acid in the lungs can cause some problems," said Fisichella, who is also an assistant professor, department of surgery, Stritch School of Medicine. "Once we found out that she had reflux all the way up to her throat, we were confident that the reflux was most likely going into her lungs."

To treat her reflux, Fisichella surgically recreated the valve that leads from the stomach into the esophagus. Instead of a large incision, he utilized a minimally invasive treatment that involved specially designed instruments and the insertion of a tiny camera through a small incision in her abdomen in order to get a magnified look at the area to be treated.

"Her surgery consisted of four small incisions and involved very little pain," Fisichella said. "She stayed overnight in the hospital for observation and was discharged the next day to resume her normal activities."

"We thought that by avoiding reflux, we could avoid the aspiration into the lungs and make the lungs function better," said Fisichella, who added that of the 15 lung transplant patients that have been referred to the Swallowing Center, nine were found to have acid reflux disease.

"The surgical procedures that lung transplant patients have may pre-dispose them to have acid reflux disease," he said. "We found that one-third had reflux before transplant. After the transplant, 70 percent of patients develop reflux."

A couple of weeks after her surgery, Prucha returned to Loyola to see Dilling about some unrelated back pain she was having. She was still skeptical about the acid reflux link until the end of her appointment when Dilling decided to run a lung function test.

"We saw that her lung function had actually improved," Dilling said. "She cracked a smile from ear to ear. She forgot her back was hurting that day and was absolutely thrilled."