Golytely

To the Editor:

We greatly appreciated the review by Gilljam et al (1) (January, 2003) on GI complications after lung transplantation in patients with cystic fibrosis (CF). Their experience mirrors our own: distal intestinal obstruction syndrome (DIOS) can be as important an issue after transplant in individuals with CF as management of pulmonary complications. In the initial days after lung transplant, the continuation of high-dose narcotics, postoperative ileus, poor oral intake, and bed rest creates a risk for DIOS that makes the estimate of 20% incidence seem optimistically low. Gill jam et al (1) wisely, suggest "prevention and early medical treatment" to prevent DIOS after transplant, and report success with a routine of early enteral feeding and, if needed, administration of electrolyte GI lavage solution 24 h after transplantation.

We too have noted a dramatic effect of a preventive protocol on the incidence of DIOS after lung transplant in individuals with CF. We now start this preventive protocol prior to surgery. After having three consecutive CF lung transplants complicated after surgery by DIOS, we adopted a protocol that included all individuals with CF awaiting lung transplant having access at home to polyethylene glycol lavage solution (GoLytely; Braintree Laboratories; Braintree. MA). As soon as they are contacted to come to the hospital for their transplant because donor lungs are available, they immediately drink 2 L of polyethylene glycol lavage solution. Combining this approach with the steps recommended in the article by Gilljam et al (1) has virtually eliminated the incidence of DIOS in our CF population immediately after transplant. This protocol has been adopted by other transplant centers, including the University of North Carolina at Chapel Hill, with similar success, Initial concern about patients drinking a large volume of liquid prior to surgery has been tempered by the much less complicated postoperative courses mid the observation that several hours invariably lapse between patient notification and actual surgery.

The principles of prevention and early treatment espoused by Gilljam et al (1) can be extended to apply to all surgeries in individuals with CF hi which Surgery will likely be followed by narcotic use and postoperative a dynamic ileus. After having postoperative DIOS occur in individuals with CF undergoing cholecystectomy and other ,abdominal surgeries, we have now made pretreatment with polyethylene glycol lavage solution a standard part of preoperative preparation.

Kudos to Dr. Gilljam and coworkers for their thorough review of an underrecognized complication of CF. By applying their principles of prevention and early treatment for DIOS, we should be able to dramatically decrease the incidence of GI complications not only after lung transplantation in CF, but after all surgeries.

REFERENCE

(1) Gilljam M, Chaparro C, Tullis E, et al. GI complications after lung transplantation in patients with cystic fibrosis. Chest 2003:1:23:37-41

Michael P. Boyle, MD, FCCP

Johns Hopkins Adult CF Program

Jonathan B. Orens, MD, FCCP

Johns Hopkins Lung Transplant Program

Baltimore, MD

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Correspondence to: Michael P. Boyle, MD, FCCP, Assistant Professor of Medicine, Director, Johns Hopkins Adult CF Program The Johns Hopkins, Hospital, 1830 E. Monument St, Fifth Floor, Baltimore, MD 21205; e-mail: mboyle@jhmi.edu

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