Nissen fundoplication is considered the standard of care for patients with chronic gastroesophageal reflux disease (GERD) whose condition has failed to respond to medical therapy. Developed as an alternate laparoscopic procedure, implantation of the LINX® Reflux Management System has gained use. It does not alter gastric anatomy, augments the physiologic barrier to reflux, and can easily be reversed if necessary (Figure 1). However, the LINX device is not appropriate for all patients. Here we describe a case that illustrates the factors that indicate LINX System implantation over standard surgical treatments for GERD.
A 36-year-old male with a history of GERD of 4 to 5 years’ duration presented at University of Minnesota Medical Center with worsening symptoms of a foul taste in the mouth in the morning, excessive belching, and sore throat. The patient’s symptoms persisted despite his receiving the maximum dose of proton pump inhibitors. The patient was very active, with an occupation that required extensive heavy lifting and frequent pushing and pulling motions.
Impedance pH monitoring revealed a high number of reflux incidences with symptom correlation. The patient’s DeMeester score was elevated at 39 (>14.72 indicates reflux), confirming that acidic gastric contents were washing up into the esophagus. Esophageal manometry testing revealed that the patient’s lower esophageal sphincter had been weakened as a result of prolonged acid exposure.
The multidisciplinary esophageal team recommended the LINX System as the preferred surgical treatment for this patient, particularly given his active occupation. Nissen fundoplications can fail under frequent, strong elevations in intra-abdominal pressure,1 whereas the LINX device is not affected by this issue. With LINX System implantation, the patient would be an outpatient, whereas Nissen fundoplication typically requires a 2-3 day stay, an advantage considering the patient’s active lifestyle. This patient had no contraindications to the LINX System.
The LINX System was placed surgically (Figure 2), and the patient recovered without sequelae. He resumed his normal diet and activity level, including work requirements, within one week. The patient has experienced complete resolution of all reflux symptoms, no longer requires any antacids medications and is able to sleep flat on his back again without interruptions 4 months out from his surgery.
For a younger, non-obese patient without contraindications, use of the LINX device is often the preferred surgical approach. Nissen fundoplication can be associated with side effects that prompt patient dissatisfaction, such as gas bloat syndrome, the inability to belch and vomit, and the occurrence of persistent dysphagia that may require surgical revision.2 The LINX System allows for expansion of the esophagus, accommodating a swallowed bolus of food and allowing for belching and vomiting (Figure 1). This provides control of reflux without compromising the physiologic function of the lower esophageal sphincter.3 In this case, the patient’s active occupation would likely have caused pressure on and loosening of the Nissen fundoplication. For these reasons, the LINX System became the preferred treatment option.
Contributed by Eitan Podgaetz, MD
1. Hunter JG, Smith CD, Branum GD, et al. Laparoscopic fundoplication failures: patterns of failure and response to fundoplication revision. Ann Surg. 1999;230:595-604; discussion 604-6.
2. Humphries LA, Hernandez JM, Clark W, Luberice K, Ross SB, Rosemurgy AS. Causes of dissatisfaction after laparoscopic fundoplication: the impact of new symptoms, recurrent symptoms, and the patient experience. Surg Endosc. 2013;27:1537-45.
3. Ganz RA, Peters JH, Horgan S, et al. Esophageal sphincter device for gastroesophageal reflux disease. N Engl J Med. 2013;368:719-27.
For those with gastroesophageal reflux disease that failed to respond to medication, a new implantable device shows promise in relieving symptoms and limiting side effects.Continue reading