The case of the week is a 40-year-old male with chest pain and discomfort 2 years after LINX™ placement. The patient underwent LINX™ surgery for symptomatic GERD poorly responsive to proton pump inhibitor therapy. He had significant food regurgitation and daily heartburn. Concomitantly, he had symptomatic biliary dyskinesia confirmed by HIDA scan. He had an uneventful laparoscopic cholecystectomy and LINX™ procedure. His abdominal pain and GERD related symptoms have resolved following surgery and he was happy with the outcome of his surgical intervention. Two years later, he started developing chronic chest pain and discomfort worse with sitting and not related to activity or food intake. He started having occasional heartburn attacks but denied any significant food regurgitation. He went back to the surgeon who placed the LINX™ device and underwent upper endoscopy and a barium swallow. Both studies were unremarkable and the surgeon reassured him. He was then referred to a gastroenterologist who performed an esophageal manometry and gastric emptying study and both studies were normal too. Patient however continued to suffer from his chest pain and presented to Houston Heartburn and reflux Center for a second opinion.
Upon presentation the patient has been having chest pain and discomfort for approximately one year. He has lost around 80 pounds due to lack of appetite secondary to pain. He denied cough, sore throat and hoarseness. He had no food regurgitation and no dysphagia. I decided to perform a video esophagogram to evaluate his esophagus and contrast movement across the gastro-esophageal junction. I use thin Barium for these studies. It was evident from the first few swallows that the esophagus was struggling to move contrast across the LINX™ device into the stomach. Multiple tertiary esophageal contractions can be seen as well as delayed contrast movement requiring several dry swallows to clear the esophagus. Consequently, an esophageal impedance manometry was performed to further elucidate esophageal motility. Interestingly, the study was almost normal except for incomplete bolus clearance on most swallows. The Lower esophageal sphincter pressure was slightly low. The contractile wave amplitude, peristalsis and intra-bolus pressure were within normal.
The genesis of chest pain and discomfort in this particular case may be attributable to esophageal wall strain activating tension-sensitive afferent nerves in the submucosa and muscularis propria. Pain due to esophageal spasm immediately following LINX™ placement has been reported. LINX™ device removal several years after implantation for chest pain has also been reported. Asti et al have published a study in Annals of Surgery titled “Removal of the Magnetic Sphincter Augmentation Device: Surgical Technique and Results of a Single Center Cohort Study”. The study followed 164 LINX™ patients over 4 years and 11 patients, 6.7%, underwent LINX™ explantation. 5 patients had recurrent heartburn and food regurgitation, 4 patients had dysphagia and 2 patients had chest pain. Is it possible that magnetic sphincter augmentation device creates a partial obstruction leading to tertiary esophageal contractions on barium swallow and incomplete bolus clearance on impedance manometry? How common are these findings and is esophageal dysmotility the cause of pain in certain patients?
We still don’t have answers to these important questions. A cause effect relationship between LINX™ surgery and esophageal dysmotility is difficult to establish in this particular case but is highly suspected. LINX™ device removal and conversion to a short floppy Nissen fundoplication is probably the only option left for this patient.