I recently joined a LINX support group on Facebook for patients who had the LINX or about to have it. I was following all those patients who had the procedure and learning about their experience with this new device. More than half of the patients had post-operative complications related to dysphagia and food regurgitation. A good number of them had poor control of their GERD related symptoms. A week after I joined the group, the organizer decided to create a separate LINX complication support group and move all patients with complications to a new group. It seemed that patients with LINX related complaints were discouraging those interested or thinking of having LINX surgery. The organizer wanted to keep only those with positive and encouraging thoughts about LINX. So I joined the second group and kept on following the same complaints of dysphagia and poor reflux control until I finally posted the question: What is the advantage of LINX over the traditional Nissen fundoplication? I think it was a fair and relevant question. However, the organizer did not like it especially after I introduced myself as an acid reflux specialist in Houston, TX.
Social media is a double edge sword in the health industry. On one hand, it serves as great educational tool for thousands of patients. On the other hand, it may be inaccurate and misleading. Marketing disguised as a support group on Facebook is particularly dangerous. It may also be considered unethical, and unfair. Why not keep those patients with complaints and problems related to LINX in the support group? Patients are entitled to know the truth and social media like Facebook ought to make sure the truth is delivered.
Back to my question: Is there any advantage of LINX surgery over the traditional Nissen procedure? Obviously, for patients with hiatal hernias LINX is not indicated. For GERD patients with no structural defect, LINX may be a less invasive procedure than Nissen procedure. However, LINX device is a foreign body placed around the distal esophagus. For me, encircling the esophagus with foreign body material is more invasive than wrapping the esophagus with gastric fundus. The gastro-esophageal area is continuously contracting, shortening relaxing and contorting to changes in intra-abdominal and intra-thoracic pressures. History has taught us that foreign bodies placed in that area are likely to erode into the esophagus. Scar tissue created by LINX in addition to magnet chain compression contributes to dysphagia. Overtime, as the esophagus is continuously compensating to overcome this extrinsic obstruction, peristaltic abnormalities may result leading to poor esophageal acid clearance, dysphagia and worsening GERD.
Last but not least, GERD is a multifactorial problem and lower sphincter augmentation by itself is not enough to stop reflux. In 1995, John Dent el al published an interesting study in Gastroenterology journal. “Effect of Atropine on the Frequency of Reflux and Transient Lower Esophageal Sphincter Relaxation in Normal Subjects” showed that the incidence of acid reflux did not increase after atropine injection in the lower esophageal sphincter. In other words, sphincter relaxation by itself does not lead to acid reflux contrary to common belief. The authors further noted that transient lower esophageal sphincter relaxation (TLESR) events decreased. They attributed this finding to gastric fundus relaxation secondary to atropine injection. In another study published in 2006 in Gastroenterology, Pandolfino et al showed that several key events leading to opening of the esophagogastric junction have to occur during TLESR for acid reflux to happen. The study was titled “Transient Lower Esophageal Sphincter Relaxations and Reflux: Mechanistic Analysis Using Concurrent Fluoroscopy and High-Resolution Manometry”. The authors state that: “Our current understanding of gastroesophageal reflux draws a fundamental distinction between LES relaxation and esophagogastric junction (EGJ) opening, the latter being essential for reflux to occur. During swallow-induced LES relaxation, for instance, EGJ opening occurs well after relaxation in response to a transmural pressure gradient attributable to peristalsis and intrabolus pressure. However, this mechanism is not operational during TLESR, leaving open the question of how EGJ opening occurs in that circumstance”. The authors rightly conclude that TLSER by itself does not lead to opening of the esophago-gastric junction area. Additional concurrent events have to occur like esophageal shortening, crural diaphragm inhibition, and a positive pressure gradient between the stomach and the esophago-gastric junction lumen for reflux to occur. The Nissen fundoplication mitigate many of these GERD contributing factors leading to durable and effective acid reflux control. LINX device theoretically addresses only one factor. Hence, it is my firm conviction that LINX surgery has limited efficacy and durability for the treatment of GERD. If you suffer from stage 3 or 4 GERD, LINX is not a solution you can depend on. If you suffer from stage 2 GERD, LINX may help you in the short term. With time, however, GERD may continue to progress and esophageal peristalsis may become impaired. Hopefully, quality long-term outcome studies for LINX device will become available in the near future.