LINX, Sleeve and Heartburn treatment in Houston?

Sleeve gastrectomy when properly performed is almost as good as a Nissen fundoplication in alleviating heartburn and effectively resolving acid reflux. Unfortunately, narrowed or twisted gastric sleeve lumen at the incisura angularis results in severe acid reflux as well as hiatal hernia development. A number of acid reflux specialist in Houston have advocated the use of LINX surgery for treatment of de novo acid reflux following sleeve gastrectomy. LINX surgery, however, is not likely to stop acid reflux for a number of reasons. First, the FDA approved indications for LINX surgery for treatment of acid reflux are limited and do not extend to sleeve gastrectomy patients. Second, there are no real studies evaluating the use of LINX surgery for acid reflux treatment in this situation. Few case reports of limited follow up duration have been published in the literature but are of no scientific value. Third, acid reflux and heartburn pathogenesis following sleeve gastrectomy is most likely not related to transient lower esophageal sphincter relaxation, TLESR. Therefore, LINX, a sphincter augmentation device, is not likely to work in the setting of a sleeve. TLESR has been extensively studied in an intact stomach as an important cause for acid reflux. I suspect that when the gastric fundus is resected, transient lower esophageal sphincter relaxation resolves. For this reason, a properly performed sleeve gastrectomy that entails complete gastric fundus resection without narrowing at the level of the incisura angularis results in acid reflux resolution.

New onset or worsening heartburn following gastric sleeve surgery is a sign of poorly performed surgery. Augmenting the lower esophageal sphincter with LINX device is not likely to resolve heartburn in these cases. The only effective solution is conversion to Roux-en-Y gastric bypass and repair of hiatal hernia if present.