The Lower esophageal sphincter (LES) is among the many small miracles of normal bodily function. It is a one-way valve that allows food to get into the stomach while preventing food and acid back flow into the esophagus. The LES mechanism of action is quite complex. Many anatomic and physiologic properties of the gastro-esophageal area work in harmony to create this one-way valve we call LES. It is crucial to understand how these mechanisms function in order to formulate effective treatment strategies for GERD.
LES function depends on at least three main components:
- Lower esophageal sphincter muscle tone
- The angle at which the esophagus joins the stomach
- Diaphragmatic hiatus: opening in the breathing muscle through which the esophagus enters the abdominal cavity.
If any of these components is not functioning properly, the LES weakens predisposing the patient to acid reflux. The Nissen Fundoplication, considered as the gold standard surgical treatment for acid reflux, corrects all 3 components of LES. In fact, during Nissen surgery the diaphragmatic hiatal opening is completely dissected. The esophagus is freed from surrounding tissue and brought into its original anatomic position. The purpose is to recreate the angle at which the esophagus joins the stomach. This represents a critical step in building an anti-reflux valve. A one-way valve that allows easy, unhampered food flow into the stomach while preventing acid reflux into the esophagus. During surgery, carefully placed sutures in the hiatal muscle ensure adequate closure of the diaphragmatic opening around the esophagus. The upper part of the stomach is then wrapped around the end of the esophagus to stabilize and reinforce the lower esophageal sphincter muscle. As these steps are performed, care is taken not to narrow the LES in order to prevent difficulty swallowing. Because it addresses all three components of the LES, Nissen surgery is a highly effective treatment for acid reflux.
The LINX procedure, on the other hand, targets one single component of the LES: the sphincter muscle tone. LINX device is a band of small magnets placed around the LES with the assumption that it will reinforce the sphincter to prevent acid backflow into the esophagus. LINX surgery does not address the angle at which the esophagus joins the stomach and is in fact, contraindicated in the presence of a hiatal hernia. As a result, most patients suffering from stage 3 and 4 GERD do not qualify for LINX. Several small short-term studies have been published demonstrating the efficacy of LINX in improving heartburn symptoms. Two major concerns are worth noting. The first one is the very high rate of dysphagia (difficulty swallowing) following the procedure. The second concern is related to the long-term consequences of placing a foreign body around the esophagus. The esophagus is a dynamic organ; it is continuously stretching and contracting as it moves food into the stomach. Any foreign object placed in proximity of the esophagus ends up eroding into the esophagus. We have seen this with permanent mesh, Angelchik anti-reflux device, and adjustable gastric banding. LINX device is no exception and the risk of erosion is a major concern.
In conclusion, LINX surgery has no advantage over the Nissen Fundoplication. In fact, LINX surgery has no use in most patients suffering from stage 3 and 4 acid reflux disease. The traditional gold standard procedure for treatment of GERD, when performed by experienced and knowledgeable surgeons, offers reliable, safe and durable acid control. To find out more about the Nissen Fundoplication and how it helps your acid reflux, contact us today.