Sam from Houston sent us this question: “I am a 53-year-old male. A Linx device was installed 18 months ago, and I believe is failing, leaving me with tremendous difficultly sleeping, as I must be upright, with a persistent dry cough when I’m not standing straight up and with breathing difficulties after eating. My chest X-ray was clear. There are signs my esophagus has lost some motility on contrast study. Do I need to have the Linx removed before conceding other actions, like Laparoscopic Nissen Fundoplication surgery? Can you remove the Linx, or do I need the physician who installed it to do that?”
Nighttime dry cough and difficulty swallowing are classic symptoms of impaired esophageal emptying. Esophagus motility consists of well-coordinated contractile waves that push food down through lower esophageal sphincter and into stomach. When a contraction starts at the upper esophagus in response to swallowing a food bolus, lower esophagus sphincter immediately relaxes to allow for unhampered food propagation down the esophagus. Lower esophagus sphincter function depends on two components. Active muscle fiber tension and passive stiffness or compliance of esophagus wall and surrounding structures. LINX device placement around the lower esophagus sphincter alters the later component: wall compliance. As a foreign body, LINX device induces scar tissue formation around lower esophagus sphincter leading to increased stiffness or decreased compliance. The degree of compliance change varies from patient to patient. In most acid reflux cases, there is increased compliance (decreased stiffness). Decreased compliance of the esophago-gastric junction is desirable to some extent to stop acid reflux. However, if compliance continues to decrease due to excessive scar tissue formation, esophageal emptying may be hampered.
The esophagus will initially adapt to increased wall stiffness by increasing peristaltic vigor. Over time, however, esophageal muscular contractions gradually weaken, and patient starts to experience dysphagia or difficulty swallowing. Pooling of saliva and gastric secretion in distal esophagus due to poor esophageal clearance causes retrograde fluid movement into the larynx and trachea especially at night. This leads to nighttime cough, aspiration, wheezing, shortness of breath, and adult-onset asthma.
Balloon dilation can be tried to break down scar tissue formation and increase lower esophagus wall compliance. However, studies have shown that late onset dysphagia rarely responds to such an approach. This is particularly true if repeat esophageal manometry shows deterioration in esophageal peristalsis which is typically the case. At this point, LINX device removal is strongly indicated. A Nissen or Toupet fundoplication with redo hiatal hernia repair can be performed at the same time to restore the anti-reflux barrier. Rarely, severe scar tissue formation prevents a concomitant fundoplication and hiatal hernia repair. In this case, LINX is removed, and patient is given 3 to 6 months before re-operation to allow for scar tissue to melt away.