Janet from Dallas sent us this question: “I had my GERD surgery done 4 years ago. It was the LINX™ procedure. My heartburn went away. Over the past one year I have been having difficulty swallowing my meals. I have lost around 20 pounds and I am currently on liquid diet only. My gastroenterologist recommended endoscopy with balloon dilation. I had this done 2 weeks ago but my swallowing did not improve. He then did a manometry test that showed increased LES pressure. I was told the sphincter is not relaxing due to LINX™ device placement and scar tissue formation. It’s hard to live like this”.
Dear Janet,
I agree with your gastroenterologist’s diagnosis. You have developed dysphagia, difficulty swallowing, secondary to esophageal outflow obstruction 4 years after magnetic sphincter augmentation, LINX™, surgery. LINX™ device causes scar tissue to form around distal esophagus and lower esophageal sphincter (LES). Scarring stiffens esophageal wall leading to decreased esophagus wall compliance. It also limits the ability of lower esophagus sphincter to relax in response to a swallow. Esophageal manometry measures esophagus contraction and sphincter pressure. Manometry is quite useful in evaluating cases of dysphagia or difficulty swallowing.
A recent study titled: “The Impact of Magnetic Sphincter Augmentation (MSA) on Esophagogastric Junction (EGJ) and Esophageal Body Physiology and Manometric Characteristics” was published in the Annals of surgery journal. Using manometry testing at baseline and one year after LINX™ surgery, the authors demonstrate increased outflow resistance at the lower esophageal sphincter. However, esophageal contraction amplitude also increased. This compensation for increased outflow resistance increased intra-bolus pressure and prevented a decrease in bolus clearance. In this study, 4 patients (4%) required device removal secondary to persistent dysphagia or chest pain not relived by up to 3 endoscopic dilations. The small number of events prevented a detailed analysis on factors associated with the risk of device removal. However, there was a trend toward higher lower esophagus sphincter pressure on manometry for these patients. The authors conclude that “it is likely that the compensatory response in esophageal contractility after MSA may have not been sufficient in these patients to facilitate bolus transit across the augmented lower esophagus sphincter”.
We currently don’t have enough data to predict lower esophageal sphincter function years after magnetic sphincter augmentation. In a recent article published in 2023 in the European Surgery Journal, Bonavina et al state: “The mechanism of action and the long-term physiologic effects of MSA on esophageal motility and wall compliance are not completely understood due to the relative paucity of objective high-resolution manometry (HRM) and functional luminal imaging probe (FLIP) data available in the literature”. The article title is: Real world evidence with magnetic sphincter augmentation for GERD: a scoping review.
For now, treatment for patient with dysphagia or chest pain who do not respond to balloon dilation, relies on device removal. LINX™ removal will allow scar tissue to gradually melt away. Repeat manometry one year after surgery is recommended to document resolution of esophageal outflow obstruction and recovery of LES function. A properly performed Nissen fundoplication, at this point, will protect you against acid reflux without hampering food swallowing.