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”.
I agree with your gastroenterologist’s diagnosis. You have developed esophageal outflow obstruction secondary to LINX device 4 years after initial surgery. LINX device has caused 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. Hence, the increased LES pressure on manometry. Esophageal manometry measures esophagus contraction and sphincter pressure. Manometry is quite useful in evaluating cases of dysphagia or difficulty swallowing.
Balloon dilation stretches scar tissue to break it down. Its efficacy however is limited in the presence of foreign body like LINX device especially 4 years after implantation. At this point, scar tissue has spread all over the lower esophagus and it has most likely infiltrated the muscle fibers of LES. The intrinsic LES function of relaxing in response to a swallow is disrupted leading to esophageal outflow obstruction and dysphagia.
Treatment at this point consists of LINX removal and conversion to Nissen fundoplication. 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 will protect you against acid reflux without hampering food swallowing.
LINX, an LES augmentation device, carries the inherent risk of LES damage in the long run. Despite newer recommendations of placing a “loose” LINX device around LES, long-term dysphagia will persist. For scar tissue formation cannot be avoided whether a magnet ring is placed loosely or tightly around distal esophagus. I should mention that long-term outcomes for LINX surgery are still lacking. It would be interesting to repeat manometry on 100 LINX patients 4 years after implantation to check LES function. A study by Bonavina et al published in 2020 in the journal of gastroenterology and motility demonstrated increased LES sphincter pressure, LES relaxation pressure and intrabolus pressure one year after LINX surgery. If these pressure measurements continue to slowly increase, years after implantation, LINX patients will eventually develop dysphagia.