By Marti Webb Slay
Surgeons at UAB are finding that the LINX® (Laparoscopic magnetic sphincter augmentation) is giving patients an option besides medication or laparoscopic fundoplication to treat reflux.
LINX is a magnetic device that is similar to a beaded bracelet that stretches apart and then, using the magnets, goes back into place around the esophagus. “Prior devices were fixed so they didn’t expand,” said Britney Corey MD MACM FACS, General Surgery Residency Program Director, Minimally Invasive GI Surgery in the Department of Surgery at UAB. “Over time, there was too much erosion into the esophagus or too much scar tissue. The idea of having magnetic beads was developed so that the beads could pop apart with pressure to let food pass and then come back together. That would protect you from reflux and keep that valve closed. Similarly, if you need to belch or vomit, your stomach can generate the pressure to pop open the beads.”
That ability to belch or vomit is one of the ways LINX can be preferable to the more traditional fundoplication surgery in which the stomach is wrapped around the esophagus. Many patients have difficulty or the inability to belch or vomit following fundoplication which can cause bloating and discomfort. The tissue can also come unwrapped, causing the need for a return to reflux medicine in time.
The LINX device is inserted as an outpatient procedure, and patients must follow a diet of soft food, eating every few hours, for several weeks after surgery. “Any time you put a foreign body into the body, it has a reaction and forms scar tissue,” Corey said. “Scar tissue will form around the LINX, and you don’t want that scar to get tight around the device. So it’s really important for those first few weeks that you regularly open the device. That means you are going to try and eat every two hours while you are awake. Often it’s just one or two tablespoons of food. And we want it to be soft, easy-to-pass-through food. We aren’t confident liquid is enough, so it needs to be applesauce, yogurt, mashed potatoes, or scrambled eggs.
“It’s not necessary to wake every two hours to eat. You don’t have to set an alarm, but if you get up during the night to go to the bathroom, stop by the refrigerator and have a couple of spoonful’s of something. It’s physical therapy for the esophagus, exercising that opening.
“The scar formation is usually heaviest around the two-week mark. That’s when some patients have difficulty swallowing, and they have to work through that. They have to keep eating anyway and keep opening the device. Over time, the scar tissue will start to soften. Oftentimes we will prescribe a steroid dose pack to soften up the scar tissue.”
In order to be a candidate for the LINX procedure, patients cannot have an MRI over 1.5 Tesla. Most patients who qualify see an immediate improvement in reflux. “Sometimes it’s hard to appreciate that right away because you are dealing with other side effects from the surgery like swelling or difficulty swallowing, but if you are going to have success, you are typically going to have it almost immediately,” Corey said.
The device is new enough to make it difficult to determine long-term results for LINX, but all the studies thus far have been promising. “In general, I still think it’s a very good option for the right patient,” Corey said. “The tricky thing is to define who is the right patient. We’ve had great success with patients who have small hiatal hernias, whose most persistent symptom is reflux, and who have normal esophageal function.”
LINX has proven overall to be better than medicines to treat reflux, and about the same for fundoplication, but without the side effects of that more traditional surgery.
“Since some patients with reflux will eventually develop esophageal cancer, having an additional treatment option is important,” Corey said. “Reflux is a big problem, and surgical therapy should never be the first-line treatment, but in patients who have failed medical therapy and made all the lifestyle modifications and are still having reflux, it can really improve their quality of life. It’s always helpful to have options for patients, and that’s what excites us about this.”
