LINX Procedure and Bariatric SurgeryMarch 30, 2020
Roux-en-Y gastric bypass is a widely accepted procedure for patients with the disease of obesity and intractable gastroesophageal reflux disease (GERD). Many experts believe that the sleeve gastrectomy does not reliably relieve or improve GERD symptoms and may induce GERD in some previously asymptomatic patients. Medical therapy is the first-line therapy for GERD after sleeve gastrectomy. The LINX procedure might be an option for you to help with GERD.
Options are very limited for those who continue to suffer from reflux despite maximal medical therapy. For patients that have had a sleeve gastrectomy and develop GERD, the LINX procedure may be a safe and effective choice.
GERD, Sleeve Gastrectomy & Roux-en-Y Gastric Bypass
Patients with acid reflux symptoms that are perusing weight loss surgery have done better with Roux-en Y gastric bypass over the sleeve gastrectomy.
Gastric bypass, by nature of the procedure, is an effective anti-reflux surgery in addition to its metabolic and weight-loss effects. Although sleeve gastrectomy is now the most commonly performed bariatric procedure in North America, 1 in 11 patients who didn’t have GERD before gastrectomy developed the condition after their procedure (Goodman, 2014).
In a study published in JAMA Surgery Feb 5, 2014, researchers looked at over 4,800 patients that had sleeve gastrectomy and 34,000 that had gastric bypass. Before the study, 45 percent of the sleeve group and 50 percent of the gastric bypass group had reported GERD symptoms.
Six months postoperatively, 84 percent of the sleeve patients continued to have symptoms, and 9 percent stated that the symptoms worsened. In contrast, 63 percent of the gastric bypass group saw a complete resolution of their symptoms. In addition, 9 percent of patients that did not have preoperative GERD symptoms before undergoing sleeve gastrectomy developed symptoms after surgery.
Treatment of reflux includes various life-style changes (avoiding certain foods that weaken the lower esophageal sphincter (LES), raising the top of the bed 30 degrees, avoiding eating right before bed, etc.) in addition to medications (antacids, H2-blockers, proton pump inhibitors). Daily or sometimes twice daily proton pump inhibitors are the most effective therapy and are often available over-the-counter. Unfortunately, some patients continue with intractable reflux despite these modalities.
Surgical options exist for patients with intractable reflux. Repair of any associated hiatal hernia with a fundoplication (either full or partial wrapping of the stomach) is the traditional surgical therapy and offers excellent reflux control. Sometimes, however, patients complain of bloating and difficulty belching/vomiting after fundoplication.
In sleeve gastrectomy patients, there is no stomach left to wrap, so fundoplication is not an option. Traditionally, sleeve gastrectomy patients that remain unresponsive to medication and other conservative management attempts are traditionally treated by surgically converting to Roux-en Y gastric bypass.
The LINX Procedure and Bariatric Surgery
In 2012, the LINX device was approved by the FDA for the treatment of GERD. As defined by the FDA Summary of Safety and Effectiveness Data (SSED), the LINX reflux management system is a sterile, single-use, surgically placed device used to treat the symptoms associated with GERD.
The device is placed at the area of the lower esophageal sphincter (LES) and is designed to augment it and hence minimize or eliminate GERD related symptoms. It is intended to strengthen the LES barrier function while preserving the normal physiology. It consists of a ring of magnetic beads which can spread apart by the force of esophageal peristalsis, thus allowing liquid and food to pass.
To work properly, the esophagus must have a normal contractile function. Poor esophageal peristalsis can result in food becoming stuck and result in dysphagia. To prevent reflux, the magnetic bead will not open by normal intragastric pressure, thus preventing acid and bile in the stomach from refluxing into the esophagus. The gastric force generated by belching and vomiting, however, will allow the magnetic bead to open. Hence there are less bloating side effects of the LINX compared with traditional fundoplication.
LINX is an outpatient surgery and is easily reversable should there be a need.
The LINX System is currently not approved for the use in patients that have had bariatric surgery. Still, several centers are currently participating in studies on LINX in post sleeve gastrectomy patients with intractable GERD. It is known that several patients have been treated this way as an “off-label” use.
In 2015, the Department of Minimally Invasive Surgery at St. John Hospital and Medical Center, Detroit, MI, performed a laparoscopic placement of a LINX System to treat severe reflux in a 25-year old female patient that had undergone sleeve gastrectomy surgery. This case opened the door for alternative management of this problem while maintaining the original sleeve gastrectomy (Hawasli, Tarkji, & Tarough, 2016).
Reflux after sleeve gastrectomy is a serious issue with few treatment options beyond medical therapy or conversion to gastric bypass. The LINX System is a promising safe, and reversible procedure for patients that experience the increased or new symptoms of GERD after sleeve gastrectomy surgery that fails medical management.
If studies continue to verify its safety and efficacy, it will likely be approved for this use as a less invasive means to cure intractable reflux in sleeve gastrectomy patients.
- Goodman, B. (2014). New Weight-Loss Surgery May Not Ease Heartburn. Web MD. Retrieved from https://www.webmd.com/heartburn-gerd/news/20140205/new-weight-loss-surgery-may-not-ease-chronic-heartburn#1
- Hawasli, A., Tarakji, M., & Tarboush, M. (2016, Nov 29). Laparoscopic management of severe reflux after sleeve gastrectomy using LINX system: Technique and one year follow up case report. PMC. US National Library of Medicine. National Institute of Health, 30(), 148-151. http://dx.doi.org/10.1016/j.ijscr.2016.11.050
- Mann, MD, O. (2017, Jan 3). LINX to resolve reflux after sleeve gastrectomy. Advances in Surgery Channel. Retrieved from https://aischannel.com/society/linx-to-resolve-reflux-after-sleeve-gastrectomy/
- Surgical Treatment for Heartburn or Gastroesophageal Reflux Disease (GERD). Retrieved from http://surgery.ucla.edu/bariatrics-anti-reflux-surgery
- Desart, K. Rossidis, G. Michel M. et al. Gastroesophageal Reflux Management with the LINX System for Gastroesophageal Reflux Disease Following Laparoscopic Sleeve Gastrectomy. Journal of Gastrointestinal Surgery. Oct 2015. 1782-6
ABOUT THE AUTHORRichard S. Gordon, MD, FACS, FRCSC, FASMBS is a board-certified general surgeon specializing in the treatment of obesity with minimally invasive bariatric surgery. He is a proud member of the Tampa Bay Surgical Group and the Director of Advanced Surgical Associates/Tampa Bay Surgical Group, LLP. Dr. Gordon is also on staff at Largo Medical Center, Mease Countryside Hospital, Mease Dunedin Hospital, and Morton Plant Hospital. As an integral part of the Largo Medical Center Residency Program, Dr. Gordon serves as an educator to future surgeons.