LINX
On the many on-line forums and facebook groups I frequent, I am often asked my views of the LINX procedure instead of fundoplication.
The following are only my personal views:
It may be the best artificial augmentation device for the Lower Oesophageal Sphincter but newer and more expensive doesn't necessarily mean better.
It has been heavily promoted, particularly in America, gaining news coverage whenever a hospital or clinic starts offering this new technique, and it looks "pretty".
You will find many people who are definitely pro LINX. Personally, although I am not anti-LINX, I am a bit guarded and definitely pro Laparoscopic Nissen Fundoplication (LNF).
Most of my gastroenterologist friends, colleagues and surgeons are anti-LINX. You need to weigh up pros and cons to decide and getting feedback from those who have had it implanted is a good first step. What we don't know yet, and they can't tell you, is how it will last over a lifetime.
LINX pros:
It's ring of magnetic beads help close the lower oesophageal sphincter.
The surgery for this is slightly less invasive and slightly shorter than for LNF and there is less (internal) healing for the body to do. It has been available for nearly 15 years. The operation is minimal and patients can go home the next day with some able to go home the same day.
You can eat normally afterwards.
If it doesn't work or goes wrong, it can be removed and LNF performed instead.
A "long term" study over 6 years (with a mean implantation time of 3 years) of 100 recipients showed 85% of them no longer required daily PPIs for acid reflux and were glad they had had the procedure.
LINX cons:
It costs over twice as much as LNF.
It cannot be used in everybody (depends on presence of Barrett's and hiatus hernia).
If needed, MRI scans can only be at low power.
63% of recipients experience swallowing difficulties.
LINX unknowns:
Will it migrate or erode the adventia (outer wall of oesophagus) over time? 40 years ago, a new device was being enthusiastically embraced. Angelchik was effectively a broad gel rubber band / collar attached around the oesophagus that kept the oesophagus closed by elasticity. However over a long period, it's movement against the adventia caused gradual erosion. Migration and erosion issues occurred causing a clamour of patients having it removed.
(In 2010, a director of Torax medical admitted to me they had concerns over possible migration and erosion issues of the LINX device over time.)
LNF pros:
It is the gold standard for reflux reduction surgery.
Nissen fundoplications have been used for 60 years with surgeons becoming more expert and techniques improving all the time. It has been performed laparoscopically for over 20 years.
The operation is minimal with patients able to go home the next day (and some on the same day as their operation).
It uses natural body tissue with similar elasticity to the organ it surrounds.
A recent study of nearly 200 patients who had LNF 20 years ago found 94% satisfaction with it.
There is no risk of erosion or migration.
Any hiatus hernia will be corrected and the Nissen wrap prevents it from recurring.
It can be performed if the patient has Barrett's.
LNF cons:
85% of patients experience problems with burping or vomitting whilst the scar tissue heals.
50% of patients have swallowing difficulties while the scar tissue heals. Soft foods are required at first but you can eat normally within a few weeks.
In the 20 year study, the wrap had failed in 18% of patients, when it can be redone. (Newer techniques mean that failure rates are now estimated to be only around 5%.)
LINX vs LNF mistruths:
LINX has been heavily promoted in USA. Every time a new clinic offers the treatment it gets press coverage and being "New" and with the device looking "sexy" it is a popular choice until patients find their insurance may not pay for it. In UK, it has received NICE approval but the cost (together with the reservations expressed above) means it's not easily available on NHS.
Torax medical who make LINX sell it on its being removable if it goes wrong and you can still get LNF. (That's like selling you a Ferrarri that may not run and being told if it goes wrong, you can still buy a Ford.)
They say LNF cannot be undone. If necessary it can, but who'd want to?
They also make a big deal about the burping and vomiting issues but cover up their dysphagia issues.
See the pages on Reflux reduction on the Down With Acid website for details of LNF, LINX and other reflux reduction technologies that have been tried or recently introduced.
TIF
I'm similarly not impressed by TIF (Transoral Incissionless Fundoplication.
The chapter on TIF in Down With Acid, here, cites some of the many studies which crucially show effectiveness as:
"Global assessment revealed that 56% of patients were “cured” of their GERD based on the clinically significant reduction of their heartburn and complete cessation off PPIs."
"By the 12-month follow-up, ... only 29% had normalization of distal esophageal pH and 44% still required PPIs on a daily basis."
"Although TIF resulted in an improved GERD-related quality of life and produced a short-term improvement of the antireflux barrier in a selected group of GERD patients, no long-term objective reflux control was achieved."
One surgeon went on the record with: "The procedure should not currently be recommended for a GERD patient still symptomatic on PPIs,"
In a survey I conducted of 200 refluxers, only one had had TIF which he said had not benefitted him. 50 had had Nissen Fundoplication and one had had Linx. They had all seen benefits.
Although its been improved, the underlying remaining problem with TIF is the staples pull out.
This article in Healthy Living magazine, "TIF Underperforming As Long-Term GERD Treatment" looks at a study published in 2015:
"Dr. Robert A. Ganz from Minnesota Gastroenterology and University of Minnesota in Minneapolis told Reuters Health, "Numerous uncontrolled trials have demonstrated rapid deterioration of TIF results. Since the TIF procedure does not allow mobilization of the gastric fundus, tension on the wrap causes the TIF fasteners to pull apart. The TIF procedure has no proven long-term benefit."
""The procedure should not currently be recommended for a GERD patient still symptomatic on PPIs," Dr. Ganz, who was not involved in the new work, said in an email."