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Melanie Cole (Host): UAB Med Cast is an ongoing medical education podcast. The UAB division of continuing education designates that each episode of this enduring material is worth a maximum of .25 AMA PRA category 1 credit. To collect credit please visit www.uabmedicine.org/medcast and complete the episode’s posttest.

If your patient’s current heartburn treatment is not giving them results and you’d like to reduce or eliminate dependence on medication; there’s a minimally invasive option, the LINX procedure. We’re talking about it today in this panel discussion. My guests are Dr. Abhisek Parmar. He’s an Assistant Professor and a Minimally Invasive General Surgeon, Dr. Jayleen Grams. She’s an Associate Professor and a Minimally Invasive Foregut Surgeon and Dr. Britney Corey. She’s Fellowship trained Minimally Invasive Gastrointestinal Surgeon specializing in foregut and anti-reflux operations and they are all with UAB Medicine. Doctors, thank you so much for joining us today. Dr. Parmar, I’d like to start with you. What had been the typical treatment after first line of defense for GERD. Tell us about Nissan Fundoplication and why there was a need for newer treatments.

Abhisek Parmar, MD (Guest): Sure so, the conventional medical therapy for reflux, I think most people in America know is the proton pump inhibitor that decreases the amount of acid in the stomach. But the surgical treatment that’s the Nissan Fundoplication which is usually done minimally invasively and almost I think at UAB done exclusively minimally invasively through small incisions where the proximal part of the stomach is kind of wrapped around the distal esophagus to create kind of a valve, a one-way valve that prevents acid from going back up into the chest. The Nissan Fundoplication has been around for decades. It’s well-established. It works very well. Usually 90% of people will be off PPIs in the long term, five to ten years after surgery.

But there are certainly side effects to having Nissan Fundoplication. Patients can have a gas bloat syndrome where gas is kind of trapped in the stomach. There’s an inability to belch. And there’s inability to vomit. So, those are some side effects of the Nissan procedure. But it does work very well for refractory reflux.

Host: Dr. Grams, what is LINX? How does it work?

Jayleen Grams MD (Guest): So, LINX is the commercial name for something that generically would be called a magnetic sphincter augmentation device. And it’s a ring of little magnets, like magnetic beads that both expand and contract with a food bolus. So, unlike a Nissan which is kind of a fixed floppy wrap 360 degrees around the esophagus; this little magnet gets placed around the esophagus, the distal esophagus and when the patient swallows a food bolus; or liquids, it expands and then after the bolus passes, it contracts again. And so, this might be a more physiologic method to help reflux. And it may prevent things like the gas bloating because patients are usually able to belch and vomit.

Host: That’s a really good point. Dr. Corey, please expand on this for us. Compare and contrast Nissan and LINX for us and tell us some of the advantages of LINX over Nissan and some additional symptoms that are not so much seen with LINX.

Britney Corey, MD (Guest): When my patients come to see me in clinic the ability to vomit is something they are always very concerned about. And we think that LINX long term will give them that ability and that it will really replicate what their lower esophageal sphincter should be doing which is protecting them from reflux. But opening normally to allow their food to go down and then once their food goes down, it closes, and everything stays down.

So, I think as already mentioned, the real advantage is that patients once they recover from their operation and heal up is that they are hopefully not going to really notice that anything is different beyond the fact that their reflux is well-controlled and better controlled. So, ability to release gas off their stomach or belch more normally, to vomit and also typically there’s a little bit less dissection required during the operation with the LINX and so we don’t have to disrupt as many of the normal attachments that are there in that area and it’s possible that doing less is going to also help with the recovery and the symptoms that the patients will experience long term as far as advantages.

Another advantage in the immediate postoperative period is that we are a little bit more aggressive about feeding these patients and letting them eat more frequently and so patients may experience a little bit better of a recovery we hope. And in that after a Nissan Fundoplication typically on a pureed diet for two weeks after surgery and a lot of patients just have a rough time during those two weeks. It’s hard to take in as many calories through a pureed diet. So you don’t feel quite as perky and we would hope that patients after the LINX procedure will be able to get back to their normal activities and normal eating a little quicker.

Host: Dr. Parmar, who’s a good candidate for this procedure?

Dr. Parmar: Well I think the one thing that patients may not realize is that there’s a lot of work and preoperative evaluation that goes into determining whether or not anyone is a candidate for surgical therapy for reflux. So, one thing I tell my patients, anytime I’m going to mess with someone’s swallowing ability, I want to make absolutely sure I’m doing it for the right reasons, and I have all the information I need. So, there are a number of tests that patients have to undergo and I’m quite frank with them. The tests aren’t very comfortable, there’s a high resolution manometry test where a tube is placed down their nose into their esophagus and stomach and they are asked to swallow and there’s a pH probe and endoscopy and esophagram where they have to drink this chalky substance.

So, it is uncomfortable. Most of the patients who come to see us are kind of fed up with the lack of relief they’ve gotten with their current medical therapy of reflux. And they really want a more salient approach that’s going to last a long time. So, if someone has normal motility on the tests and they have absolutely pathologic reflux on their pH study, then those are the people who would be candidates for a LINX, just the same as those who would for a Nissan.

Host: Dr. Parmar, sticking with you for a second. Sometimes there’s more than just physiological origin such as a weakened lower esophageal sphincter or hiatal hernia that can’t be managed by medications and lifestyle changes alone. Tell us about that.

Dr. Parmar: Absolutely yeah so, I think hiatal hernias are also extremely common. In fact, probably all four of us may have some component of a hiatal hernia. So as I think Dr. Grams mentioned, there is a pathophysiologic basis for how reflux occurs and a big part of it is the failure of the lower esophageal sphincter which is made up of the diaphragmatic fibers and also the way the stomach is kind of oriented specifically in space there. So, if the stomach slides up into the chest, those patients are a lot of times at risk for developing reflux. Not always, but many times that’s the case.

So, again, that lends to the need for the preoperative workup because it will identify those kinds of things that could potentially be corrected surgically and anytime, we place a LINX, we absolutely repair a hiatal hernia at the same time. Just as we would with a Nissan.

Host: Well thank you for that answer. So, Dr. Grams, what have been your outcomes and have there been post approval studies that you know about? Tell us what you’ve seen.

Dr. Grams: Well to answer your first question what have the outcomes been, I think and all three of us have been placing these now and I think for all three of us, we found that our patients have done great. The patients that I personally have done, I’ve seen them all in follow up and they’ve been really happy with the results and they were really happy that they had the LINX procedure.

One of the patients particularly, she was afraid of having the Nissan because she had known family or friends who had previously had the procedure and had significant complications. So, for her, it was – she would have been a candidate for a LINX or a Nissan but for her, it was LINX or nothing. So, I was really glad that UAB is able to now offer this procedure to patients.

In terms of I think you asked me about postop studies. The studies with the LINX have actually been really promising. We, at UAB, we were not the first to jump on the bandwagon because we kind of wanted to see how longer term outcomes were going to be. We are still waiting for long term outcomes, ten year follow up, et cetera, but initially, the outcomes are really good. They’ve learned a lot along the way with placing the LINX. The device has been adjusted. The sizing has changed, the indications have changed and so I think we’re really in a good place right now for offering this to our patients.

Host: Dr. Corey, tell us a little bit about the procedure itself and how is it sized and give a little technical considerations for us.

Dr. Corey: So, the set up for the operation is very similar to the Nissan Fundoplication. It still requires five small incisions through the abdominal wall and into the abdomen. We do this using long instruments that go through small trocars inserted into the abdominal wall and that allows us to access the abdomen and its contents through these small incisions and really give patients a quicker recovery and of course, less chance of hernias and et cetera.

Once we get into the abdomen, we are going to go up and focus on the stomach and lower esophagus. So, as previously mentioned, if there’s a hiatal hernia, where a portion of the stomach has slid up into the chest; we will pull down the stomach and release all the attachments that it has up into the chest, and we will suture back together that hiatal opening that is allowing the stomach to slid up there. So, we will tighten that back into place as it should be. And then we’ll turn our attention to the lower esophagus where we create a window around the esophagus and there is a sizer that we use to determine the size of the esophagus and what would be the appropriate size of the magnetic sphincter augmentation device or the LINX device.

So, once that’s determined, we open the device and essentially the sizing determines the number of magnetic beads. We place the magnetic beads around the esophagus, and these are all – these are on a string and so we have to clasp them or attach them together very similar to how you would attach a necklace. So, once we clasp them, then we will pass an EGD or a camera down the throat into the esophagus and all the way down into the stomach and we will then look back on that opening, the lower esophageal sphincter or the gastroesophageal junction where the esophagus meets the stomach and we want to just make sure that the device is appropriately closing that lower esophagus around the scope.

So, that gives us an idea of if it’s in the right position and if it’s doing its job properly and as long as everything looks great; then we remove the scope and take out all of our trocars and sew up our incisions and that completes the procedure. The patients will then go to the recovery room where they will begin a soft diet in the recovery room. And we ask them to snack every two hours when they are in the hospital and really for the first couple of weeks to allow that lower esophageal sphincter, those magnetic beads, to open and close frequently as they are recovering and as the LINX device is settling in.

There is some scar tissue that can form in the immediate postoperative period and so we don’t want that scar tissue to get too tight. So, that is why we ask them to eat frequently. We also, the following morning will get a swallow study where they will go to the radiology department and drink some contrast and that gives us a view to make sure that everything is in good position and also to have a comparison for in the future if anything comes up. If there are any problems that arise.

Host: Dr. Parmar, as you do yours would you please tell us if the patients still need meds for reflux, will they be able to feel it, when can they eat normally again? Just a few of the basics for other providers that they can counsel their patients on when they are considering this procedure.

Dr. Parmar: Sure. I think the first thing I understand for me and is most striking about the LINX compared to the Nissan is really like Dr. Corey mentioned, the postoperative care. Traditionally after a Nissan, patients will be on a liquid and a pureed diet for four to six weeks after surgery. But with the LINX, they eat, and they really need to be eating normally right after surgery. And for me, that’s a little bit of a game changer when it comes to considering surgical therapy for reflux. In the old days and kind of like we’ve been talking about, most of the time, people start up with a PPI first and then consider surgery only after they absolutely have to.

With the LINX device, the fact that patients can eat pretty quickly, and they actually need to eat, I think has really changed how these patients are managed and how we think about the surgical treatment. I think one of the things to consider that makes UAB a real powerful place to visit for anti-reflux surgery, whatever it may be whether it’s a Nissan or a LINX; is that as this podcast demonstrates, it’s very collaborative atmosphere here. We are not just one surgeon operating alone. There’s at least three of us here who do this operation and we all meet twice a month to discuss cases that are complicated.

So, if you come to UAB as a patient, you are considering anti-reflux surgery or really any treatment for a hiatal hernia or paraoesophageal hernia; you are not just getting the opinion of one surgeon. You are getting the opinion of three kind of experts in their field and I think that’s a really powerful thing to be able to offer as a single institution.

Host: I agree with you completely. It’s very multidisciplinary and comprehensive approach. So. Dr. Grams what would you like other providers to know about the LINX procedure and your comprehensive approach at UAB?

Dr. Grams: In terms of the LINX procedure, I think what I would like other providers to know is that first we obviously think that this is going to benefit patients, or we would not offer it to patients. And I think the Nissan Fundoplication has been around for so long and has really been the standard of care but as has been mentioned throughout this podcast, there have been side effects of it. And so, this is a really exciting new therapy we can offer patients for reflux. And it makes physiological sense in the sense that the magnet expands and contracts whereas other things that we’ve place around the stomach or esophagus in the past for whatever reasons has really been fixed including the Nissan although it is floppy.

And so, presumably, this will be a viable good alternative treatment for reflux. On the other hand, I would like to balance that with knowing that we are still really early in our experience with LINX. The Nissan has been around for decades. This while not brand new, we’re still waiting for five, ten, year longer follow up to really be able to see what’s the durability, what are the long term outcomes of this device. And so, while we are enthusiastic about it; I would just balance that with knowing that we still need to know what the longer term outcomes are going to be.

And so, I think Dr. Parmar briefly touched on this in that it is a multidisciplinary approach and we see quite a few patients who come to us because they’re concerned about what they hear in the news or see in reports about the risks of being on long term PPI therapy. And I think having the multidisciplinary conference, having gastroenterologists engaged, the surgeons engaged really helps us discuss the pros and cons, benefits, risks, of each of these interventions with the patients but also among ourselves to really give the best picture to the patient.

Host: And Dr. Corey, last word to you. What would you like patients, other providers to know about the LINX procedure and how it can help in the long term?

Dr. Corey: I think I would like other providers to know that we are always happy to see their patients and to have a discussion in clinic face to face with the patient about options and sometimes that options is just to continue therapy and to keep surgery on the back burner and see how they are treated. But we are happy to give them our experience, give the patients our experience and always happy to discuss patients on the phone or via our secure messaging system here so that we can just make sure that we are taking a kind of 360 degree view of the patient and approach to the patient in considering all options for them beyond just medical therapy.

So, that’s what I would like other providers to know. We are always happy to pick up the phone. For patients, I would like to echo what my partners have said about the multidisciplinary approach but also just let them know that we have outstanding people that are working here with the patient in the GI lab where we do testing. Our techs are wonderful people who really do everything they can to make some uncomfortable tests as comfortable as they can be. And that everybody here is really dedicated to taking a very thoughtful approach to the treatments that we offer because we want to do what’s best for the patient.

There’s no better feeling as a provider, as a physician than having our patients come back to clinic and be excited about how for the first time in five, ten, fifteen years they have been able to sleep lying flat and not experience this intense burning in their chest and are able to really get their symptoms managed and back under control. And we all really appreciate that, and we want to do what’s best for our patients and give them relief from their heartburn.

Host: Thank you so much, all of you and thank you for coming on and sharing your expertise and explaining to other providers this procedure and the technical considerations and the advantages. Thank you again.

A community physician can refer a patient to UAB Medicine by calling the MIST line at 1-800-UAB-MIST. That wraps up this episode of UAB Med Cast. For more information on resources available at UAB Medicine, please head on over to our website at www.uabmedicine.org/physician. If as a provider, you found this podcast as informative, as I did, please share with other providers. Share it with your patients, share on social media and be sure not to miss all the other fascinating podcasts in the UAB library. Until next time, this is Melanie Cole.