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Melanie Cole (Host):  If your current heartburn treatment isn’t giving you the results you desire, and you’d like to reduce or eliminate dependence on potentially risky medication; there is another option, including a new minimally invasive procedure called LINX. My guest is Dr. Aaron Schwaab. He’s a general surgeon with Stoughton Hospital. So, Dr. Schwaab, what’s typically been the treatment and first line of defense if someone is diagnosed with gastroesophageal reflux or acid reflex disease?

Aaron Schwaab, MD (Guest):  Hi Melanie. Thanks for having me. Well, the first line of defense has typically started with avoiding spicy foods, caffeine, fatty foods; so, diet modification, avoiding alcohol and carbonated beverages. They recommend to prop the head of your bed up at night when you sleep. So, that’s kind of the initial interventions that are recommended to people. We also have medications that block the acid production in your stomach. Because basically, that’s what gastroesophageal reflux disease is, is it’s the stomach contents refluxing up into the esophagus and it’s that acid that causes the symptoms of heartburn and the regurgitation and things like that. So, the different kinds of medications. The most common kind that people are on now are called PPIs or proton pump inhibitors. And just some general statistics about one in five Americans suffer from GERD and there is 20 million patients in the United States on these PPI drugs. But 38% of patients still have symptoms even while taking these drugs. So, it’s a significant health problem in the United States.

Melanie:  And are there complications to untreated GERD, things like Barrett’s esophagus or esophageal cancer? Can any of these things result from untreated GERD?

Dr. Schwaab:  Absolutely. So, about 10-15% of patients with GERD will develop Barrett’s esophagus which are basically some changes in the lining of the esophagus, so it is damage from the acid and the other stomach contents and we know that patients with Barrett’s esophagus have about a 40 times increase risk of esophageal cancer. And incidentally, if you look at the statistics for esophageal cancer in this country; around the same time that these acid blocking medications came out in the mid-80s and you compare the rate of esophageal cancer then to now, there has been about a 600-fold increase in the incidence of esophageal cancer. So, what we are concerned about is that these medications may be improving the symptoms of reflux because they are lowering the acid counts, but in reality, it’s not solving the problem and patients are still having a lot of reflux that could be damaging their esophagus.

Melanie:  So, tell us about the LINX procedure. What is it? How does it work?

Dr. Schwaab:  Right, so the – in order to understand that, I have to give you a little bit of background of what the traditional surgery is for reflux. So the traditional surgery for reflux is something called the Nissen Fundoplication and basically, that’s a procedure where a portion of the stomach is wrapped around the lower esophagus in order to try and bolster that sphincter to help reduce the reflux and that’s a surgery that’s been done for decades and it’s actually been a fairly successful surgery depending on the surgeon that’s doing it, so there’s been some variability in the results. It also changes the entire anatomy of the stomach and it requires often an overnight stay and there’s some dietary restrictions. So, it’s a major operation. So, with the LINX treatment, what that is basically is it’s a little beaded bracelet about the size of a quarter and it is little titanium magnets that we put around the end of the esophagus and those magnets bolster that sphincter rather than having to change the anatomy of the stomach. So, the advantages of doing this is that it is minimally invasive. It is done laparoscopically. Patients typically go home the same day. The procedure takes about an hour. And some of the advantages over the Nissen Fundoplication is that it doesn’t change the anatomy of the stomach. It does not have food restriction, so we actually encourage people to start eating right away after this surgery. Patients generally retain the ability to belch and vomit which with the other surgery, that’s not possible. So, you wrap that stomach around the esophagus and patients couldn’t belch and couldn’t vomit, so they have a lot of gas, bloating and other symptoms that go along with that. And this LINX device is also removable, so that’s kind of the advantage of this over the traditional surgery.

Melanie:  Who’s a good candidate for it? Are there some things that might preclude somebody from having this type of procedure?

Dr. Schwaab:  Yes. So, the candidates are basically, anybody who is taking reflux medication and is still having symptoms of reflux. So, that’s 38% of patients who are taking those pills according to statistics. We also see patients who are on a double dose, so instead of taking these pills once a day, they take them twice a day. Those patients are a candidate for this procedure and then also a lot of patients maybe don’t suffer from heartburn, but they still get the regurgitation type symptoms that go along with reflux and the LINX is excellent for that. So, what we see as far as the benefits of the LINX, is five years post operatively, we see 85% of patients are free of their medications. So, they are free of reflux symptoms and off of their medications. We see 88% of those patients who no longer have heartburn and 99% of those patients no longer have regurgitation. And also, we don’t see the bloating and the gassiness that we talked about with the other surgery. So, those are the benefits of the LINX.

Melanie:  Wow. That’s kind of amazing. So, would they be able to feel this implanted LINX? How is it sized? Is it sort of one size fits all or not really?

Dr. Schwaab:  Not really. There actually are several different sizes and part of the procedure to place the LINX, there is a sizing device that we use so that we can get the exact fit for patients. And actually, the question about whether patients can feel it, is a very good question. Initially, the most common side effect of placing this LINX is something that we call dysphagia. So, patients when they swallow can feel that the food is kind of going through a tighter area in their esophagus and just like if someone has a hip replacement, there is physical therapy for a hip replacement surgery. There is physical therapy after a LINX is placed and we actually have people swallow solid foods and liquid foods on a very regular basis and we see that that dysphagia actually should disappear after about three months post-operatively. That being said, about one percent of these LINX devices have been removed and the most common reason for removing them is that dysphagia or that sensation of things as you are swallowing going through a tighter area. But like I said, the majority of patients after three months do not experience that any longer.

Melanie:  And what about things like an MRI, or airports. Does this kind of device set anything off?

Dr. Schwaab:  So, it’s not going to set off any airport alarms or anything like that. And in fact, it is MRI safe, so up to – there are different levels of MRI machines. The most common MRI machine that we see is something we call the 1.5 Tesla machine. There are some major, like maybe UW and some of the other major health centers that have a3 Tesla or one of the newest state of the art MRIs and the device at this point is not safe for those MRIs, but in a 1.5 Tesla machine, it is safe and worst case scenario if you did have an MRI with this device in and it was a 3 Tesla MRI; it’s not like this thing is going to come tearing out of your body, it basically just demagnetizes it so that it doesn’t work as well anymore. So, that – so it’s not a life-threatening thing if someone where to go in and do an MRI. One thing that we do need to make sure before we place it is that people don’t have an allergy to either titanium or nickel because those metals are included in the device, so if someone were to have an actual allergy to one of those metals we wouldn’t want to place the device.

Melanie:  So speaking of long-term success, and you mentioned that it is not permanent, it can be removed if they have dysphagia that lasts for a certain amount of time or they are very, very uncomfortable with it; but as far as long-term success;, if you were to remove it, then would they have to go back on medications, would they try the Nissen Fundoplication? What are you seeing as far as your patients and results and their happiness with this procedure?

Dr. Schwaab:  So, the large majority of patients are very happy at five years you have basically 90% of patients who are satisfied with the results of the surgery. So, that’s more – that’s much more than you look at the patients who are satisfied with the fundoplication and it’s also more than patients who are just taking the medication. So that’s a higher satisfaction rate. If you do take the device out, they are going to go back to having the reflux that they had before you put the device in and they would have to probably go back on their medications. You wouldn’t probably want to do a Nissen fundoplication in those patients because one of the side effects with that is also the dysphagia problems and actually those dysphagia problems are even more prominent in the Nissen patients. So, I think if you were to have it removed, you would probably be saying to that patient that they are just going to have to take the medications at that point.

Melanie:  So, since GERD can be silent, what do you want people to know as a wrap up Dr. Schwaab, about GERD, about the fact that it can be silent, not everybody feels it, or notices that heartburn feeling and getting checked or possibly preventing it and what would like them to know about the LINX procedure, if they are diagnosed with GERD?

Dr. Schwaab:  Well as far as it being silent, it’s true that there are some patients who have some atypical symptoms, so there’s some respiratory symptoms, so people can have voice hoarseness, or coughing of persistent cough, those kind of things but most patients who are having pathologic reflux meaning it’s abnormal, the large majority of them are going to have some sort of symptoms of either regurgitation or heartburn or as I said some of the more atypical symptoms of voice hoarseness or chronic cough, so we don’t see that many patients who have real pathologic silent reflux. As far as the patients – what I would like them to know about LINX is that ask your doctor if you or someone who is taking one of these PPI medications, certainly if you are someone who is taking them and still having symptoms or unhappy with the way you are feeling on these medications or if you are finding that the dose of the medications is increasing, you are potentially a very good candidate for this LINX procedure.

Melanie:  Thank you so much. It’s great information and such an interesting procedure. Thank you for sharing your expertise with us today. This is Stoughton Hospital Health Talk and for more information you can go to www.stoughtonhospital.com that’s www.stoughtonhospital.com. This is Melanie Cole. Thanks so much for tuning in.