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Eriksson SE, Sarici IS, Zheng P, Gardner M, Jobe BA, Ayazi S. Magnetic Sphincter Augmentation for Laryngopharyngeal Reflux: An Assessment of Efficacy and Predictors of Outcome. J Voice 2024:S0892-1997(24)00098-5. [PMID: 38641520 DOI: 10.1016/j.jvoice.2024.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/20/2024] [Accepted: 03/21/2024] [Indexed: 04/21/2024]
Abstract
INTRODUCTION Magnetic sphincter augmentation (MSA) is an effective treatment for typical reflux symptoms, but data on its impact on laryngopharyngeal reflux (LPR) is limited. This study aimed to determine the efficacy of MSA for LPR and to identify predictors of outcome. METHODS This was a retrospective review of 775 patients who underwent MSA between 2013 and 2021. LPR was defined as presence of atypical reflux symptoms and a reflux symptom index (RSI) score >13. Favorable outcome was defined as primary symptom resolution, freedom from proton pump inhibitors, and five-point improvement or RSI score normalization. Preoperative clinical, high-resolution manometry, and impedance-pH data were analyzed for impact on favorable outcome using univariate followed by multivariable analysis. RESULTS There were 128 patients who underwent MSA for LPR. At a mean (SD) follow-up of 13 (5.4) months, favorable outcome was achieved by 80.4% of patients, with median (IQR) RSI score improving from 29 (22-35) to 9 (4-17), (P < 0.001). Independent predictors of favorable outcome on multivariable analysis included LPR with typical reflux symptoms [OR (95% CI): 8.9 (2.3-31.1), P = 0.001], >80% intact swallow on high-resolution manometry [OR (95% CI): 3.8 (1.0-13.3), P = 0.035], upper esophageal sphincter (UES) resting pressure >34 mmHg [OR (95% CI): 4.1 (1.1-14.1), P = 0.027] and short total proximal acid clearance time [OR (95% CI): 1.1 (1.0-1.1), P = 0.031]. Impedance parameters including number of LPR events, full column reflux and proximal acid exposure events were similar between outcome groups (P > 0.05). CONCLUSION MSA is an effective surgery for patients with LPR. Patients with concomitant typical reflux symptoms, normal esophageal body motility, and competent UES benefit the most from surgery. Individual impedance-pH parameters were not associated with outcome.
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Affiliation(s)
- Sven E Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania; Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Inanc S Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania; Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Ping Zheng
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Margaret Gardner
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - Blair A Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania; Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania; Department of Surgery, Drexel University, Philadelphia, Pennsylvania
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, Pittsburgh, Pennsylvania; Chevalier Jackson Research Fellowship, Esophageal Institute, Western Pennsylvania Hospital, Allegheny Health Network, Pittsburgh, Pennsylvania; Department of Surgery, Drexel University, Philadelphia, Pennsylvania.
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Wisniowski P, Putnam LR, Gallagher S, Rawal R, Houghton C, Lipham JC. Short term safety of magnetic sphincter augmentation vs minimally invasive fundoplication: an ACS-NSQIP analysis. Surg Endosc 2024; 38:1944-1949. [PMID: 38334778 PMCID: PMC10978616 DOI: 10.1007/s00464-024-10672-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 12/30/2023] [Indexed: 02/10/2024]
Abstract
PURPOSE Magnetic Sphincter Augmentation (MSA) is an FDA-approved anti-reflux procedure with comparable outcomes to fundoplication. However, most data regarding its use are limited to single or small multicenter studies which may limit the generalizability of its efficacy. The purpose of this study is to evaluate the outcomes of patients undergoing MSA vs fundoplication in a national database. MATERIALS AND METHODS The 2017-2020 American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) Registry was utilized to evaluate patients undergoing MSA or fundoplication. Patients requiring Collis gastroplasty, paraesophageal hernia repair, and emergency cases, were excluded. Patient outcomes included overall complication rates, readmissions, reoperations, and mortality. RESULTS A total of 7,882 patients underwent MSA (n = 597) or fundoplication (n = 7285). MSA patients were younger (51 vs 57, p < 0.001), and more often male (49.6 vs 34.3%, p < 0.001). While patients undergoing MSA experienced similar rates of reoperation (1.0 vs 2.0%, p = 0.095), they experienced fewer readmissions (2.2 vs 4.7%, p = 0.005), complications (0.6 vs 4.0%, p < 0.001), shorter mean (SD) hospital length of stay(days) (0.4 ± 4.3 vs 1.8 ± 4.6, p < 0.001) and operative time(min) (80.8 ± 36.1 vs 118.7 ± 63.7, p < 0.001). Mortality was similar between groups (0 vs 0.3%, p = 0.175). On multivariable analysis, MSA was independently associated with reduced postoperative complications (OR 0.23, CI 0.08 to 0.61, p = 0.002), readmissions (OR 0.53, CI 0.30 to 0.94, p = 0.02), operative time (RC - 36.56, CI - 41.62 to - 31.49. p < 0.001) and length of stay (RC - 1.22, CI - 1.61 to - 0.84 p < 0.001). CONCLUSION In this national database study, compared to fundoplication MSA was associated with reduced postoperative complications, fewer readmissions, and shorter operative time and hospital length of stay. While randomized trials are lacking between MSA and fundoplication, both institutional and national database studies continue to support the use of MSA as a safe anti-reflux operation.
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Affiliation(s)
- Paul Wisniowski
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Luke R Putnam
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Shea Gallagher
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Rushil Rawal
- California University of Science and Medicine, Colton, CA, USA
| | - Caitlin Houghton
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - John C Lipham
- Division of Upper GI and General Surgery, Department of Surgery, Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA.
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Peine BS, Denning MT, Brea F, Wolf SE, Bethea JP, Speicher JE, Anciano CJ. Esophageal magnetic sphincter augmentation following bariatric surgery improves quality of life and reduces proton pump inhibitor usage. J Gastrointest Surg 2024; 28:72-74. [PMID: 38353078 DOI: 10.1016/j.gassur.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 09/01/2023] [Accepted: 10/28/2023] [Indexed: 02/16/2024]
Affiliation(s)
- Brandon S Peine
- Department of Cardiovascular Sciences, East Carolina University Brody School of Medicine, Greenville, North Carolina, United States.
| | - Michael T Denning
- East Carolina University Brody School of Medicine, Greenville, North Carolina, United States
| | - Fernando Brea
- Department of Cardiovascular Sciences, East Carolina University Brody School of Medicine, Greenville, North Carolina, United States
| | - Seth E Wolf
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina, United States
| | - Joseph P Bethea
- Department of Surgery, East Carolina University Brody School of Medicine, Greenville, North Carolina, United States
| | - James E Speicher
- Department of Cardiovascular Sciences, East Carolina University Brody School of Medicine, Greenville, North Carolina, United States
| | - Carlos J Anciano
- Department of Cardiovascular Sciences, East Carolina University Brody School of Medicine, Greenville, North Carolina, United States
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Sujka J, McEwen C, Sandhu M, Sunderland M, Mhaskar R, Mooney A, DuCoin C. Staple Line Bacterial Load May Not Be a Contra-Indication to Magnetic Sphincter Augmentation Placement During Primary Sleeve Gastrectomy. Obes Surg 2023; 33:3703-3705. [PMID: 37792251 DOI: 10.1007/s11695-023-06869-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2023] [Revised: 09/20/2023] [Accepted: 09/25/2023] [Indexed: 10/05/2023]
Affiliation(s)
- Joseph Sujka
- Department of Surgery, University of South Florida, Tampa, FL, USA.
| | - Courtney McEwen
- University of South Florida College of Medicine, Tampa, FL, USA
| | - Mannat Sandhu
- University of South Florida College of Medicine, Tampa, FL, USA
| | | | - Rahul Mhaskar
- University of South Florida College of Medicine, Tampa, FL, USA
| | - Ashley Mooney
- Department of Surgery, University of South Florida, Tampa, FL, USA
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Sarici IS, Eriksson SE, Zheng P, Hoppo T, Jobe BA, Ayazi S. Need for frequent dilations after magnetic sphincter augmentation: an assessment of associated factors and outcomes. Surg Endosc 2023; 37:7159-7169. [PMID: 37336846 DOI: 10.1007/s00464-023-10197-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 06/02/2023] [Indexed: 06/21/2023]
Abstract
BACKGROUND Dysphagia is the most common complaint after magnetic sphincter augmentation (MSA), with nearly one-third of patients requiring at least one dilation following MSA. A subset of patients require frequent dilations, but there is a paucity of data on the characteristics of this population. This study aimed to identify predictors of the need for frequent dilations within the first year after implant and to assess these patients' outcomes. METHODS This is a retrospective review of prospectively collected data of patients who underwent MSA over an 8-year period. Frequent dilations were defined as 2 or more dilations within 1 year of surgery. Patients completed baseline and 1-year postoperative GERD-HRQL questionnaires and objective physiology testing. Baseline demographic, clinical characteristics, and objective testing data were compared between patients who did and did not require frequent dilations. RESULTS A total of 697 (62.7% female) patients underwent MSA, with 62 (8.9%) patients requiring frequent dilation. At a mean (SD) of 12.3 (3.4) months follow-up, the frequent dilation group had higher median GERD-HRQL total scores (21.0 vs. 5.0, p < 0.001), PPI use (20.8% vs.10.1%, p = 0.023), dissatisfaction (46.7% vs. 11.6%, p < 0.001), and device removal (25.8% vs. 2.2%, p < 0.001) rates. Acid normalization was comparable (p = 0.997). Independent predictors of frequent dilation included preoperative odynophagia (OR 2.85; p = 0.001), IRP > 15 mmHg (OR 2.88; p = 0.006), and > 30% incomplete bolus clearance (OR 1.94; p = 0.004). At a mean (SD) of 15.7 (10.7) months, 28 (45.1%) patients underwent device removal after frequent dilation. Independent predictors of device removal after frequent dilation within 5 years of surgery were preoperative odynophagia (OR 7.18; p = 0.042), LES resting pressure > 45 mmHg (OR 28.5; p = 0.005), and ≥ 10% failed swallows (OR 23.5; p < 0.001). CONCLUSIONS The need for frequent dilations after MSA is a marker for poor symptom control, dissatisfaction, and device removal. Patients with preoperative odynophagia, high LES pressures, and poor esophageal motility should be counseled of their risk for these poor outcomes.
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Affiliation(s)
- Inanc S Sarici
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Sven E Eriksson
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Toshitaka Hoppo
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Blair A Jobe
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Foregut Division, Surgical Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
- Department of Surgery, Drexel University, Philadelphia, PA, USA.
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Eriksson SE, Zheng P, Sarici IS, Shen X, Jobe BA, Ayazi S. The impact of delayed gastric emptying as measured by gastric emptying scintigraphy on the outcome of magnetic sphincter augmentation. Surg Endosc 2023; 37:7144-7152. [PMID: 37328595 PMCID: PMC10462528 DOI: 10.1007/s00464-023-10190-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2023] [Accepted: 05/30/2023] [Indexed: 06/18/2023]
Abstract
INTRODUCTION The impact of delayed gastric emptying (DGE) on the outcome of anti-reflux surgery (ARS) is controversial. There is concern that poor gastric emptying diminishes outcomes. Magnetic sphincter augmentation (MSA) may have a comparatively mild impact on gastric physiology, but the relationship between DGE and MSA outcomes is unknown. This study aims to evaluate the relationship between objective DGE and MSA outcomes over time. METHODS Patients who completed gastric emptying scintigraphy (GES) prior to MSA between 2013 and 2021 were included. DGE was defined as a 4 h retention > 10% or half emptying time > 90 min on GES. Outcomes were compared between DGE and normal gastric emptying (NGE) groups at 6 months, 1 and 2 years. Sub-analysis of patients with severe (> 35%) DGE and correlation analysis between 4-h retention and symptom and acid-normalization were performed. RESULTS The study population consisted of 26 (19.8%) patients with DGE and 105 with NGE. DGE was associated with more 90-days readmissions (18.5 vs 2.9%, p = 0.009). At 6 months patients with DGE had higher median (IQR) GERD-HRQL total [17.0(10-29) vs 5.5(3-16), p = 0.0013], heartburn [1(1-3) vs 0(0-1), p = 0.0010) and gas-bloat [4(2-5) vs 2(1-3), p = 0.033] scores. Outcomes at 1 and 2 years follow-up were comparable (p > 0.05). From 6 months to 1-year the gas-bloat score decreased from 4(2-5) to 3(1-3), p = 0.041. Total and heartburn scores decreased, but not significantly. Severe DGE (n = 4) patients had lower antiacid medication freedom at 6 months (75 vs 87%, p = 0.014) and 1-year (50 vs 92%, p = 0.046). There were non-significant trends for higher GERD-HRQL scores, dissatisfaction, and removal rates in severe DGE at 6 months and 1-year. There was a weak correlation between 4-h retention and 6-month GERD-HRQL total score [R = 0.253, 95%CI (0.09-0.41), p = 0.039], but not acid-normalization (p > 0.05). CONCLUSION Outcomes after MSA are diminished early on in patients with mild-to-moderate DGE, but comparable by 1 year and durable at 2 years. Severe DGE outcomes may be suboptimal.
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Affiliation(s)
- Sven E Eriksson
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Inanc S Sarici
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Xinxin Shen
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Blair A Jobe
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
- Department of Surgery, Drexel University, Philadelphia, PA, USA
| | - Shahin Ayazi
- Esophageal Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
- Department of Surgery, Drexel University, Philadelphia, PA, USA.
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Eriksson S, Schwameis K, Ayazi S, Hoppo T, Zheng P, Jobe BA. Removal of the magnetic sphincter augmentation device: an assessment of etiology, clinical presentation, and management. Surg Endosc 2023. [PMID: 36689039 DOI: 10.1007/s00464-023-09878-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Accepted: 01/08/2023] [Indexed: 01/24/2023]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) erosion, disruption or displacement clearly requires device removal. However, up to 5.5% of patients without anatomical failure require removal for dysphagia or recurrent GERD symptoms. Studies characterizing these patients or their management are limited. We aimed to characterize these patients, compare their outcomes, and determine the necessity for further reflux surgery. METHODS This is a retrospective review of 777 patients who underwent MSA at our institution between 2013 and 2021. Patients who underwent device removal for persistent dysphagia or recurrent GERD symptoms were included. Demographic, clinical, objective testing, and quality of life data obtained preoperatively, after implantation and following removal were compared between removal for dysphagia and GERD groups. Sub-analyses were performed comparing outcomes with and without an anti-reflux surgery (ARS) at the time of removal. RESULTS A total of 40 (5.1%) patients underwent device removal, 31 (77.5%) for dysphagia and 9 (22.5%) for GERD. After implantation, dysphagia patients had less heartburn (12.9-vs-77.7%, p = 0.0005) less regurgitation (16.1-vs-55.5%, p = 0.0286), and more pH-normalization (91.7-vs-33.3%, p = 0.0158). Removal without ARS was performed in 5 (55.6%) GERD and 22 (71.0%) dysphagia patients. Removal for dysphagia patients had more complete symptom resolution (63.6-vs-0.0%, p = 0.0159), freedom from PPIs (81.8-vs-0.0%, p = 0.0016) and pH-normalization (77.8-vs-0.0%, p = 0.0455). Patients who underwent removal for dysphagia had comparable symptom resolution (p = 0.6770, freedom from PPI (p = 0.3841) and pH-normalization (p = 0.2534) with or without ARS. Those who refused ARS with removal for GERD had more heartburn (100.0%-vs-25.0%, p = 0.0476), regurgitation (80.0%-vs-0.0%, p = 0.0476) and PPI use (75.0%-vs-0.0%, p = 0.0476). CONCLUSIONS MSA removal outcomes are dependent on the indication for removal. Removal for dysphagia yields excellent outcomes regardless of anti-reflux surgery. Patients with persistent GERD had worse outcomes on all measures without ARS. We propose a tailored approach to MSA removal-based indication for removal.
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Patel SH, Smith B, Polak R, Pomeranz M, Patel PV, Englehardt R. Laparoscopic magnetic sphincter augmentation device placement for patients with medically-refractory gastroesophageal reflux after sleeve gastrectomy. Surg Endosc 2022; 36:8255-8260. [PMID: 35474390 DOI: 10.1007/s00464-022-09261-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 04/10/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The use of the magnetic sphincter augmentation (MSA) in patients with de novo or persistent gastroesophageal reflux disease (GERD) after sleeve gastrectomy has not been thoroughly investigated. OBJECTIVE The aim of this study is to evaluate the efficacy of MSA device placement in improving GERD symptoms and reducing anti-reflux medication usage in patients with persistent or de novo GERD after sleeve gastrectomy. METHODS This is a retrospective analysis of patients who underwent laparoscopic MSA device placement between January 2018 and July 2020 after sleeve gastrectomy. RESULTS A total of twenty-two patients met inclusion criteria. Twenty patients were female (91%) and two patients were male (9%). All patients were taking anti-reflux medications daily to control GERD symptoms prior to MSA device placement. There was a significant improvement in the mean GERD-HRQL survey scores when comparing scores prior to (43.8) and after (16.7) MSA device placement (p < 0.0001). Majority of the patients did well without any post-operative complications (77%). Nearly 82% of patients were no longer taking any anti-acid medications after MSA device placement (p < 0.0485). There were no patients that required MSA device removals. There were no adverse events such as MSA device erosions or device-related mortalities. CONCLUSIONS MSA device placement in patients with medically refractory GERD after sleeve gastrectomy is a safe and viable alternative to Roux-en-Y gastric bypass without conferring additional risks. We show an improvement in reflux symptoms after MSA device placement as evidenced by decreased post-operative GERD-HRQL scores, decreased anti-acid medication usage, and overall patient satisfaction with the procedure. Further prospective and comparative studies with longer term follow-up are needed to validate the use of MSA in patients who have undergone sleeve gastrectomy.
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Affiliation(s)
- Samik H Patel
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA.
| | - Barry Smith
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
| | - Robert Polak
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
| | - Morgan Pomeranz
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
| | - Punam V Patel
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
| | - Richard Englehardt
- Bariatric Medical Institute of Texas, 335 E Sonterra Blvd STE. 200, San Antonio, TX, 78258, USA
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O'Neill SM, Jalilvand AD, Colvin JS, Haisley KR, Perry KA. S148: Long-term patient-reported outcomes of laparoscopic magnetic sphincter augmentation versus Nissen fundoplication: a 5-year follow-up study. Surg Endosc 2022; 36:6851-6858. [PMID: 35041056 DOI: 10.1007/s00464-022-09015-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 01/03/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND Laparoscopic magnetic sphincter augmentation (MSA) has emerged as an alternative to laparoscopic Nissen fundoplication (LNF) for the management of symptomatic gastroesophageal reflux disease (GERD). While short-term outcomes of MSA compare favorably to those of LNF, direct comparisons of long-term outcomes are lacking. We hypothesized that the long-term patient-reported outcomes of MSA would be similar to those achieved with LNF. METHODS We tested this hypothesis in a retrospective cohort undergoing primary LNF or MSA between March 2013 and July 2015. The primary outcome was GERD-Health Related Quality of Life (GERD-HRQL) score at long-term follow-up relative to baseline. Secondary outcomes included dysphagia and bloating scores, proton-pump inhibitor (PPI) cessation, reoperations, and overall satisfaction with surgery. RESULTS 70 patients (25 MSA, 45 LNF) met criteria for study inclusion. MSA patients had lower baseline BMI (median: 27.1 [IQR: 22.7-29.9] versus 30.4 [26.4-32.8], p = 0.02), lower total GERD-HRQL (26 [19-32] versus 34 [25-40], p = 0.02), and dysphagia (2 [0-3] versus 3 [1-4], p = 0.02) scores. Median follow-up interval exceeded 5 years (MSA: 68 [65-74]; LNF: 65 months [62-69]). Total GERD-HRQL improved from 26 to 9 after MSA (p < 0.001) and from 34 to 7.5 after LNF (p < 0.01); these scores did not differ between groups (p = 0.68). Dysphagia (MSA: 1 [0-2]; LNF: 0 [0-2], p = 0.96) and bloating (MSA: 1.5 [0.5-3.0]; LNF: 3.0 [1.0-4.0], p = 0.08) scores did not show any statistically significant differences. Device removal was performed in 4 (16%) MSA patients and reoperation in 3 (7%) LNF patients. Eighty-nine percent of LNF patients reported satisfaction with the procedure, compared to 70% of MSA patients (p = 0.09). CONCLUSIONS MSA appears to offer similar long-term improvement in disease-specific quality of life as LNF. For MSA, there was a trend toward reduced long-term bloating compared to LNF, but need for reoperation and device removal may be associated with patient dissatisfaction.
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Affiliation(s)
- Sean M O'Neill
- Division of Minimally Invasive Surgery, University of Michigan, Ann Arbor, MI, USA
| | - Anahita D Jalilvand
- Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, OH, USA
| | - Jennifer S Colvin
- Department of Surgery, University of Cincinnati, Cincinnati, OH, USA
| | - Kelly R Haisley
- Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, USA
| | - Kyle A Perry
- Center for Minimally Invasive Surgery, The Ohio State University Wexner Medical Center, N729 Doan Hall, 410 W 10th Ave, Columbus, OH, USA.
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Callahan ZM, Amundson J, Su B, Kuchta K, Ujiki M. Outcomes after anti-reflux procedures: Nissen, Toupet, magnetic sphincter augmentation or anti-reflux mucosectomy? Surg Endosc 2022; 37:3944-3951. [PMID: 35999311 DOI: 10.1007/s00464-022-09544-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 08/07/2022] [Indexed: 10/15/2022]
Abstract
BACKGROUND Surgical treatment options of gastroesophageal reflux disease have changed significantly in the last 50 years. Magnetic Sphincter Augmentation (MSA) and Anti-reflux Mucosectomy (ARMs) are gaining traction but there is a paucity of literature comparing these novel options to Toupet fundoplication and gold standard Nissen fundoplication. METHODS This is a retrospective review of a prospectively maintained database, evaluating patients undergoing Nissen, Toupet, MSA, and ARMs. Pre-operative, intra-operative, and post-operative variables including Reflux symptom index (RSI), Gastroesophageal Reflux Disease-Health Related Quality of Life questionnaire (GERD-HRQL), and Dysphagia scores were compared between groups. RESULTS During the study period, 649 patients underwent anti-reflux surgery. Patients who underwent Nissen or Toupet were younger than those undergoing MSA or ARMs (65 ± 12 and 67 ± 14 years vs 56 ± 14 and 56 ± 18 years, P < 0.01). Average operative time for Nissen was 127 ± 40 min which was similar to a Toupet at 122 ± 32 min. These durations were significantly longer than for MSA, averaging 79 ± 29, and ARMs, at a mean 35 ± 3 min (all P < 0.001). Length of stay was significantly different among all four groups with Nissen, Toupet, MSA, and ARMs patients staying a median of 31, 24, 7, and 3 h post operatively, respectively (all P < 0.001). Complications and re-admissions were similarly low among all groups. Despite minor differences in RSI and GERD-HRQL scores at isolated follow-up time points, quality of life scores seems to be similar overall at up to 5 years follow-up. Gas bloat and dysphagia did not differ among groups at any time point. CONCLUSIONS Novel anti-reflux surgery options provide similar GERD-related quality of life compared to traditional full or partial fundoplications with the added benefit of shorter operative time and faster recovery.
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Affiliation(s)
- Zachary M Callahan
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA.
| | - Julia Amundson
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Bailey Su
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Kristine Kuchta
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Michael Ujiki
- Department of Surgery, NorthShore University HealthSystem, Evanston, IL, USA
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11
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Reddy NC, Sujka J, DuCoin C. Magnetic Sphincter Augmentation Algorithm for Post-bariatric Surgery Gastroesophageal Reflux Disease Patients. Obes Surg 2022; 32:3185-3187. [PMID: 35809197 DOI: 10.1007/s11695-022-06168-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 06/12/2022] [Accepted: 06/15/2022] [Indexed: 11/25/2022]
Affiliation(s)
- Nikhil C Reddy
- University of South Florida Morsani College of Medicine, 5 Tampa General Cir, Tampa, FL, 33606, USA.
| | - Joseph Sujka
- Department of Surgery, University of South Florida, Tampa, FL, USA
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12
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Nikolic M, Matic A, Feka J, Gensthaler L, Kristo I, Osmokrovic B, Riegler FM, Mosleh BO, Schoppmann SF. Expanded Indication for Magnetic Sphincter Augmentation: Outcomes in Weakly Acidic Reflux Compared to Standard GERD Patients. J Gastrointest Surg 2022; 26:532-541. [PMID: 34590216 PMCID: PMC8926968 DOI: 10.1007/s11605-021-05152-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2021] [Accepted: 09/11/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is a modern surgical anti-reflux technique with proven efficacy and low postoperative morbidity in patients with acidic reflux. The aim of this retrospective review study was to evaluate the symptomatic outcome of MSA in patients with weakly acidic reflux. METHODS From a prospectively collected clinical database, comprising all 327 patients that underwent MSA at our institution, a total of 67 patients with preoperative weakly acidic reflux measured in the 24-h impedance-pH-metry were identified. Postoperative gastrointestinal symptoms, proton pump inhibitor intake (PPI), GERD Health-Related Quality-of-Life (GERD-HRQL), alimentary satisfaction (AS), and patients' overall satisfaction were evaluated within highly standardized follow-up appointments. Furthermore, outcome of these patients was compared to the postoperative outcome of a comparable group of patients with a preoperative acidic reflux. RESULTS At a median follow-up of 24 months, none of the patients with weakly acidic reflux presented with persistent dysphagia, or underwent endoscopic dilatation or reoperation. The postoperative GERD-HRQL score was significantly reduced (2 vs. 20; p = 0.001) and the median AS was 9/10. Preoperative daily heartburn, regurgitations, and respiratory complaints were improved in 95%, 95%, and 96% of patients, respectively. A total of 10% of the patients continued to use PPIs postoperatively. No significant difference was observed in terms of postoperative outcome or quality of life when comparing weakly acidic reflux patients with those diagnosed with preoperative acidic reflux. CONCLUSION Magnetic sphincter augmentation significantly improves GERD-related symptoms and quality of life in patients with weakly acidic reflux with very low postoperative morbidity.
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Affiliation(s)
- Milena Nikolic
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Aleksa Matic
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Joy Feka
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Lisa Gensthaler
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Ivan Kristo
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Bogdan Osmokrovic
- Department of Trauma Surgery, Krankenhaus Oberwart, Dornburggasse 80, 7400, Oberwart, Austria
| | - Franz M Riegler
- Reflux Ordination, Mariannengasse 10/4/9, 1090, Vienna, Austria
| | - Berta O Mosleh
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Sebastian F Schoppmann
- Department of Surgery, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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13
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James TJ, Burke JF, Putnam LR, Pan J, Bildzukewicz NA, Bell R, Lipham JC. Loosening the belt on magnetic sphincter augmentation indications: does body mass index matter? Surg Endosc 2021; 36:4878-4884. [PMID: 34750701 DOI: 10.1007/s00464-021-08839-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 10/21/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is an effective treatment for gastroesophageal reflux disease (GERD). However, the impact of obesity on MSA outcomes is unknown. The objective of this study was to evaluate the effectiveness of MSA in patients with GERD and obesity. METHODS A retrospective cohort study was performed of consecutive patients who underwent laparoscopic MSA at three high-volume centers from 2016 to 2019. Patients were grouped into four cohorts according to the World Health Organization body mass index (BMI) classification: BMI < 25 (normal weight), BMI 25-29.9 (overweight), BMI 30-34.9 (obese class I), and BMI > 35 (obese class II-III). Preoperative, operative, and postoperative data were compared between groups. RESULTS A total of 621 patients underwent laparoscopic MSA during the study period. Follow-up with endoscopy or video esophagram was available for 361 patients (58%) with a median follow-up of 15.4 months. Baseline characteristics of the groups were similar except the BMI > 35 group had more females and a higher preoperative median DeMeester score. There were no significant differences in outcomes between normal weight, overweight, and obese patient groups undergoing MSA. All groups experienced significant reductions in acid suppressive medication use, low GERD-HRQL scores, low DeMeester scores, few intraoperative and postoperative complications, and low rates of hiatal hernia recurrence after MSA. CONCLUSIONS Magnetic sphincter augmentation is safe and effective in improving GERD symptoms, reducing esophageal acid exposure, and preventing hiatal hernia recurrence, irrespective of patient BMI. MSA should be considered an acceptable treatment option for obese patients with GERD.
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Affiliation(s)
- Tayler J James
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Jocelyn F Burke
- Institute of Esophageal and Reflux Surgery, Englewood, CO, USA
| | - Luke R Putnam
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Jennifer Pan
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Nikolai A Bildzukewicz
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA
| | - Reginald Bell
- Institute of Esophageal and Reflux Surgery, Englewood, CO, USA
| | - John C Lipham
- Keck Medical Center of University of Southern California, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA, 90033, USA.
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14
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Shah A, Nguyen DT, Meisenbach LM, Chihara R, Chan EY, Graviss EA, Kim MP. A novel EndoFLIP marker during hiatal hernia repair is associated with short-term postoperative dysphagia. Surg Endosc 2021; 36:4764-4770. [PMID: 34713341 DOI: 10.1007/s00464-021-08817-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 10/17/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Endoluminal functional lumen imaging probe (EndoFLIP) provides an objective measure of the distensibility index (DI) during different parts of hiatal hernia repair. However, the absolute DI measure above a cut-off after creating a barrier alone has not shown a relationship to dysphagia after surgery. We wanted to determine if the change in DI with volume change is associated with dysphagia. METHODS We included patients who had hiatal hernia repair with EndoFLIP values, including two values taken at the end of the surgical case with different volumes of fluid in the balloon (30 mL and 40 mL). We compared the absolute and change in DI during hiatal hernia repair and performed an analysis to determine if there was a correlation with short-term clinical outcomes. RESULTS A total of 103 patients met the inclusion and exclusion criteria. Most of the patients underwent Toupet fundoplication (n = 56, 54%), followed by magnetic sphincter augmentation (LINX, n = 28, 27%) and Nissen fundoplication (n = 19, 18%). There was a significant reduction in the DI from the initial DI taken after mobilization of the hiatus (3 mm2/mmHg) and after the creation of the barrier (1.4 mm2/mmHg, p < 0.001). A minority of patients had a decrease or no change in the DI with an increase in balloon volume increased from 30 to 40 mL (n = 37, 36%). Overall, after 1 month, there was a significant decrease in the GERD-HRQL score from 23 to 4 (p < 0.001) and bloat score from 3 to 2 (p = 0.003) with a non-significant decrease in the dysphagia score from 1 to 0 (p = 0.11). Patients who had a decreased or unchanged DI with an increase in the balloon volume from 30 to 40 mL had a significant decrease in their dysphagia score by 2 points (p = 0.04). CONCLUSION The decreased or unchanged DI with an increase in the balloon volume on EndoFLIP is associated with a significant reduction in dysphagia after surgery. The decrease in DI denotes the esophagus's ability to create higher pressure relative to the change in the cross-sectional area with a larger bolus across the gastroesophageal junction. This measure may be a new marker that can predict short-term outcomes in patients undergoing hiatal hernia repair.
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Affiliation(s)
- Anuj Shah
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Leonora M Meisenbach
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward Y Chan
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, Houston, TX, USA.,Department of Pathology and Genomic Medicine, Houston Methodist Hospital, Houston, TX, USA
| | - Min P Kim
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA. .,Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA.
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15
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Dominguez-Profeta R, Cheverie JN, Blitzer RR, Lee AM, McClain L, Broderick RC, Sandler BJ, Jacobsen GR, Horgan S, Kunkel DC. More beads, more peristaltic reserve, better outcomes: factors predicting postoperative dysphagia after magnetic sphincter augmentation. Surg Endosc 2021; 35:5295-302. [PMID: 33128078 DOI: 10.1007/s00464-020-08013-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 09/16/2020] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Magnetic sphincter augmentation (MSA) offers a minimally invasive anti-reflux alternative to fundoplication for gastroesophageal reflux disease. The most common side effect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA. MATERIALS AND METHODS A retrospective review of a prospectively maintained database identified patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic augmentation was defined as a ratio > 1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients. RESULTS Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/m2. 15 (22.1%) of patients had severe dysphagia requiring endoscopic dilation. Peristaltic augmentation with MRS was significantly higher in patients without dysphagia (46.1% vs 6.3% p = 0.026). 33.3% of patients requiring dilatation exhibited complete absence of smooth muscle contraction following MRS (DCI = 0). The ratio of the DCI of MRS/wet swallows predicting dysphagia following MSA was 0.56. Patients with a small (12-14 beads) versus a larger MSA implant (15-17 beads) had a significantly higher rate of postoperative dysphagia (58.5% vs 30.0% p = 0.026). CONCLUSION Adequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-reflux barrier. Routine assessment of peristaltic reserve during preoperative HRM should be considered prior to MSA placement.
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16
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Clapp B, Dodoo C, Harper B, Kim J, Castro C, Hamdan M, Grasso S, Davis B. Magnetic sphincter augmentation at the time of bariatric surgery: an analysis of the MBSAQIP. Surg Obes Relat Dis 2020; 17:555-561. [PMID: 33272856 DOI: 10.1016/j.soard.2020.10.024] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2020] [Revised: 10/14/2020] [Accepted: 10/17/2020] [Indexed: 12/17/2022]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) has gained popularity as a treatment for gastroesophageal reflux disease (GERD). The role of MSA in treating GERD in metabolic and bariatric surgery (MBS) patients at the time of primary MBS is unknown. OBJECTIVE To determine the short-term outcomes of MSA placed at the time of MBS. SETTING National database, United States. METHODS We queried the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for MSA performed at time of the sleeve gastrectomy (SG) and Roux-en-Y gastric bypass (RYGB) for the years 2017-2018. A propensity adjusted analysis was performed to assess 30-day outcomes of patients who had MSA placed versus those who did not. RESULTS There were 319,580 patients who underwent MBS in the study period. Twenty-four patients had MSA at time of surgery. These patients did not have a higher reported rate of preoperative GERD (P = .93). Six patients (25%) with MSA had a RYGB; the other 18 patients (75%) patients had SG (P < .001). Operative times were similar between the groups and there was no difference in length of stay. After propensity matched analysis (with 24 patients in each arm), patients who underwent an MSA had shorter discharge times (1.4 days [.8] versus 2.0 [.9], P = .012). CONCLUSION MSA is safe in the short term in MBS. There is no difference in major morbidity or mortality and operative times are similar in MSA patients. The long-term efficacy of this practice is unknown.
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Affiliation(s)
- Benjamin Clapp
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas.
| | - Christopher Dodoo
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Brittany Harper
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Jisoo Kim
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Christian Castro
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Marah Hamdan
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
| | - Samuel Grasso
- Department of Surgery, William Beaumont Army Medical Center, El Paso, Texas
| | - Brian Davis
- Department of Surgery, Texas Tech Paul Foster School of Medicine, El Paso, Texas
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Sun YF, Jiang HY, Gu HY, He Y, Yang Y, Zhang XB, Yang Y, Hua R, Guo XF, Ye B, Mao T, Li ZG. [Preliminary results of Chinese magnetic sphincter augmentation in treating gastroesophageal reflux disease]. Zhonghua Wai Ke Za Zhi 2020; 58:691-696. [PMID: 32878416 DOI: 10.3760/cma.j.cn112139-20200224-00133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Objective: To examine the preliminary clinical efficacy of Chinese magnetic sphincter augmentation (MSA) in the treatment of gastroesophageal reflux disease (GERD). Methods: According to the enrollment criteria for the MSA developed by ShengJieKang Co. and Shanghai Chest Hospital (SS-MSA) clinical trial, a total of 19 GERD patients were treated with SS-MSA from August 2018 to January 2020 at Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University. The majority of registered cases were male patients with age of (32.2±7.3) years (range: 22 to 50 years), height of (170.7±6.2) cm (range: 160 to 179 cm) and weight of (65.2±10.3) kg (range: 47.5 to 90.0 kg). SS-MSA was implanted via laparoscopy. The major evaluation indexs of postoperative efficacy were the total time of acid exposure within 24 hours and the total number of reflux. Secondary efficacy indicators included: (1) evaluation of the average daily dose of proton pump inhibitor medications; (2) the score of GERD health related quality of life questionnaire (GERD-Q) before and after MSA implantation. Paired design t-test was used to evaluate the efficacy of the SS-MSA. Results: A total of 19 patients underwent SS-MSA surgery successfully. The history of the GERD were 19 (54) months (M(Q(R))). The operation time was 63 (22) minutes and the in-hospital stay was 3 (2) days. No obvious surgical complications occurred. Postoperative adverse events included 14 cases with mild to moderate dysphagia exited after surgery, gradually eased within 1 to 3 months, 1 case with the removal of the device after 1 month of severe swallowing difficulties, 1 case of diarrhea. No corrosion, perforation, displacement occurred. The GERD-Q score (11.0(4.5) vs. 6(1.0), t=4.274, P=0.013), 24-hour acid exposure time (6.2(4.8)% vs. 0.1(0.9)%, t=5.814, P=0.004), and Demeester score (23.72(16.20) vs. 0.96(3.10), t=6.678, P=0.003) were significantly decreased 1 year after surgery(n=5). Proton pump inhibitor reuse rates were 6/18, 5/15, 3/10, and 1/5 in 1, 3, 6 and 12 months after the operation, respectively. Conclusions: SS-MSA implantation is feasible and safe with short hospital stay and rare perioperative complications. The preliminary results is good after 1 year follow-up. It could be expected to be an ideal substitutive for future GERD treatment.
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Affiliation(s)
- Y F Sun
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - H Y Jiang
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - H Y Gu
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Y He
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Y Yang
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - X B Zhang
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Y Yang
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - R Hua
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - X F Guo
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - B Ye
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - T Mao
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
| | - Z G Li
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
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18
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Li ZG. [Application of magnetic sphincter augmentation for treating gastroesophageal reflux disease]. Zhonghua Wai Ke Za Zhi 2020; 58:683-686. [PMID: 32878414 DOI: 10.3760/cma.j.cn112139-20200225-00138] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
The lower esophageal sphincter incompetent is fundamental pathological abnormality of gastroesophageal reflux disease (GERD). Magnetic sphincter augmentation (MSA) is a magnetic bracelet, which designed to be placed surgically around the exterior surface of the distal esophagus. In the closed position, the highest attractive force between the magnetic beads would reinforce the lower esophageal sphincter to strengthen the antireflux barrier. Animal experiments and clinical trials have verified the safety and efficacy of MSA in GERD patients. For refractory GERD and GERD with huge hernia, MSA can also achieve acceptable clinical effect. Comparative researches appeared that there is no significantly difference in clinical effect between Nissen fundoplication and MSA. MSA could preserve the function of belching and vomiting postoperatively, and it can be implanted with the use of standard laparoscopic techniques. The long-term effect of MSA is satisfactory with less complications, which has been carried out in China since 2018. It can be predicted that MSA will play an important role in the treatment of GERD in the future.
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Affiliation(s)
- Z G Li
- Section of Esophageal Surgery, Department of Thoracic Surgery, Shanghai Chest Hospital, Shanghai Jiao Tong University, Shanghai 200030, China
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19
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Nwokedi U, Nguyen DT, Meisenbach LM, Chihara R, Chan EY, Graviss EA, Kim MP. Short-term outcome of routine use of EndoFLIP during hiatal hernia repair. Surg Endosc 2020; 35:3840-3849. [PMID: 32661713 DOI: 10.1007/s00464-020-07788-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2020] [Accepted: 07/02/2020] [Indexed: 02/01/2023]
Abstract
BACKGROUND Endoluminal functional lumen imaging probe (EndoFLIP) technology is a tool that can be used to provide intraoperative objective real-time feedback during hiatal hernia repair. We wanted to determine the implication of initial distensibility index (DI) after mobilization of hiatus and final DI after creation of barrier in short-term clinical outcomes. METHODS We performed a retrospective analysis of prospectively collected data on the intraoperative use of EndoFLIP during hiatal hernia repair at a single institution from 2017 to 2019. We analyzed the initial DI and final DI with the short-term clinical outcomes. RESULTS There were 163 patients who had Nissen (n = 16), Toupet (n = 79) or magnetic sphincter augmentation (n = 68) with (n = 158) or without (n = 5) hiatal hernia repair with median initial DI was 3.2 mm2/mmHg. We used 3 mm2/mmHg as the cutoff for low (n = 84) vs. high (n = 79) initial DI group. There was no difference in DeMeester score (p = 0.76), the peristalsis on manometry (p = 0.13), type of hiatal hernia (p = 0.98), and GERD-HRQL score prior to surgery (p = 0.73) between the groups. There was significantly higher final DI in the high initial DI group compared to low initial DI group; however, there was no significant difference in the GERD-HRQL score at 1-3 months (p = 0.28). All of the patients had a final DI > 0.5 mm2/mmHg at the end of the case with median final DI of 1.6 mm2/mmHg. None of these patients required steroids (0%) and only one patient (0.6%) required EGD and dilatation as well as re-operation for dysphagia within 3 months. CONCLUSIONS The initial DI was associated with final DI, but it did not correlate with improvement in short-term GERD-HRQL score. Final DI maintained above the cutoff value led to most of the patients not to require intervention for dysphagia. Use of the EndoFLIP can provide objective data during the operation and prevent severe dysphagia after repair.
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Affiliation(s)
- Ugoeze Nwokedi
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Duc T Nguyen
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
| | - Leonora M Meisenbach
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Ray Chihara
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward Y Chan
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA
| | - Edward A Graviss
- Department of Pathology and Genomic Medicine, Houston Methodist Research Institute, Houston, TX, USA
- Department of Surgery, Houston Methodist Hospital, Houston, TX, USA
| | - Min P Kim
- Division of Thoracic Surgery, Department of Surgery, Houston Methodist Hospital, 6550 Fannin Street, Suite 1661, Houston, TX, 77030, USA.
- Department of Surgery and Cardiothoracic Surgery, Weill Cornell Medical College, Houston Methodist Hospital, Houston, TX, USA.
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Leeds SG, Ebrahim A, Potter EM, Clothier JS, Prajapati P, Ogola GO, Ward MA. The role of preoperative workup in predicting dysphagia, dilation, or explantation after magnetic sphincter augmentation. Surg Endosc 2020; 34:3663-8. [PMID: 32462333 DOI: 10.1007/s00464-020-07664-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Accepted: 05/20/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is a surgical treatment for gastroesophageal reflux disease using a ring of titanium beads to improve the function of the lower esophageal sphincter. Prior to implantation, a comprehensive preoperative esophageal workup is required to determine patient candidacy in an effort to reduce the dysphagia, dilation, and explantation rate of the device. This study was designed to assess the best predictors for these endpoints. METHODS A prospectively maintained IRB-approved database was retrospectively reviewed for patients undergoing MSA implantation. Patients were divided into 3 groups, those that needed no intervention, those that needed medical intervention with oral steroids for reported dysphagia, and surgical intervention, which included endoscopic dilation and/or surgical explantation. Primary endpoints included preoperative objective and subjective testing from a comprehensive esophageal workup including intraoperative notation of number of beads on the device. RESULTS There were 99 patients eligible for the study with a mean age of 52 and mean follow-up of 10.2 months. Mean BMI was 27 and 59% were female. The no-intervention group had 59 patients, medical intervention group had 25 patients, and surgical intervention group had 15 patients. Preoperative esophageal manometry findings, pH testing off medications, endoscopic and radiologic evaluation showed no difference between the 3 groups. No differences were seen in preoperative subjective evaluations based on GERD-HRQL or RSI scores. There was no difference in average number of beads on the device between the 3 groups. CONCLUSION A comprehensive esophageal workup is important to confirm the presence of gastroesophageal reflux disease and rule out other esophageal pathology. However, this study shows that a preoperative comprehensive esophageal workup does not predict which patients will develop dysphagia or require either medical or surgical interventions following MSA implantation.
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Abstract
Magnetic sphincter augmentation is an effective and safe surgical method for the treatment of gastroesophageal reflux disease (GERD). The device has been compared with twice-daily proton pump inhibitor therapy and laparoscopic fundoplication (in randomized trials and prospective cohort studies, respectively). Magnetic sphincter augmentation was superior to medical therapy and equivalent to surgery for the relief of GERD symptoms. Recent research focuses on implanting the device into more complex patients, such as those with larger hiatal hernias or those with Barrett's esophagus. Additional novel research topics include cost analysis and predicting and minimizing postoperative dysphagia.
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Affiliation(s)
- Colin Dunn
- General Surgery Rutgers NJMS, 185 South Orange Avenue, Medical Science Building, Room G 594, Newark, NJ 07101, USA
| | - Nikolai Bildzukewicz
- The Advanced GI/MIS Fellowship, Keck Medical Center of USC, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA 90033-4612, USA
| | - John Lipham
- Upper GI Cancer, Keck Medical Center of USC, 1510 San Pablo Street, HCC I, Suite 514, Los Angeles, CA 90033-4612, USA.
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Abstract
This report discusses the potential mechanisms that might underlie refractory GERD and functional heartburn, and how to distinguish among those mechanisms using a systematic evaluation that includes careful medical history, endoscopy with esophageal biopsy, esophageal manometry, and esophageal multichannel intraluminal impedance-pH monitoring. The report provides an approach to patient management that depends on the underlying mechanism identified by this systematic evaluation.
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Affiliation(s)
- Stuart Jon Spechler
- Division of Gastroenterology, Center for Esophageal Diseases, Baylor University Medical Center at Dallas, The Center for Esophageal Research, Baylor Scott & White Research Institute, 3500 Gaston Avenue, 2 Hoblitzelle, Suite 250, Dallas, TX 75246, USA.
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Schizas D, Mastoraki A, Papoutsi E, Giannakoulis VG, Kanavidis P, Tsilimigras D, Ntourakis D, Lyros O, Liakakos T, Moris D. LINX ® reflux management system to bridge the “treatment gap” in gastroesophageal reflux disease: A systematic review of 35 studies. World J Clin Cases 2020; 8:294-305. [PMID: 32047777 PMCID: PMC7000944 DOI: 10.12998/wjcc.v8.i2.294] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2019] [Revised: 12/06/2019] [Accepted: 12/14/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) occurs when the reflux of stomach contents causes troublesome symptoms and/or complications. When medical therapy is insufficient, surgical therapy is indicated and, until now, Laparoscopic fundoplication (LF) constitutes the gold-standard method. However, magnetic sphincter augmentation (MSA) using the LINX® Reflux Management System has recently emerged and disputes the standard therapeutic approach.
AIM To investigate the device’s safety and efficacy in resolving GERD symptoms.
METHODS This is a systematic review conducted in accordance to the PRISMA guidelines. We searched MEDLINE, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL databases from inception until September 2019.
RESULTS Overall, 35 studies with a total number of 2511 MSA patients were included and analyzed. Post-operative proton-pump inhibitor (PPI) cessation rates reached 100%, with less bloating symptoms and a better ability to belch or vomit in comparison to LF. Special patient groups (e.g., bariatric or large hiatal-hernias) had promising results too. The most common postoperative complication was dysphagia ranging between 6% and 83%. Dilation due to dysphagia occurred in 8% of patients with typical inclusion criteria. Esophageal erosion may occur in up to 0.03% of patients. Furthermore, a recent trial indicated MSA as an efficient alternative to double-dose PPIs in moderate-to-severe GERD.
CONCLUSION The findings of our review suggest that MSA has the potential to bridge the treatment gap between maxed-out medical treatment and LF. However, further studies with longer follow-up are needed for a better elucidation of these results.
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Affiliation(s)
- Dimitrios Schizas
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Aikaterini Mastoraki
- 4th Department of Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Chaidari, Athens 11527, Greece
| | - Eleni Papoutsi
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Vassilis G Giannakoulis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Prodromos Kanavidis
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Diamantis Tsilimigras
- Department of Surgery, Division of Surgical Oncology, The Ohio State University Wexner Medical Center and James Cancer Hospital and Solove Research Institute, Columbus, OH 45830, United States
| | - Dimitrios Ntourakis
- Department of Surgery, School of Medicine, European University Cyprus, Nicosia 2404, Cyprus
| | - Orestis Lyros
- Department of Visceral, Transplant, Thoracic and Vascular Surgery, University Hospital Leipzig, Leipzig 04103, Germany
| | - Theodore Liakakos
- 1st Department of Surgery, National and Kapodistrian University of Athens, Laikon Hospital, Athens 11527, Greece
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Duke University, Durham, NC 27705, United States
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Ayazi S, Zheng P, Zaidi AH, Chovanec K, Chowdhury N, Salvitti M, Komatsu Y, Omstead AN, Hoppo T, Jobe BA. Magnetic Sphincter Augmentation and Postoperative Dysphagia: Characterization, Clinical Risk Factors, and Management. J Gastrointest Surg 2020; 24:39-49. [PMID: 31388888 DOI: 10.1007/s11605-019-04331-9] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2019] [Accepted: 07/12/2019] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Magnetic sphincter augmentation (MSA) results in less severe side effects compared with Nissen fundoplication, but dysphagia remains the most common side effect reported by patients after MSA. This study aimed to characterize and review the management of postoperative dysphagia and identify the preoperative factors that predict persistent dysphagia after MSA. MATERIAL AND METHODS This is a retrospective review of prospectively collected data of patients who underwent MSA between 2013 and 2018. Preoperative objective evaluation included upper endoscopy, esophagram, high-resolution impedance manometry (HRIM), and esophageal pH testing. Postoperative persistent dysphagia was defined as a postoperative score of > 3 for the dysphagia-specific item within the GERD-HRQL at a minimum of 3 months following MSA. A timeline of dysphagia and dilation rates was constructed and correlated with the evolution of our patient management practices and modifications in surgical technique. RESULTS A total of 380 patients underwent MSA, at a mean (SD) follow up of 11.5 (8.7) months, 59 (15.5%) patients were experiencing persistent dysphagia. Thirty-one percent of patients required at least one dilation for dysphagia or chest pain and the overall response rate to this procedure was 67%, 7 (1.8%) patients required device removal specifically for dysphagia. Independent predictors of persistent dysphagia based on logistic regression model included (1) absence of a large hernia (OR 2.86 (95% CI 1.08-7.57, p = 0.035)); (2) the presence of preoperative dysphagia (OR 2.19 (95% CI 1.05-4.58, p = 0.037)); and (3) having less than 80% peristaltic contractions on HRIM (OR 2.50 (95% CI 1.09-5.73, p = 0.031)). Graded cutoffs of distal contractile integral (DCI), mean wave amplitude, DeMeester score, sex, and body mass index were evaluated within the model and did not predict postoperative dysphagia. Frequent eating after surgery, avoidance of early dilation, and increase in the size of the LINX device selected decreased the need for dilation. CONCLUSION In a large cohort of patients who underwent MSA, we report 15.5% rate of persistent postoperative dysphagia. The overall response rate to dilation therapy is 67%, and the efficacy of dilation with each subsequent procedure reduces. Patients with normal hiatal anatomy, significant preoperative dysphagia, and less than 80% peristaltic contractions of the smooth muscle portion of the esophagus should be counseled that they have an increased risk for persistent postoperative dysphagia.
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Ward MA, Ebrahim A, Kopita J, Arviso L, Ogola GO, Buckmaster B, Leeds SG. Magnetic sphincter augmentation is an effective treatment for atypical symptoms caused by gastroesophageal reflux disease. Surg Endosc 2020; 34:4909-15. [PMID: 31792691 DOI: 10.1007/s00464-019-07278-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Accepted: 11/14/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND The purpose of this study was to determine whether magnetic sphincter augmentation (MSA) could effectively treat patients with gastroesophageal reflux disease (GERD) who suffer primarily from atypical symptoms due to laryngopharyngeal reflux (LPR). MSA has been shown to treat typical symptoms of GERD with good success, but its effect on atypical symptoms is unknown. METHODS A retrospective review of a prospectively maintained institutional review board-approved database was conducted for all patients who underwent MSA between January 2015 and December 2018. All patients had objective confirmation of GERD from ambulatory pH monitoring off anti-reflux medications (DeMeester score > 14.7). Symptoms were assessed preoperatively and at 1 year postoperatively using GERD Health-Related Quality of Life (GERD-HRQL) and Reflux Symptom Index (RSI) questionnaires. RESULTS There were 86 patients (38 males; 48 females) with a median age of 51.5 years. Total GERD HRQL scores improved from a mean of 38.79 to 6.53 (p < 0.01) and RSI scores improved from a mean of 20.9 to 8.1 (p < 0.01). Atypical symptoms evaluated from the RSI questionnaire include hoarseness, throat clearing, postnasal drip, breathing difficulties, and cough. All atypical symptoms were significantly improved at 1 year following MSA (p < 0.01). All three typical symptoms of heartburn, dysphagia, and regurgitation were significantly improved based on pre and postoperative GERD HRQL questionnaires (p < 0.02). Ninety-one percent of patients were off their PPI and dissatisfaction with their current therapy decreased from 95% preoperatively to 13% postoperatively. CONCLUSION MSA is an effective treatment for typical and atypical GERD symptoms.
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Ndubizu GU, Petrick AT, Horsley R. Concurrent magnetic sphincter augmentation and hiatal hernia repair for refractory GERD after laparoscopic sleeve gastrectomy. Surg Obes Relat Dis 2020; 16:168-70. [PMID: 31753794 DOI: 10.1016/j.soard.2019.09.072] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2019] [Revised: 09/02/2019] [Accepted: 09/17/2019] [Indexed: 12/12/2022]
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Broderick RC, Smith CD, Cheverie JN, Omelanczuk P, Lee AM, Dominguez-Profeta R, Cubas R, Jacobsen GR, Sandler BJ, Fuchs KH, Horgan S. Magnetic sphincter augmentation: a viable rescue therapy for symptomatic reflux following bariatric surgery. Surg Endosc 2019; 34:3211-3215. [PMID: 31485930 DOI: 10.1007/s00464-019-07096-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2019] [Accepted: 08/21/2019] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Laparoscopic sleeve gastrectomy (LSG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) are commonly performed bariatric procedures in obesity management. Gastroesophageal reflux disease (GERD) in this population has reported rates of 23-100%. GERD after LSG has been noted with recent studies demonstrating de novo reflux or symptom exacerbation despite weight loss. Fundoplication is not an option, and medically refractory GERD after LSG is usually treated with conversion to RYGB. GERD post-RYGB is a unique entity, and management poses a clinical and technical challenge. We evaluate safety and effectiveness of magnetic sphincter augmentation after bariatric surgery. MATERIALS AND METHODS A retrospective review of a prospectively maintained database was performed identifying patients that underwent LINX placement for refractory GERD after LSG, LRYGB, or duodenal switch across three institutions. Outcomes included complications, length of stay, PPI use, GERD-HRQL scores, and patient overall satisfaction. RESULTS From March 2014 through June 2018, 13 identified patients underwent LINX placement after bariatric surgery: 8 LSG, 4 LRYGB, and 1 duodenal switch. The patients were 77% female, with mean age 43 and average BMI 30.1. Average pre-operative DeMeester score was 24.8. Pre-operatively, 5 patients were on daily PPI, 6 on BID PPI, and 1 on PPI + H2 blocker. We noted decreased medication usage post-operatively, with 4 patients taking daily PPI, and 9 off medication completely. A GERD-HRQL score was obtained pre- and post-operatively in 6 patients with average reduction from 25 to 8.5 (p value 0.002). Two patients experienced complications requiring endoscopic dilation after LINX placement. 100% of patients reported overall satisfaction post procedure. CONCLUSION LINX placement is a safe, effective treatment option for surgical management of refractory GERD after bariatric surgery. It can relieve symptoms and obviate the requirement of high-dose medical management. Magnetic lower esophageal sphincter augmentation should be another tool in the surgeon's toolbox for managing reflux after bariatric surgery in select patients.
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Affiliation(s)
- Ryan C Broderick
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA
| | | | - Joslin N Cheverie
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA
| | - Pablo Omelanczuk
- Division of Esophago-gastric and Bariatric Surgery, Hospital Italiano de Mendoza, Mendoza, Argentina
| | - Arielle M Lee
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA.
| | - Rebeca Dominguez-Profeta
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA
| | - Robert Cubas
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA
| | - Garth R Jacobsen
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA
| | - Bryan J Sandler
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA
| | - Karl-Hermann Fuchs
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA
| | - Santiago Horgan
- Division of Minimally Invasive Surgery, Center for the Future of Surgery, University of California of San Diego, MET Building, Lower Level, 9500 Gilman Drive MC 0740, La Jolla, CA, 92093-0740, USA
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Buckley FP, Havemann B, Chawla A. Magnetic sphincter augmentation: Optimal patient selection and referral care pathways. World J Gastrointest Endosc 2019; 11:472-476. [PMID: 31523378 PMCID: PMC6715569 DOI: 10.4253/wjge.v11.i8.472] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/13/2019] [Accepted: 07/20/2019] [Indexed: 02/06/2023] Open
Abstract
Outcomes associated with magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD) have been reported, however the optimal population for MSA and the related patient care pathways have not been summarized. This Minireview presents evidence that describes the optimal patient population for MSA, delineates diagnostics to identify these patients, and outlines opportunities for improving GERD patient care pathways. Relevant publications from MEDLINE/EMBASE and guidelines were identified from 2000-2018. Clinical experts contextualized the evidence based on clinical experience. The optimal MSA population may be the 2.2-2.4% of GERD patients who, despite optimal medical management, continue experiencing symptoms of heartburn and/or uncontrolled regurgitation, have abnormal pH, and have intact esophageal function as determined by high resolution manometry. Diagnostic work-ups include ambulatory pH monitoring, high-resolution manometry, barium swallow, and esophagogastroduodenoscopy. GERD patients may present with a range of typical or atypical symptoms. In addition to primary care providers (PCPs) and gastroenterologists (GIs), other specialties involved may include otolaryngologists, allergists, pulmonologists, among others. Objective diagnostic testing is required to ascertain surgical necessity for GERD. Current referral pathways for GERD management are suboptimal. Opportunities exist for enabling patients, PCPs, GIs, and surgeons to act as a team in developing evidence-based optimal care plans.
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Affiliation(s)
- F Paul Buckley
- Department of Surgery and Perioperative Care, Dell Medical School, The University of Texas at Austin, Austin, TX 78712, United States
| | | | - Amarpreet Chawla
- Department of Health Economics and Market Access, Ethicon Inc. (Johnson and Johnson), Cincinnati, OH 45242, United States
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Ayazi S, Zaidi AH, Zheng P, Chovanec K, Chowdhury N, Salvitti M, Newhams K, Levy J, Hoppo T, Jobe BA. Comparison of surgical payer costs and implication on the healthcare expenses between laparoscopic magnetic sphincter augmentation (MSA) and laparoscopic Nissen fundoplication (LNF) in a large healthcare system. Surg Endosc 2019; 34:2279-2286. [PMID: 31376004 PMCID: PMC7113225 DOI: 10.1007/s00464-019-07021-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 07/19/2019] [Indexed: 12/26/2022]
Abstract
Introduction Magnetic sphincter augmentation (MSA) is a promising antireflux surgical treatment. The cost associated with the device may be perceived as a drawback by payers, which may limit the adoption of this technique. There are limited data regarding the cost of MSA in the management of reflux disease. The aims of the study were to report the clinical outcome and quality of life measures in patients after MSA and to compare the pharmaceutical and procedure payer costs and the disease-related and overall expense of MSA compared to laparoscopic Nissen fundoplication (LNF) from a payer perspective. Methods and procedures This prospective observational study was performed in conjunction with the region’s largest health insurance company. Data were collected on patients who underwent MSA over a 2-year period beginning in September 2015 at the study network hospitals. The LNF comparison group was procured from members’ claims data of the payer. Inclusion was predicated by patients having continuous coverage during study period. The total procedural reimbursement and the disease-related and overall medical claims submitted up to 12 months prior to surgery and up to 12 months following surgery were obtained. The payer reimbursement data are presented as allowed cost per member per month (PMPM). These values were then compared between groups. Results There were 195 patients who underwent MSA and 1131 that had LNF. MSA results in comparable symptom control, PPI elimination rate, and quality of life measures compared to values reported for LNF in the literature. The median (IQR) reimbursement of surgery was $13,522 (13,195–14,439) for those who underwent MSA and $13,388 (9951–16,261) for patients with LNF, p = 0.02. In patients who underwent MSA, the median reimbursement related to the upper gastrointestinal disease was $ 305 PMPM, at 12 months prior to surgery and $ 104 at 12 months after surgery, representing 66% decrease in cost. These values were $ 233 PMPM and $126 PMPM for patients who underwent LNF, representing a 46% decrease (p = 0.0001). At 12 months following surgery, the reimbursement for overall medical expenses had decreased by 10.7% in the MSA group and 1.4% in the LNF group when compared to the preoperative baseline reimbursement. The reimbursement for PPI use after surgery showed a 95% decrease in the MSA group and 90% among LNF group when compared to the preoperative baseline (p = 0.10). Conclusion When compared with LNF, MSA results in a reduction of disease-related expenses for the payer in the year following surgery. While MSA is associated with a higher procedural payer cost compared to LNF, payer costs may offset due to reduction in the expenses after surgery.
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Affiliation(s)
- Shahin Ayazi
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ali H Zaidi
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Ping Zheng
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Kristy Chovanec
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Nobel Chowdhury
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Madison Salvitti
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Kirsten Newhams
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Jonathan Levy
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Toshitaka Hoppo
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA
| | - Blair A Jobe
- Esophageal and Lung Institute, Allegheny Health Network, 4815 Liberty Avenue, Suite 439, Pittsburgh, PA, 15224, USA.
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Ayazi S, Chowdhury N, Zaidi AH, Chovanec K, Komatsu Y, Omstead AN, Zheng P, Hoppo T, Jobe BA. Magnetic sphincter augmentation (MSA) in patients with hiatal hernia: clinical outcome and patterns of recurrence. Surg Endosc 2020; 34:1835-46. [PMID: 31286251 DOI: 10.1007/s00464-019-06950-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 06/26/2019] [Indexed: 12/16/2022]
Abstract
Introduction Magnetic sphincter augmentation (MSA) is an effective treatment for patients with gastroesophageal reflux disease. In early studies, patients with a hiatal hernia (HH) ≥ 3 cm were excluded from consideration for implantation and initially the FDA considered its use as “precautionary” in this context. This early approach has led to an attitude of hesitance among some surgeons to offer this therapy to patients with HH. This study was designed to evaluate the impact of HH status on the outcome of MSA and to report the rate of HH recurrence after MSA. Methods and procedures This is a retrospective review of prospectively collected data of patients who underwent MSA between June 2013 and August 2017. Baseline clinical and objective data were collected. Patients were divided into four groups based on HH status: no HH, small HH (< 3 cm), large HH (≥ 3 cm), and paraesophageal hernia (PEH). Patient satisfaction, GERD–HRQL and RSI data, freedom from PPI, need for postoperative dilation, length of hospitalization, 90-day readmission rate, need for device removal, and HH recurrence was compared between groups. Results There were 350 patients [60% female, mean (SD) age: 53.5 (13.8)] who underwent MSA. There were 65 (18.6%) with no HH, 205 (58.6%) with small HH (< 3 cm), 58 (16.6%) with large HH (≥ 3 cm) and 22 (6.2%) with PEH. At a mean follow-up of 13.6 (10.4) months, the rate of outcome satisfaction was similar between the groups (86%, 87.9%, 92.2% and 93.8%, p = 0.72). This was also true for GERD–HRQL total score clinical improvement (79.1%, 77.8%, 82% and 87.5%, p = 0.77). The rate of postoperative dysphagia (p = 0.33) and freedom from PPIs (p = 0.96) were similar among the four groups. Duration of hospitalization was higher among those with a large HH or PEH, and only PEH patients had a higher 90-day readmission rate (p = 0.0004). There was no difference between the need for dilation among groups (p = 0.13). The need for device removal (5% overall) was similar between the four groups (p = 0.28). HH recurrence was 10% in all groups combined, and only 7 of 240 (2.9%) patients required reoperation; the majority of these patients underwent a minimal dissection approach (no hernia repair) at the index operation. The incidence of recurrent HH increased in direct correlation with the preoperative HH size (0%, 10.1%, 16.6 and 20%, p = 0.032). Conclusion In the largest series of MSA implantation, we demonstrate that the excellent outcomes and high degree of satisfaction after MSA are independent of the presence or size of HH. Despite higher rates of hernia recurrence in large HH and PEH patients, the rates of postoperative endoscopic intervention, and device removal is similar to those with no or small HH. The minimal dissection approach to MSA should be abandoned.
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Abstract
Proton pump inhibitor (PPI)-refractory gastroesophageal reflux disease (GERD) is defined by the presence of troublesome GERD symptoms despite PPI optimization for at least 8 weeks in the setting of ongoing documented pathologic gastroesophageal reflux. It arises from a dysfunction in protective systems to prevent reflux and as propagation of physiologic reflux events. Treatment possibilities include pharmacologic options, invasive management strategies, and endoluminal therapies. Management strategy should be personalized to the patient's needs and mechanistic dysfunction. This article reviews the definition, mechanisms, and management options for PPI-refractory GERD.
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Affiliation(s)
- Rena Yadlapati
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue B158, Aurora, CO 80045, USA.
| | - Kelli DeLay
- Division of Gastroenterology and Hepatology, University of Colorado Anschutz Medical Campus, 12631 East 17th Avenue B158, Aurora, CO 80045, USA
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Abstract
Gastroesophageal reflux disease (GERD) is a common affliction in Western society. In patients in whom GERD is resistant to medical therapy or who desire nonpharmacological definitive therapy, several surgical interventions are available. The most common and traditional surgical therapy is partial or complete gastric fundoplication; however, new alternatives, including the magnetic augmentation system LINX and EndoStim device, are increasingly common and efficacious.
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Affiliation(s)
- James M Tatum
- Department of Surgery, Division of General and Laparoscopic Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street HCC 4, Suite 6200, Los Angeles, CA 90033, USA
| | - John C Lipham
- Division of General Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street HCC 4, Suite 6200, Los Angeles, CA 90033, USA; Division of Minimally Invasive Surgery, Keck School of Medicine, University of Southern California, 1450 San Pablo Street HCC 4, Suite 6200, Los Angeles, CA 90033, USA.
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Aiolfi A, Asti E, Bernardi D, Bonitta G, Rausa E, Siboni S, Bonavina L. Early results of magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: Systematic review and meta-analysis. Int J Surg 2018; 52:82-88. [PMID: 29471155 DOI: 10.1016/j.ijsu.2018.02.041] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2017] [Revised: 01/16/2018] [Accepted: 02/15/2018] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic Nissen and Toupet fundoplication (LF) are currently considered gold-standard surgical treatment for Gastroesophageal Reflux Disease (GERD). Magnetic Sphincter Augmentation (MSA) is an innovative surgical procedure that has been showed to be effective to control GERD symptoms and to reduce esophageal acid exposure. The aim of this systematic review and meta-analysis was to compare early outcomes of LF and MSA. MATERIALS AND METHODS PubMed, MEDLINE, Embase, and Cochrane databases were consulted matching the terms "Gastroesophageal reflux or heartburn", "LINX or magnetic sphincter augmentation" and "fundoplication". Pooled effect measures were calculated using an inverse-variance weighted or Mantel-Haenszel in random effects meta-analysis. Heterogeneity was evaluated using I2-index and Cochrane Q-test. Meta-regression was used to address the effect of potential confounders. RESULTS Seven observational cohort studies, published between 2014 and 2017, matched the inclusion criteria. Overall, 1211 patients, 686 MSA and 525 LF, were included. Postoperative morbidity ranged from 0 to 3% in the MSA group and from 0 to 7% in the LF group, and there was no mortality. Dysphagia requiring endoscopic dilatation occurred in 9.3% and 6.6% of patients respectively (OR = 1.56, 95% CI = 0.61-3.95, p = 0.119). The pooled OR of gas/bloat symptoms, ability to vomit, and ability to belch were 0.39 (95% CI 0.25-0.61; p < 0.001), 10.10 (95% CI 5.33-19.15; p < 0.001), and 5.53 (95% CI 3.73-8.19; p < 0.001), respectively. The postoperative GERD-HRQL was similar (p = 0.101). The pooled OR of PPI suspension, endoscopic dilation, and reoperation were similar in the two patients groups (p = 0.548, p = 0.119, p = 0.183, respectively). CONCLUSION Both anti-reflux procedures are safe and effective up to 1-year follow-up. PPI suspension rate, dysphagia requiring endoscopic dilatation, and disease-related quality of life are similar in the two patient groups. MSA is associated with less gas/bloat symptoms and increased ability to vomit and belch.
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Affiliation(s)
- Alberto Aiolfi
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Emanuele Asti
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Daniele Bernardi
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Gianluca Bonitta
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Emanuele Rausa
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Stefano Siboni
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
| | - Luigi Bonavina
- University of Milan, Department of Biomedical Sciences for Health, Division of General Surgery, IRCCS Policlinico San Donato, Italy.
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Rona KA, Tatum JM, Zehetner J, Schwameis K, Chow C, Samakar K, Dobrowolsky A, Houghton CC, Bildzukewicz N, Lipham JC. Hiatal hernia recurrence following magnetic sphincter augmentation and posterior cruroplasty: intermediate-term outcomes. Surg Endosc 2018; 32:3374-3379. [PMID: 29340828 DOI: 10.1007/s00464-018-6059-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2017] [Accepted: 01/11/2018] [Indexed: 01/12/2023]
Abstract
BACKGROUND We have previously reported short-term outcomes after hiatal hernia repair (HHR) at the time of magnetic sphincter augmentation (MSA) for gastroesophageal reflux disease (GERD). Here we report intermediate-term outcomes and hernia recurrence rate after concomitant MSA and HHR. METHODS This is a retrospective cohort study of patients who underwent repair of a hiatal hernia 3 cm or larger at the time of MSA implantation between May 2009 and December 2015. The primary endpoint was hiatal hernia recurrence identified by routine postoperative videoesophagography or endoscopy. Recurrence was defined by a 2 cm or greater upward displacement of the stomach through the diaphragmatic esophageal hiatus. Secondary endpoints included cessation of proton-pump inhibitor (PPI), persistent dysphagia requiring intervention, and GERD health-related quality-of-life (HRQL) scores 1 year from surgery. RESULTS During the study period, 47 of 53 (89%) patients underwent concomitant MSA with HHR and complied with surveillance. Hiatal hernias ranged from 3 to 7 cm (mean 4 ± 1). Mean clinical follow-up time was 19 months (range 1-39). GERD-HRQL score decreased from 20.3 to 3.1 (p < .001), 89% of patients remained off PPIs, and 97% of patients reported improvement or resolution of symptoms. Two recurrent hiatal hernias were identified on surveillance imaging for a recurrence rate of 4.3% at a mean 18 (± 10) months after initial operation. Persistent dysphagia occurred in 13% (6/47) over the first year, which resolved after a single balloon dilation in 67% (4/6). Two patients elected for device removal due to dilation-refractory dysphagia and persistent reflux symptoms. CONCLUSION Concomitant magnetic sphincter augmentation and hiatal hernia repair in patients with gastroesophageal reflux disease and a moderate-sized hiatal hernia demonstrates durable subjective reflux control and an acceptable hiatal hernia recurrence rate at 1- to 2-year follow-up.
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Affiliation(s)
| | | | | | | | - Carol Chow
- Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | | | | | - Caitlin C Houghton
- Keck Hospital of USC, Los Angeles, CA, USA.,Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - Nikolai Bildzukewicz
- Keck Hospital of USC, Los Angeles, CA, USA.,Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA
| | - John C Lipham
- Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA. .,Keck Hospital of USC, 1510 San Pablo St., HCC Suite 514, Los Angeles, CA, 90033, USA.
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Abstract
PURPOSE OF REVIEW This paper provides an overview of current and future surgical interventions available for the management of gastroesophageal reflux disease (GERD) beyond the well established and recognized fundoplication. Review the current indications and outcomes of these surgical procedures. RECENT FINDINGS Fundoplication has been a cornerstone of the surgical management of GERD. However, other effective surgical options exist and can be considered based on prior interventions as well as patient, anatomical or other factors. These options are intended to address some of the shortcomings or potential complications of fundoplication such as symptom recurrence, dysphagia, or gas bloating, for example. Alternative procedures to fundoplication include magnetic sphincter augmentation, electrical stimulation and Roux-en-Y gastric bypass. The indication for surgical management remains failure of or inability to tolerate medical therapy.
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Buckley FP, Bell RCW, Freeman K, Doggett S, Heidrick R. Favorable results from a prospective evaluation of 200 patients with large hiatal hernias undergoing LINX magnetic sphincter augmentation. Surg Endosc. 2018;32:1762-1768. [PMID: 28936790 PMCID: PMC5845067 DOI: 10.1007/s00464-017-5859-4] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2017] [Accepted: 08/22/2017] [Indexed: 12/19/2022]
Abstract
Introduction Magnetic sphincter augmentation (MSA) of the lower esophageal sphincter restores the antireflux barrier in patients with hiatal hernias ≤3 cm. We performed a prospective study in patients undergoing MSA with the LINX device during repair of paraesophageal and hernias over 3 cm axial component. Methods and procedures Multicenter, prospective study of consecutive patients treated with MSA at the time of repair of hiatal hernias >3 cm. Results 200 patients (110 female) were treated between March 2014 and February 2017 via laparoscopic hernia repair and MSA. Mean age was 59.5 years, mean BMI 29.4. 40% had esophagitis, 20% intestinal metaplasia, 72 of 77 tested had abnormal pH studies. Preoperative PPI use was reported by 87%. Eighteen patients had prior hiatal hernia/fundoplication. All had normal function. 78% of patients had axial hiatal hernia ≥5 cm or large paraesophageal component. Mean operative time was 81 min (38–193), EBL was 10 cc. Non-permanent mesh reinforcement of hiatal repair was performed in 83% of the patients. There were two readmissions for dehydration; 2 patients with pulmonary embolism, and 1 patient with cardiac ischemia. Nineteen patients required dilation. 156 pts were followed at a median of 8.6 months. GERD-HRQL scores improved from 26 preoperatively to 2 postoperatively. Complete PPI independence was achieved in 94% (147/156). Videoesophagram in 51 patients at median 11 months found 3 asymptomatic hernias <3 cm. One symptomatic patient underwent successful repair of the hernia without MSA manipulation. There have been no device explants, erosions, or migrations to date. Conclusions This prospective study of 200 patients with >3 cm hernias undergoing MSA with hiatoplasty resulted in favorable outcomes with median of 9 months follow-up. Comparing this to published reports of MSA in patients with <3 cm hernias, the safety and clinical efficacy of MSA are independent of initial hernia size.
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Warren HF, Brown LM, Mihura M, Farivar AS, Aye RW, Louie BE. Factors influencing the outcome of magnetic sphincter augmentation for chronic gastroesophageal reflux disease. Surg Endosc 2017; 32:405-412. [PMID: 28664433 DOI: 10.1007/s00464-017-5696-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2017] [Accepted: 06/22/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Magnetic sphincter augmentation (MSA) is a surgical treatment option for patients with gastroesophageal reflux disease (GERD). MSA consistently improves quality of life, maintains freedom from PPIs, and objectively controls GERD. However, up to 24% of patients did not achieve these outcomes. We sought to identify factors predicting outcomes after MSA placement with the aim of refining selection criteria. METHODS We retrospectively analyzed clinical, endoscopic, manometric, pH data, and intraoperative factors from two databases: Pivotal Trial (N = 99) and our prospectively maintained esophageal database (N = 71). A priori outcomes were defined as excellent (GERD-HRQL <5, no PPI, no esophagitis), good (GERD-HRQL 6-15, no PPI, grade A esophagitis), fair (GERD-HRQL 16 to 25, PPI use, grade B esophagitis), and poor (GERD-HRQL >25, PPI use, grade C/D esophagitis). Univariable and multivariable logistic regression analyses were performed to determine predictors of achieving an excellent/good outcome. RESULTS A total of 170 patients underwent MSA with a median age of 53 years, [43-60] and a median BMI of 27 (IQR = 24-30). At baseline, 93.5% of patients experienced typical symptoms and 69% atypical symptoms. Median DeMeester score was 37.9 (IQR 27.9-51.2) with a structurally intact sphincter in 47%. Esophagitis occurred in 43%. At 48 [19-60] months after MSA, excellent outcomes were achieved in 47%, good in 28%, fair in 22%, and poor in 3%. Median DeMeester score was 15.6 (IQR = 5.8-26.6), esophagitis in 17.6% and daily PPI use in 17%. At univariable analysis, excellent/good outcomes were negatively impacted by BMI, preoperative LES residual pressure, Hill grade, and hiatal hernia. At multivariable analysis, BMI >35 (OR = 0.05, 0.003-0.78, p = 0.03), structurally defective LES (OR = 0.37, 0.13-0.99, p = 0.05), and preoperative LES residual pressure (OR = 0.89, 0.80-0.98, p = 0.02) were independent negative predictors of excellent/good outcome. CONCLUSIONS Magnetic sphincter augmentation results in excellent/good outcomes in most patients but a higher BMI, structurally defective sphincter, and elevated LES residual pressure may prevent this goal.
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Affiliation(s)
| | - Lisa M Brown
- Section of Thoracic Surgery, University of California Davis, Sacramento, CA, USA
| | - Matias Mihura
- Division of Thoracic Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA, 98104, USA
| | - Alexander S Farivar
- Division of Thoracic Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA, 98104, USA
| | - Ralph W Aye
- Division of Thoracic Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA, 98104, USA
| | - Brian E Louie
- Division of Thoracic Surgery, Swedish Medical Center and Cancer Institute, 1101 Madison Street Suite 900, Seattle, WA, 98104, USA.
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Skubleny D, Switzer NJ, Dang J, Gill RS, Shi X, de Gara C, Birch DW, Wong C, Hutter MM, Karmali S. LINX ® magnetic esophageal sphincter augmentation versus Nissen fundoplication for gastroesophageal reflux disease: a systematic review and meta-analysis. Surg Endosc 2017; 31:3078-84. [PMID: 27981382 DOI: 10.1007/s00464-016-5370-3] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2016] [Accepted: 11/21/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND The LINX® magnetic sphincter augmentation system (MSA) is a surgical technique with short-term evidence demonstrating efficacy in the treatment of medically refractory or chronic gastroesophageal reflux disease (GERD). Currently, the Nissen fundoplication is the gold-standard surgical treatment for GERD. We are the first to systematically review the literature and perform a meta-analysis comparing MSA to the Nissen fundoplication. METHODS A comprehensive search of electronic databases (e.g., MEDLINE, EMBASE, SCOPUS, Web of Science and the Cochrane Library) using search terms "Gastroesophageal reflux or heartburn" and "LINX or endoluminal or magnetic" and "fundoplication or Nissen" was completed. All randomized controlled trials, non-randomized comparison study and case series with greater than 5 patients were included. Five hundred and forty-seven titles were identified through primary search, and 197 titles or abstracts were screened after removing duplicates. Meta-analysis was performed on postoperative quality of life outcomes, procedural efficacy and patient procedural satisfaction. RESULTS Three primary studies identified a total of 688 patients, of whom 273 and 415 underwent Nissen fundoplication and MSA, respectively. MSA was statistically superior to LNF in preserving patient's ability to belch (95.2 vs 65.9%, p < 0.00001) and ability to emesis (93.5 vs 49.5%, p < 0.0001). There was no statistically significant difference between MSA and LNF in gas/bloating (26.7 vs 53.4%, p = 0.06), postoperative dysphagia (33.9 vs 47.1%, p = 0.43) and proton pump inhibitor (PPI) elimination (81.4 vs 81.5%, p = 0.68). CONCLUSION Magnetic sphincter augmentation appears to be an effective treatment for GERD with short-term outcomes comparable to the more technically challenging and time-consuming Nissen fundoplication. Long-term comparative outcome data past 1 year are needed in order to further understand the efficacy of magnetic sphincter augmentation.
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Czosnyka NM, Buckley FP, Doggett SL, Vassaur H, Connolly EE, Borgert AJ, Kallies KJ, Kothari SN. Outcomes of magnetic sphincter augmentation - A community hospital perspective. Am J Surg 2016; 213:1019-1023. [PMID: 27837903 DOI: 10.1016/j.amjsurg.2016.09.044] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 09/21/2016] [Accepted: 09/29/2016] [Indexed: 12/14/2022]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is FDA approved for the surgical treatment of GERD. While multiple reports from academic settings exist, we report the early experience from two community-based health systems. METHODS The first 102 post-trial cases of MSA were reviewed. Outcomes were compared to those in the initial clinical trial. RESULTS Mean follow-up duration was 7.6 months. GERD medication use decreased from 98% preoperative to 8% postoperative (P<0.001). Median GERD health-related quality of life (HRQL) improved from 27 preoperative to 5 postoperative (P<0.001). Patient satisfaction increased from 8% preoperative to 84% postoperative (P<0.001). Results were similar to the trial data. CONCLUSIONS MSA is a safe and effective treatment for GERD, with significant improvement in quality of life. GERD-HRQL, medication reduction, operative times, and dysphagia rates were similar to other reports, demonstrating the reproducibility of MSA. Lower dilation rates may be due to refinements in technique and postoperative dietary management.
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Affiliation(s)
- Nicholas M Czosnyka
- General Surgery Residency, Department of Medical Education, Gundersen Medical Foundation, La Crosse, WI, USA
| | - F Paul Buckley
- The Heartburn & Acid Reflux Center, Baylor Scott & White Healthcare, Round Rock, TX, USA
| | - Stephanie L Doggett
- The Heartburn & Acid Reflux Center, Baylor Scott & White Healthcare, Round Rock, TX, USA
| | - Hannah Vassaur
- The Heartburn & Acid Reflux Center, Baylor Scott & White Healthcare, Round Rock, TX, USA
| | - Erin E Connolly
- Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI, USA
| | - Andrew J Borgert
- Department of Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Kara J Kallies
- Department of Research, Gundersen Medical Foundation, La Crosse, WI, USA
| | - Shanu N Kothari
- Department of General and Vascular Surgery, Gundersen Health System, La Crosse, WI, USA.
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Rona KA, Reynolds J, Schwameis K, Zehetner J, Samakar K, Oh P, Vong D, Sandhu K, Katkhouda N, Bildzukewicz N, Lipham JC. Efficacy of magnetic sphincter augmentation in patients with large hiatal hernias. Surg Endosc 2016; 31:2096-2102. [PMID: 27553803 DOI: 10.1007/s00464-016-5204-3] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2016] [Accepted: 08/17/2016] [Indexed: 12/18/2022]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) has demonstrated long-term safety and efficacy in the treatment of patients with gastroesophageal reflux (GERD), but its efficacy in patients with large hiatal hernias has yet to be proven. The aim of our study was to assess outcomes of MSA in patients with hiatal hernias ≥3 cm. METHODS We retrospectively reviewed all patients who underwent MSA at our institutions over a 6-year period. Information obtained consisted of patient demographics, symptoms of GERD, preoperative GERD Health-Related Quality-of-Life (HRQL) scores, perioperative details, and implantation of the MSA device. Primary endpoints included postoperative GERD-HRQL scores, proton-pump inhibitor (PPI) use, symptom change, and procedure-related complications. A large hiatal hernia was defined as a hernia measuring ≥3 cm by intraoperative measurement. RESULTS A total of 192 patients were reviewed. Median follow-up was 20 months (3-75 months). Mean GERD-HRQL scores in the overall population before and after MSA were 18.9 and 5.0, respectively (p < 0.001). In the majority of patients symptoms improved or resolved (N = 177, p < 0.001). Fifty-two patients (27.0 %) had a hiatal hernia ≥3 cm (range 3-7 cm). Their mean GERD-HRQL score decreased from 20.5 to 3.6 (p < 0.001) following MSA. When compared to patients with smaller hernias, patients with large hiatal hernias had decreased postoperative PPI requirement (9.6 vs. 26.6 %, p = 0.011) and lower mean postoperative GERD-HRQL scores (3.6 vs. 5.6, p = 0.027). The percent of patients requiring postoperative intervention for dysphagia was similar (13.5 vs. 17.9 %, p = 0.522), as was the incidence of symptom resolution or improvement (98.1 vs. 91.3 %, p = 0.118). CONCLUSION MSA in patients with large hiatal hernias demonstrates decreased postoperative PPI requirement and mean GERD-HRQL scores compared to patients with smaller hernias. The incidence of symptom resolution or improvement and the percentage of patients requiring intervention for dysphagia are similar. Short-term outcomes of MSA are encouraging in patients with gastroesophageal reflux disease and large hiatal hernias.
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Affiliation(s)
- Kais A Rona
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | | | | | - Joerg Zehetner
- Keck School of Medicine of USC, Los Angeles, CA, USA.,Department of General Surgery, Keck Hospital of USC, 1510 San Pablo St., HCC Suite 514, Los Angeles, CA, 90033, USA
| | - Kamran Samakar
- Keck School of Medicine of USC, Los Angeles, CA, USA.,Department of General Surgery, Keck Hospital of USC, 1510 San Pablo St., HCC Suite 514, Los Angeles, CA, 90033, USA
| | - Paul Oh
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - David Vong
- Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Kulmeet Sandhu
- Keck School of Medicine of USC, Los Angeles, CA, USA.,Department of General Surgery, Keck Hospital of USC, 1510 San Pablo St., HCC Suite 514, Los Angeles, CA, 90033, USA
| | - Namir Katkhouda
- Keck School of Medicine of USC, Los Angeles, CA, USA.,Department of General Surgery, Keck Hospital of USC, 1510 San Pablo St., HCC Suite 514, Los Angeles, CA, 90033, USA
| | - Nikolai Bildzukewicz
- Keck School of Medicine of USC, Los Angeles, CA, USA.,Department of General Surgery, Keck Hospital of USC, 1510 San Pablo St., HCC Suite 514, Los Angeles, CA, 90033, USA
| | - John C Lipham
- Keck School of Medicine of USC, Los Angeles, CA, USA. .,Department of General Surgery, Keck Hospital of USC, 1510 San Pablo St., HCC Suite 514, Los Angeles, CA, 90033, USA. .,James and Pamela Muzzy Endowed Chair in Gastrointestinal Cancer, Hoag Memorial Hospital Presbyterian, Newport Beach, CA, USA.
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Affiliation(s)
- Yulia Zak
- Mount Sinai Beth Israel, First Avenue at 16th Street, New York, NY 10003, USA.
| | - David W Rattner
- Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
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Zhang H, Dong D, Liu Z, He S, Hu L, Lv Y. Revaluation of the efficacy of magnetic sphincter augmentation for treating gastroesophageal reflux disease. Surg Endosc 2016; 30:3684-90. [PMID: 26659236 DOI: 10.1007/s00464-015-4701-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2015] [Accepted: 11/18/2015] [Indexed: 12/31/2022]
Abstract
BACKGROUND Gastroesophageal reflux disease (GERD) is a prevalent disease which severely impacts the quality of life of the patients. The surgical options are limited to such patients who are not satisfied with medical therapies. Magnetic sphincter augmentation (MSA) is a new antireflux surgical technique for treating GERD, which could physiologically reinforce the lower esophageal sphincter by magnetic force. Many clinical and animal studies have focused on this new therapy. The purpose of this work was to review the feasibility, efficacy and safety of MSA as a new treatment for GERD. METHODS We performed a PubMed database search for the MSA and GERD-related studies between 2008 and September 22, 2015. One animal study, two case reports and fifteen clinical studies were identified in this review. RESULTS The MSA device reinforces the lower esophageal sphincter to antireflux via magnetic force. The feasibility of this laparoscopic technique has been proved by the experimental and clinical studies. The clinical studies demonstrate that MSA treatment could effectively reduce the percent time of esophageal acid exposure (pH < 4) and improve the GERD health-related quality of life score. The operation time of MSA is shorter than that of the Nissen fundoplication, and the efficacy of MSA treatment is equal to that of fundoplication. The most frequent postoperative complication is dysphagia, and the majority of them could be self-resolved with conservative treatment. CONCLUSION MSA (or LINX) devices provide an alternative surgical option for the patients who had failed in medical therapy. This review of the current literatures demonstrates that MSA is as effective as the medical and conventional surgical therapies. In the future, MSA will play a more important role in the treatment of GERD because of its unique advantage.
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Reynolds JL, Zehetner J, Nieh A, Bildzukewicz N, Sandhu K, Katkhouda N, Lipham JC. Charges, outcomes, and complications: a comparison of magnetic sphincter augmentation versus laparoscopic Nissen fundoplication for the treatment of GERD. Surg Endosc. 2016;30:3225-3230. [PMID: 26541730 DOI: 10.1007/s00464-015-4635-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Accepted: 10/17/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Magnetic sphincter augmentation (MSA) is approved for uncomplicated GERD. Multiple studies have shown MSA to compare favorably to laparoscopic Nissen fundoplication (LNF) in terms of symptom control with results out to 5 years. The MSA device itself, however, is an added cost to an anti-reflux surgery, and direct cost comparison studies have not been done between MSA and LNF. The aim of the study was to compare charges, complications, and outcome of MSA versus LNF at 1 year. METHODS This is a retrospective analysis of all patients who underwent MSA or LNF for the treatment of GERD between January 2010 and June 2013. Patient charges were collected for the surgical admission. We also collected data on 30-day complications and symptom control at 1 year assessed by GERD-HRQL score and PPI use. RESULTS There were 119 patients included in the study, 52 MSA and 67 LNF. There was no significant difference between the mean charges for MSA and LNF ($48,491 vs. $50,111, p = 0.506). There were significant differences in OR time (66 min MSA vs. 82 min LNF, p < 0.01) and LOS (17 h MSA vs. 38 h LNF, p < 0.01). At 1-year follow-up, mean GERD-HRQL was 4.3 for MSA versus 5.1 for LNF (p = 0.47) and 85 % of MSA patients versus 92 % of LNF patients were free from PPIs (p = 0.37). MSA patients reported less gas bloat symptoms (23 vs. 53 %, p ≤ 0.01) and inability to belch (10 vs. 36 %, p ≤ 0.01) and vomit (4 vs. 19 %, p ≤ 0.01). CONCLUSION The side effect profile of MSA is better than LNF as evidenced by less gas bloat and increase ability to belch and vomit. LNF and MSA are comparable in symptom control, safety, and overall hospital charges. The charge for the MSA device is offset by less charges in other categories as a result of the shorter operative time and LOS.
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Loh Y, McGlone ER, Reddy M, Khan OA. Is the LINX reflux management system an effective treatment for gastro-oesophageal reflux disease? Int J Surg 2014; 12:994-7. [PMID: 25062898 DOI: 10.1016/j.ijsu.2014.07.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2014] [Revised: 06/13/2014] [Accepted: 07/21/2014] [Indexed: 11/19/2022]
Abstract
A best evidence topic in surgery was written according to a structured protocol. The question addressed whether LINX™ Reflux management system is an efficacious treatment for patients with symptoms of gastro-oesophageal reflux disease (GORD) not controlled by proton pump inhibitors (PPI). Forty-eight LINX-related papers were identified using the reported search, of which three represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group, study type, relevant outcomes and results of these papers are tabulated. All three studies were prospective case studies. They demonstrated that LINX is an efficacious treatment for GORD patients with good short and medium term outcomes and an acceptable safety profile. Further studies are required to determine its long term outcomes and its relative efficacy as compared to other established treatments.
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Affiliation(s)
- Yiwen Loh
- Department of Upper GI Surgery, St Georges Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Emma Rose McGlone
- Department of Upper GI Surgery, St Georges Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Marcus Reddy
- Department of Upper GI Surgery, St Georges Hospital, Blackshaw Road, London SW17 0QT, UK
| | - Omar A Khan
- Department of Upper GI Surgery, St Georges Hospital, Blackshaw Road, London SW17 0QT, UK.
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