Gastroesophageal Reflux Management with the LINX® System for Gastroesophageal Reflux Disease Following Laparoscopic Sleeve Gastrectomy

Management of Gastroesophageal Reflux Disease after Sleeve Gastrectomy: Effectiveness of Medical, Endoscopic, and Surgical Therapies

Introduction: Sleeve gastrectomy (SG) has become the most frequently performed bariatric operation in the United States. One of the main disadvantages of this procedure is the risk of developing gastroesophageal reflux disease (GERD) after the operation. We aimed to analyze different approaches for the treatment of GERD after SG. Methods: A literature review was performed to identify all possible treatment options for post-SG GERD. All the studies were assessed for full eligibility by manual assessment of their aims, methodology, results, and conclusions. Records were individually reviewed by the authors comparing outcomes and complications between procedures. Results: Although some studies have shown improvement or even resolution of GERD symptoms after SG, most patients develop or worsen symptoms. Lifestyle modifications along with medical therapy should be started on patients with GERD after SG. For those who are refractory to medication, endoscopic and surgical therapies can be offered. Conversion to Roux-en-Y gastric bypass (RYGB) is consistently effective in treatment of GERD and is the ideal therapy in patients with associated insufficient weight loss. Endoscopic and alternative surgical procedures are also available and have shown acceptable short-term outcomes. Conclusions: Several treatment options exist for the treatment of GERD after SG. Although conversion to RYGB remains the most effective therapy, other emerging endoscopic and surgical procedures could avoid the potential morbidity of this procedure and should be further evaluated. An evidence-based algorithm for the management of GERD after SG is proposed to guide decision making.

Current Management and Treatment Paradigms of Gastroesophageal Reflux Disease following Sleeve Gastrectomy

Obesity is associated with serious comorbidities and economic implications. Bariatric surgery, most commonly Roux-en-Y gastric bypass and sleeve gastrectomy, are effective options for weight loss and the improvement of obesity-related comorbidities. With the growing obesity epidemic, there has been a concomitant rise in bariatric surgeries, particularly in sleeve gastrectomy, which has been the most widely performed bariatric surgery since 2013. Gastroesophageal reflux disease (GERD) is highly prevalent in obese individuals, can significantly impact quality of life and may lead to serious complications. Obesity and GERD both improve with weight loss. However, as the incidence of sleeve gastrectomy rises, recent data have revealed a risk of exacerbation of pre-existing GERD or the development of de novo GERD following sleeve gastrectomy. We performed a detailed review of GERD post-sleeve gastrectomy, including its overall incidence, pathophysiology and current treatment paradigms.

Gastroesophageal Reflux Disease in Obesity: Bariatric Surgery as Both the Cause and the Cure in the Morbidly Obese Population

Gastrointestinal reflux disease (GERD) is a chronic, highly prevalent condition in the United States. GERD can significantly impact quality of life and lead to complications including aspiration pneumonia, esophageal stricture, Barrett's esophagus (BE) and esophageal cancer. Obesity is a risk factor for GERD, which often improves with weight loss and bariatric surgery. Though the incidence of bariatric surgery, in particular, minimally invasive sleeve gastrectomy, has risen in recent years, emerging data has revealed that the severity or new onset of GERD may follow bariatric surgery. We performed a literature review to provide a detailed analysis of GERD with an emphasis on bariatric surgery as both the cure and the cause for GERD in the morbidly obese population. We also describe the pathophysiological mechanisms, management approach and treatment strategies of GERD following bariatric surgery.

Best practice approach for redo-surgeries after sleeve gastrectomy, an expert's modified Delphi consensus

BACKGROUND

Sleeve gastrectomy (SG) is the most common metabolic and bariatric surgical (MBS) procedure worldwide. Despite the desired effect of SG on weight loss and remission of obesity-associated medical problems, there are some concerns regarding the need to do revisional/conversional surgeries after SG. This study aims to make an algorithmic clinical approach based on an expert-modified Delphi consensus regarding redo-surgeries after SG, to give bariatric and metabolic surgeons a guideline that might help for the best clinical decision.

METHODS

Forty-six recognized bariatric and metabolic surgeons from 25 different countries participated in this Delphi consensus study in two rounds to develop a consensus on redo-surgeries after SG. An agreement/disagreement ≥ 70.0% on statements was considered to indicate a consensus.

RESULTS

Consensus was reached for 62 of 72 statements and experts did not achieve consensus on 10 statements after two rounds of online voting. Most of the experts believed that multi-disciplinary team evaluation should be done in all redo-procedures after SG and there should be at least 12 months of medical and supportive management before performing redo-surgeries after SG for insufficient weight loss, weight regain, and gastroesophageal reflux disease (GERD). Also, experts agreed that in case of symptomatic GERD in the presence of adequate weight loss, medical treatment for at least 1 to 2 years is an acceptable option and agreed that Roux-en Y gastric bypass is an appropriate option in this situation. There was disagreement consensus on efficacy of omentopexy in rotation and efficacy of fundoplication in the presence of a dilated fundus and GERD.

CONCLUSION

Redo-surgeries after SG is still an important issue among bariatric and metabolic surgeons. The proper time and procedure selection for redo-surgery need careful considerations. Although multi-disciplinary team evaluation plays a key role to evaluate best options in these situations, an algorithmic clinical approach based on the expert's consensus as a guideline can help for the best clinical decision-making.

Feasibility and Efficacy of Magnetic Sphincter Augmentation for the Management of Gastroesophageal Reflux Disease Post-Sleeve Gastrectomy for Obesity

BACKGROUND

Patients with medically intractable GERD after laparoscopic sleeve gastrectomy (LSG) have limited surgical options. Fundoplication is difficult post-LSG. Roux-en-Y gastric bypass may be used as a conversion procedure but is more invasive with potential for serious complications. Magnetic sphincter augmentation (MSA) is a less invasive GERD treatment alternative. The objective of this study was to assess safety and efficacy outcomes of MSA after LSG.

METHODS

The primary outcome of this observational, multicenter, single-arm prospective study was the rate of serious device and/or procedure-related adverse events (AEs). The efficacy of the LINX device was measured comparing baseline to 12-month post-implant reductions in distal acid exposure, GERD-HRQL score, and average daily PPI usage.

RESULTS

Thirty subjects who underwent MSA implantation were followed 12 months post-implant. No unanticipated adverse device effects were observed. There were two adverse events deemed serious (dysphagia, pain, 6.7%) which resolved without sequelae. GERD-HRQL scores showed significant improvement (80.8%, P < 0.001), and reduction in daily PPI usage was seen (95.8%, P < 0.001). Forty-four percent of subjects demonstrated normalization or >  = 50% reduction of total distal acid exposure time (baseline 16.2%, 12 months 11%; P = 0.038).

CONCLUSIONS

Post-LSG, MSA showed an overall improvement of GERD symptoms, and reduction in PPI use with explants within anticipated range along with improvement in distal esophageal acid exposure time.

Laparoscopic magnetic sphincter augmentation device placement for patients with medically-refractory gastroesophageal reflux after sleeve gastrectomy

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.

Laparoscopic management of pathologic gastroesophageal reflux after sleeve gastrectomy using the magnetic sphincter augmentation (MSA) device-a Video Vignette

Purpose

The development of gastroesophageal reflux disease (GERD) has been shown to be not infrequent after laparoscopic sleeve gastrectomy (LSG). Management may vary from medical therapy to Roux-en-Y gastric bypass (RYGB) conversion. Magnetic sphincter augmentation (MSA) device has been shown to be a promising option with excellent results. The purpose of this video was to demonstrate the laparoscopic management of post-LSG GERD with MSA device implant.

Materials and Methods

An intraoperative video has been edited to demonstrate the MSA device placement after LSG for the treatment of pathologic GERD.

Results

The procedure started with the lysis of the perigastric adhesions to free the distal esophagus circumferentially. The posterior vagus nerve was identified, and a small window was created between the posterior esophageal wall anteriorly and the vagus nerve posteriorly. A hiatoplasty was performed using two non-resorbable interrupted 2.0 Prolene® sutures. The system’s sizer was placed to measure the junctional circumference. A 15-mm MSA device was implanted.

Conclusion

MSA device placement seems technically feasible and safe with promising results in term of improved LES resting pressure and esophageal acid exposure. While future studies are necessary to corroborate these preliminary indications, MSA device may possibly become a valid option in surgeon armamentarium.

Supplementary Information

The online version contains supplementary material available at 10.1007/s11695-022-06007-x.

Gastroesophageal Reflux After Sleeve Gastrectomy

Sleeve gastrectomy continues to be the most commonly performed bariatric operation worldwide. Development or worsening of pre-existing GERD has been recognized as a significant issue postoperatively. There is a paucity of information concerning the most appropriate preoperative workup and the technical and anatomical factors that may or may not contribute to the occurrence of reflux symptoms. Contemporary data quality is deficient given the predominantly retrospective nature, limited follow-up time, and heterogeneous outcome measures across studies. This has produced mixed results regarding the postoperative incidence and severity of GERD. Ultimately, better-constructed investigations are needed in order to offer evidence-based recommendations that may guide preoperative workup and improved patient selection criteria.

Diagnostic Criteria for Gastro-esophageal Reflux Following Sleeve Gastrectomy

Background

Gastro-esophageal reflux disease (GERD) post-sleeve gastrectomy (SG) is a controversial issue and diagnostic dilemma. Strong heterogeneity exists in the assessment of reflux post-SG, and better diagnostic tools are needed to characterize symptomatic reflux. We aimed to determine the discriminant factors of symptomatic reflux and establish diagnostic thresholds for GERD following SG.

Materials and Methods

Patients post-SG were categorized into asymptomatic and symptomatic cohorts and completed validated symptom questionnaires. All patients underwent stationary esophageal manometry and 24-h ambulatory pH monitoring. Univariate and multivariate analyses were conducted to determine the strongest discriminant factors for GERD.

Results

Baseline characteristics of the asymptomatic cohort (n = 48) and symptomatic cohort (n = 76) were comparable. The median post-operative duration was 7.3 (14.1) vs 7.5 (10.7) months (p = 0.825). The symptomatic cohort was more female predominant (90.8 vs 72.9%, p = 0.008). Reflux scores were significantly higher in the symptomatic group (36.0 vs 10.5, p = 0.003). Stationary manometry parameters were similar, including hiatus hernia prevalence and impaired esophageal motility. The symptomatic cohort had significantly higher total acid exposure, especially while supine (11.3% vs 0.6%, p < 0.001). Univariate and multivariate regressions delineated reflux score and supine acid exposure as discriminant factors for symptomatic reflux. The thresholds for distinguishing symptomatic reflux are as follows: reflux score of 11.5 (sensitivity 84.0%, specificity 68.2%) and supine acid exposure of 2.65% (sensitivity 67.1%, specificity 70.8%).

Conclusion

A reflux score of 11.5 or more or supine acid exposure of 2.65% or more should be considered diagnostic in defining symptomatic reflux following SG.

Sleeve gastrectomy with tailored 360° fundoplication according to Rossetti in patients affected by obesity and gastroesophageal reflux: a prospective observational study

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) is the most frequently performed bariatric procedure. Recent studies demonstrated the correlation between LSG and gastroesophageal reflux disease (GERD).

OBJECTIVES

To evaluate the effectiveness of LSG + Rossetti antireflux fundoplication in patients affected by morbid obesity and GERD.

SETTING

High-volume bariatric center, Italy.

METHODS

This is a prospective, observational cohort study that enrolled 58 patients affected by obesity and GERD who underwent surgery. All the patients had a 12-month follow-up. Gastroscopies were performed preoperatively and at month 12 for 35 patients.

RESULTS

At 1 year after surgery, patients had a consistent decrease in body mass index, from 41.9 ± 4.6 kg/m² to 28.2 ± 3.7 kg/m². GERD improved in 97.1% of patients. Co-morbidities, such as hypertension, type 2 diabetes, respiratory dysfunction, and arthropathies improved as well. The visual analogue scale score regarding the global state of health increased significantly, from 58.1 ± 17.1% before surgery to 98.8 ± 4.1% at 1 year after surgery. Two patients had a fundoplication perforation and needed reparative surgery (3.5%). One patient had anemia that needed a blood transfusion (1.7%). Complications were reduced with a learning curve.

CONCLUSION

LSG + Rossetti fundoplication was shown to be a safe and effective intervention. It could be considered an option in obese patients affected by GERD. A longer follow-up is needed to establish the long-term outcomes.

Magnetic Sphincter Augmentation Placement for Recalcitrant Gastroesophageal Reflux Disease Following Bariatric Procedures: A Systematic Review and Bayesian Meta-Analysis

Background: This study aims to consolidate all available articles on this topic and evaluate MSA effectiveness in the management of gastroesophageal reflux disease (GERD). Matherials and Methods: We conducted an electronic systematic search using MEDLINE databases (PubMed), EMBASE, and Web of Science. An electronic systematic search of articles comparing preoperative and postoperative health-related quality of life (GERD-HRQL) scores in patients who underwent MSA placement for management of GERD following bariatric surgery was performed. Three retrospective studies totaling 33 patients met the inclusion criteria and were included in this meta-analysis. Results: The pooled mean difference in change from preoperative GERD-HRQL score was 17.5 (95% CrI; -22.88 to -12.20) and it was statistically significant. The between-study variability is 3.621 (95% HPD; 1.39 4.99) with low heterogeneity (I² = 15%; 95% HPD; 2.1 26.2%). Conclusions: MSA for refractory GERD following bariatric surgery appears feasible. Prospective randomized controlled with standardized surgical technique and objective follow-up evaluation is needed to better assess short- and long-term efficacy.

Magnetic sphincter augmentation at the time of bariatric surgery: an analysis of the MBSAQIP

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.

Does Sleeve Gastrectomy Increase the Risk of Barret's Esophagus?

PURPOSE

Sleeve gastrectomy (SG) is the most commonly performed bariatric surgical procedure worldwide. However, the impact of SG on Barrett's esophagus (BE) remains unknown. The main objective was to determine the rate of BE 5 years after SG.

MATERIALS AND METHODS

Patients, operated in 2012 by SG in one center, who preoperatively and postoperatively (5 years) underwent upper gastrointestinal endoscopy (UGIE), 24-h pH monitoring, and esophageal manometry, were included.

RESULTS

A total of 59 (81.4% of females) patients were included. Preoperative mean age and body mass index were 45.2 ± 11.7 years and 45.2 ± 8.1 kg/m² respectively. Preoperative 24-h pH monitoring reported gastroesophageal reflux disease (GERD) in 18 (30.5%) patients. The mean total body weight loss at 5 years was 16.1 ± 11.2%. No significant difference was observed between preoperative and postoperative de Meester's score (20.2 ± 27.1 and 21.0 ± 21.5 respectively (p = 0.91)) nor between preoperative and postoperative number of acid reflux episodes per 24 h (65.1 ± < 40.0 and 50.3 ± 40.3 (p = 0.21)). The UGIE revealed 5 patients (8.5%) with endoscopically suspected esophageal metaplasia, without confirmed metaplasia on histologic examination. GERD was diagnosed in 32 patients (54.2%), de novo GERD in 16 (27.1%) patients and esophagitis in 16 (27.1%) patients. At 5 years, 25 patients (42.4%) reported a lack of regular medical follow-up.

CONCLUSIONS

This study highlights the incidence of postoperative GERD and endoscopic lesions following SG. Even though SG is not contraindicated in case of reflux, GERD patients who undergo SG may be supervised by a close endoscopic surveillance.

Robotic-assisted approaches to GERD following sleeve gastrectomy

BACKGROUND

Sleeve gastrectomy (SG) is the most common bariatric operation in the United States but increases the incidence of gastroesophageal reflux disease (GERD). The aim of our study was to describe our experience with robotic-assisted management of intractable GERD after SG.

METHODS

A systematic review of a prospectively maintained database was performed of consecutive patients undergoing robotic-assisted magnetic sphincter augmentation placement after sleeve gastrectomy (MSA-S group) or conversion to Roux-en-Y gastric bypass (RYGB group) for GERD from 2015 to 2019 at our tertiary- care bariatric center. These were compared to a consecutive group of patients undergoing robotic-assisted magnetic sphincter augmentation placement (MSA group) for GERD without a history of bariatric surgery from 2016 to 2019. The primary outcome was perioperative morbidity. Secondary outcomes were operative time (OT), 90-day re-intervention rate, length of stay, symptom resolution and weight change.

RESULTS

There were 51 patients included in this study; 18 patients in the MSA group, 13 patients in the MSA-S group, and 20 patients in the RYGB group. There was no significant difference in age, gender, ASA score, preoperative endoscopic findings, or DeMeester scores (P > 0.05). BMI was significantly higher in patients undergoing RYGB compared to MSA or MSA-S (P < 0.0001). There were significant differences in OT between the MSA and RYGB groups (P < 0.0001) and MSA-S and RYGB groups (P = 0.009), but not MSA group to MSA-S group (P = 0.51). There was no significant difference in intraoperative and postoperative morbidity (P = 1.0 and P = 0.60, respectively). 30-day morbidity: 5.6% (MSA), 15.4% (MSA-S) and 15% (RYGB). There was no difference on PPI discontinuation among groups, with more than 80% success rate in all.

CONCLUSIONS

The use of the robotic platform in the different approaches available for treatment of GERD after SG appears to be a feasible option with low morbidity and high success rate. Further data is needed to support our findings.

Magnetic Sphincter Augmentation After Gastric Surgery

Background

Persistent or de novo gastroesophageal reflux disease (GERD) may be a significant clinical issue after gastric/bariatric surgical procedures. We investigated the effect of magnetic sphincter augmentation (MSA) in the treatment of GERD after previous gastric/bariatric surgery.

Database

We conducted a systematic review according to the Preferred Reporting Items For Systematic Reviews and Meta-analyses statement. We searched multiple databases (PubMed, Cochrane, Embase, Scopus) up to May 2019. We also queried the prospectively collected database of patients who underwent MSA at our tertiary-care hospital and compared postsurgical to naïve patients operated during the same time period.

Results

Seven studies (3 case series and 4 case reports), for a total of 35 patients, met the inclusion criteria in the systematic review. The most common index operation was a bariatric procedure, either sleeve gastrectomy or Roux-en-Y gastric bypass. After MSA implant, the Gastroesophageal Reflux Disease-Health-Related Quality of Life (GERD-HRQL) score significantly improved compared to baseline (P = .005). Two patients (5.7%) required laparoscopic device removal. In the local institutional cohort series of 67 patients treated by MSA, the prevalence of preoperative grade B esophagitis, operative time, size of MSA, and length of stay were greater in patients with prior gastric surgery compared to naïve patients.

Conclusions

MSA is a safe, simple, and standardized antireflux procedure. It is also feasible in patients with refractory GERD following gastric/bariatric surgery. Further prospective and comparative studies are needed to validate the preliminary clinical experience in this subset of patients.

Surgical strategy for gastroesophageal reflux disease in patients with obesity

Gastroesophageal reflux disease (GERD) and obesity have become serious problems affecting global health. The surgical treatment strategy for GERD patients with obesity is still a difficult point. In particular, obesity exacerbates the occurrence of GERD, and simple anti-reflux surgery has limited efficacy in obese patients. Currently, bariatric surgery is a good choice for the treatment of such patients, and Roux-en-Y gastric bypass is the best choice. Revisional surgery remains to be standardized for serious complications in postoperative patients. In addition, the new anti-reflux bariatric surgery that has been emerging in recent years is expected to be an effective alternative treatment for GERD patients with obesity.

LINX® reflux management system to bridge the “treatment gap” in gastroesophageal reflux disease: A systematic review of 35 studies

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.

Lower oesophageal peptic stricture after laparoscopic sleeve gastrectomy: World's first case report

Laparoscopic sleeve gastrectomy (LSG) is the most commonly performed bariatric surgery worldwide. De novo gastroesophageal reflux disease after LSG has been reported in the range of 0%–34.9%. Benign lower oesophageal peptic stricture is rare and has not been reported till date. We present the first case report of benign oesophageal peptic stricture post-sleeve gastrectomy and its management. The management modalities for peptic stricture post-LSG include proton pump inhibitors, endoscopic dilatation and surgical management. Revisional Roux-en-Y gastric bypass along with optimal usage of serial dilatation and medical treatment has been shown to be an effective treatment for the same.

Systematic review of the introduction and evaluation of magnetic augmentation of the lower oesophageal sphincter for gastro-oesophageal reflux disease

BACKGROUND

Magnetic sphincter augmentation (MSA) is reported to be an innovative alternative to antireflux surgery for patients with gastro-oesophageal reflux disease. Although used in practice, little is known about how it has been evaluated. This study aimed to systematically summarize and appraise the reporting of MSA and its introduction into clinical practice, in the context of guidelines (such as IDEAL) for evaluating innovative surgical devices.

METHODS

Systematic searches were used to identify all published studies reporting MSA insertion. Data collected included patient selection, governance arrangements, surgeon expertise, technique description and outcome reporting.

RESULTS

Searches identified 587 abstracts; 39 full-text papers were included (1 RCT 5 cohort, 3 case-control, 25 case series, 5 case reports). Twenty-one followed US Food and Drug Administration eligibility criteria for MSA insertion. Twenty-six documented that ethical approval was obtained. Two reported that participating surgeons received training in MSA; 18 provided information about how MSA insertion was performed, although techniques varied between studies. Follow-up ranged from 4 weeks to 5 years; in 14 studies, it was less than 1 year.

CONCLUSION

Most studies on MSA lacked information about patient selection, governance, expertise, techniques and outcomes, or varied between studies. Currently, MSA is being used despite a lack of robust evidence for its effectiveness.

Thirteen-Year Experience of Laparoscopic Sleeve Gastrectomy: Surgical Risk, Weight Loss, and Revision Procedures

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has been validated as a safe and effective treatment for morbid obesity. However, data of the long-term outcome remains lacking.

METHODS

A total of 1759 LSG was performed as primary bariatric procedure from 2005 to 2017 with mean age of 35.2 ± 10.3 years old (14-71), female 69.7%, mean body mass index (BMI) 37.9 ± 7.7 kg/m², and mean waist width 113.7 ± 17.9 cm. All patients were evaluated and managed under a strict multidisciplinary team approach. A retrospective analysis of a prospective bariatric database and telephone interview of patients who defaulted clinic follow-up at 10 years was conducted.

RESULTS

The mean operating time, intraoperative blood, and hospital stay of LSG were 121.5 ± 36.5 min, 40.8 ± 69.7 ml, and 2.8 ± 2.7 days, respectively. The 30-day postoperative major complication occurred in 25 (1.4%) patients. The major complication rate was 15% at first year and 0% at the last year. The follow-up rate at 1, 5 and 10 years were 89.3%, 52.1 and 64.4%. At postoperative 1, 5, and 10 years, the mean percentage of total weight loss (%TWL) and excess weight loss (EWL%) of LSG patients were 33.4, 28.3, and 26.6% and 92.2, 80.1, and 70.5%, respectively. The mean BMI became 27, 26.2, and 27.1 kg/m² at postoperative 1, 5, and 10 years. At follow-up, a total 69 patients needed surgical revision due to reflux disease (n = 45), weight regain (n = 19), persistent diabetes (n = 2), and chronic fistula (n = 3). The type of revision procedures were hiatal repair and gastropexy (n = 29), Roux-en Y gastric bypass (RYGB) (n = 23), and single anastomosis bypass (n = 17) with median time to revision 33 months (range 3-62). At 10 years, the overall revision rate was 21.5% (14/65) and 11(16.9%) of 65 patients were converted to RYGB. The other 54 patients remained at LSG anatomy, but 45% of them required proton pump inhibitor for reflux symptoms.

CONCLUSIONS

Our results showed that primary LSG is a durable primary bariatric procedure with sustained weight loss and a high resolution of comorbidities at 10 years, but about half the patients had de novo GERD. The need for conversion to RYGB was 16.9% at 10 years.

Magnetic sphincter augmentation: a viable rescue therapy for symptomatic reflux following bariatric surgery

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.

Comparative Analysis of Laparoscopic Fundoplication and Magnetic Sphincter Augmentation for the Treatment of Medically Refractory GERD

We have recently introduced laparoscopic magnetic sphincter augmentation (MSA) combined with hiatal hernia repair for treatment of patients with medically refractory gastroesophageal reflux disease (GERD). MSA is a novel surgical approach to the treatment of severe GERD, in which magnetic beads are secured around the lower esophageal sphincter, augmenting the lower esophageal sphincter function as an anti-reflux barrier. We hypothesize that patients undergoing MSA will achieve GERD relief, equal to that obtained after laparoscopic Nissen fundoplication. The GERD Health Related Quality of Life (GERD HRQL) Questionnaire is a validated clinical tool that was used to quantify patient outcomes in terms of GERD-related symptoms both on and off proton pump inhibitors and after acute radiation syndrome. We retrospectively reviewed data from patients at our institution enrolled in a prospective institutional review board–approved database “Registry Outcomes Anti-Reflux Surgery” that applies objective and subjective information about patients undergoing anti-reflux surgery. Information from both the database and patient HRQL scores were used to compare the effectiveness of medical intervention with acute radiation syndrome (laparoscopic Nissen fundoplication and MSA) in decreasing GERD-related symptoms in patients. Results are expressed as mean ± SE, and single-factor ANOVA test was used to compare groups. We found that MSA and laparoscopic fundoplication both lead to a comparable decrease in HRQL score and an increase in patient satisfaction when compared with patient's preoperative symptoms with maximum proton pump inhibitor use. In addition, our study shows that MSA is a safe minimally invasive anti-reflux procedure without the negative side-effects, such as gas bloat, inability to belch, and inability to vomit, commonly associated with NF.

Laparoscopic placement of the LINX® system in management of severe reflux after sleeve gastrectomy

BACKGROUND

Management of severe reflux after sleeve gastrectomy (SG) is often done by conversion to Roux-en-Y gastric bypass (RYGB). The LINX^® system could be an alternative treatment.

METHOD

Between 2015 and 2017, 13 patients had LINX^® system placed to manage their reflux after SG. Pre-operative evaluation included a barium swallow, endoscopy with pH monitor and esophageal motility.

RESULTS

Ten females and three males with mean age of 49 ± 13 years were evaluated. Their mean weight before placing the LINX^® system was 193 ± 45 lbs. and mean BMI of 33 ± 6 kg/m². The mean time between SG and placing the LINX^® system was 43 ± 19 months. The mean Bravo score was 46 ± 26 (normal 14.7). One patient developed severe dysphagia post-operatively requiring removal of the LINX^® after 18 days and one patient was lost to follow up. The mean follow-up in the remaining 11 patients was 26 ± 12 months. The mean GERD-HRQL score dropped significantly from 47/75 ± 17/75 to 12/75 ± 14/75 (p = .0003).

CONCLUSION

The LINX^® system may be used as an alternative to RYGB conversion in managing refractory post-SG reflux.

Refractory GERD, beyond proton pump inhibitors

Pharmacologic therapy, surgery, minimally invasive therapies, and alternative therapies are different options available for the management of refractory GERD. The choice may depend on the cause of refractoriness. Increased gastric acid suppression therapy might be useful in the rare patients with persistent elevated esophageal acid exposure on proton pump inhibitors (PPI). Potassium-competitive acid blockers (P-CAB) might induce a more important acid inhibition than PPI. Baclofen might act as a reflux inhibitor and demonstrates a significant efficacy in rumination syndrome. The role of topical antacid-alginate in refractory GERD might be limited. Surgery might be a valid option in case of persistent pathological acid esophageal exposure despite PPI. Further evaluation of minimally invasive procedures is necessary. Finally diet, diaphragmatic breathing and transcutaneous electrical acustimulation might be of interest in patients with esophageal hypersensivity or functional symptoms.

Weight Loss and Resolution of Comorbidities After Sleeve Gastrectomy: A Review of Long-Term Results

BACKGROUND AND AIMS:

Laparoscopic sleeve gastrectomy (SG) has massively increased in numbers over the last decade and is the most frequently performed bariatric procedure worldwide today. The aim of this review is to evaluate SG in terms of weight loss and resolution of comorbidities, based on data gained from the latest long-term studies available.

MATERIAL AND METHODS:

This review includes the results of any long-term studies on SG available at this point as well as a selection of short- and mid-term studies.

RESULTS:

There are only a handful of studies on sleeve gastrectomy with long-term follow-up available at this point. Conversion rates in these long-term studies amount to up to one-third of their cohorts; however, excess weight loss in patients maintaining their sleeve is over 50%. Results on the resolution of comorbidities vary among the studies available today.

SUMMARY:

Sleeve gastrectomy is a valid bariatric method but one has to be aware of its limitations.

Spotlight on the Linx™ Reflux Management System for the treatment of gastroesophageal reflux disease: evidence and research

BACKGROUND

The initial approach to gastroesophageal reflux disease (GERD) management typically involves lifestyle modification and medical therapy utilizing acid reducing agents such as histamine blockers and proton pump inhibitors. In severe cases refractory to such treatments, surgical therapy may be indicated. The gold standard for surgical treatment of GERD is the laparoscopic Nissen fundoplication. In recent years, a new technique known as magnetic sphincter augmentation (MSA) has been developed using the Linx™ Reflux Management System. This is an implantable ring of magnetic beads that is placed around the esophagus at the gastroesophageal junction to restore lower esophageal integrity. The aim of this review is to discuss the current literature regarding indications, surgical technique, efficacy, and complications of MSA using the Linx device.

METHODS

A standardized literature search was performed yielding 367 abstracts. After elimination due to duplicates between databases and irrelevance, 96 articles remained. The information found to be significant and non-redundant was included in this review.

CONCLUSION

After several years of clinical application, the Linx device has been shown to not only be effective for the management of GERD but also be as effective as fundoplication. With respect to safety, the most common complication of MSA is dysphagia. This often resolved without intervention, but esophageal dilation or device explanation are occasionally necessary. Not fully appreciated in earlier reviews, erosion of the device into the esophagus appears to be the most significant complication of the device after extended follow-up. While very rare, the potentially severe consequences of this phenomenon suggest that the device should be used with some restraint and that patients should be made aware of this potential morbidity. Fortunately, in the few cases of device erosion described in the literature reviewed, the Linx device was easily and safely removed.

Reflux, Sleeve Dilation, and Barrett's Esophagus after Laparoscopic Sleeve Gastrectomy: Long-Term Follow-Up

BACKGROUND

Laparoscopic sleeve gastrectomy (SG) has become the most frequently performed bariatric procedure worldwide. De novo reflux might impact patients' quality of life, requiring lifelong proton pump inhibitor medication. It also increases the risk of esophagitis and formation of Barrett's metaplasia. Besides weight regain, gastroesophageal reflux disease (GERD) is the most common reason for conversion to Roux-en-Y gastric bypass.

METHODS

We performed 24-h pH metries, manometries, gastroscopies, and questionnaires focusing on reflux (GIQLI, RSI) in SG patients with a follow-up of more than 10 years who did not suffer from symptomatic reflux or hiatal hernia preoperatively.

RESULTS

From a total of 53 patients, ten patients after adjustable gastric banding were excluded. From the remaining 43, six patients (14.0%) were converted to RYGB due to intractable reflux over a period of 130 months. Ten out of the remaining non-converted patients (n = 26) also suffered from symptomatic reflux. Gastroscopies revealed de novo hiatal hernias in 45% of the patients and Barrett's metaplasia in 15%. SG patients suffering from symptomatic reflux scored significantly higher in the RSI (p = 0.04) and significantly lower in the GIQLI (p = 0.02) questionnaire.

CONCLUSIONS

This study shows a high incidence of Barrett's esophagus and hiatal hernias at more than 10 years after SG. Its results therefore suggest maintaining pre-existing large hiatal hernia, GERD, and Barrett's esophagus as relative contraindications to SG. The limitations of this study-its small sample size as well as the fact that it was based on early experience with SG-make drawing any general conclusions about this procedure difficult.

SLEEVE GASTRECTOMY AND FUNDOPLICATION AS A SINGLE PROCEDURE IN PATIENTS WITH OBESITY AND GASTROESOPHAGEAL REFLUX

BACKGROUND

Bariatric surgery in Chile has seen an exponential increase in recent years, especially in sleeve gastrectomy. Its use is currently discussed in patients suffering from gastroesophageal reflux disease. Different options have been considered for the management of these patients but up to now laparoscopic Roux-en-Y gastric bypass seems to be the best option. Sleeve gastrectomy plus concomitant fundoplication or hiatal hernia repair also has been suggested in patients having reflux or small hiatal hernia.

AIM

To present a cohort of obese patients with gatroesophageal reflux undergoing this procedure, which seeks to provide the benefits of both laparoscopic gastric sleeve (LSG) and antireflux surgery focused on the evaluation of presence of reflux and BMI after surgery, and to compare the result observed in this cohort with a previous group of obese patients without reflux submitted to sleeve gastrectomy alone.

METHODS

Retrospective case series in 15 patients who underwent this surgery between the years 2003 and 2012. Clinical records were analyzed and values ​​of 24 hr pH monitoring, esophageal manometry and clinical outcome were recorded. Results were compared to a previous series of patients who underwent LSG. No statistical analyses were made.

RESULTS

Group A consisted of 15 patients submitted to LSG plus fundoplication. 93% (n=14) were female. Mean age was 46.2 years. Mean preoperative body mass index (BMI) was 33.9. All patients had altered pH monitoring and manometry preoperatively. There was one minor complication corresponding to a seroma. There was no perioperative mortality. Group B consisted of 23 obese patients who underwent LSG. These patients developed de novo reflux, hypotensive LES and esophagitis after the surgery. Group A patients showed improvement in esophageal pH monitoring and manometry at three months. During long-term follow-up, six underwent revision surgery, four for weight regain, one regained weight associated with symptomatic reflux, and one underwent re-intervention for reflux.

CONCLUSIONS

Good results are observed in the short-term follow up in both reflux resolution and weight loss. Nevertheless, results at long term are discouraging, with 53.3% of the patients requiring revision surgery during follow-up.

Gastroesophageal reflux disease and morbid obesity: To sleeve or not to sleeve?

Laparoscopic sleeve gastrectomy (LSG) has reached wide popularity during the last 15 years, due to the limited morbidity and mortality rates, and the very good weight loss results and effects on comorbid conditions. However, there are concerns regarding the effects of LSG on gastroesophageal reflux disease (GERD). The interpretation of the current evidence is challenged by the fact that the LSG technique is not standardized, and most studies investigate the presence of GERD by assessing symptoms and the use of acid reducing medications only. A few studies objectively investigated gastroesophageal function and the reflux profile by esophageal manometry and 24-h pH monitoring, reporting postoperative normalization of esophageal acid exposure in up to 85% of patients with preoperative GERD, and occurrence of de novo GERD in about 5% of cases. There is increasing evidence showing the key role of the surgical technique on the incidence of postoperative GERD. Main technical issues are a relative narrowing of the mid portion of the gastric sleeve, a redundant upper part of the sleeve (both depending on the angle under which the sleeve is stapled), and the presence of a hiatal hernia. Concomitant hiatal hernia repair is recommended. To date, either medical therapy with proton pump inhibitors or conversion of LSG to laparoscopic Roux-en-Y gastric bypass are the available options for the management of GERD after LSG. Recently, new minimally invasive approaches have been proposed in patients with GERD and hypotensive LES: the LINX^® Reflux Management System procedure and the Stretta^® procedure. Large studies are needed to assess the safety and long-term efficacy of these new approaches. In conclusion, the recent publication of pH monitoring data and the new insights in the association between sleeve morphology and GERD control have led to a wider acceptance of LSG as bariatric procedure also in obese patients with GERD, as recently stated in the 5^th International Consensus Conference on sleeve gastrectomy.

"The missing LINX" for gastroesophageal reflux disease: Operative techniques video for the Linx magnetic sphincter augmentation procedure

In 2012 the FDA approved a magnetic sphincter augmentation (MSA) device (LINX, Torax Medical, Inc) for placement around the lower esophageal sphincter as an alternative approach to fundoplication for gastroesophageal reflux disease (GERD). This is a relatively new procedure and there is not widespread familiarization with the standard indications and techniques of device placement. We present two operative videos to highlight the standard surgical technique and technical points needed for successful LINX placement. First will be placement in a standard indications setting of uncomplicated GERD with no hiatal hernia. Second will be placement with complicated anatomy due to alterations from prior gastric surgery and a hiatal hernia. Our experience has revealed that the LINX device can be placed safely in patients with normal or significantly altered anatomy but requires adherence to several key principles and technical points. This procedure offers a new option that is anatomically and physiologically unique compared to standard fundoplication, and that offers highly effective control of GERD with a less invasive approach.

What are the long-term results 8 years after sleeve gastrectomy?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) became the most frequent bariatric procedure performed in France (2011) and in the United States (2013), but studies reporting long-term results are still rare.

SETTING

Private hospital, France.

METHODS

This is a retrospective analysis of a prospective cohort of 168 patients who underwent LSG between 2005 and 2008. The objective of this study was to present the 8-year outcome concerning weight loss, modification of co-morbidities, and to report the revisional surgery after sleeve.

RESULTS

The preoperative mean body mass index was 42.8 kg/m2 (31.1-77.9), 35 patients were super obese, and 64 patients had a previous gastric band. For LSG as a definitive bariatric procedure, 8 years of follow-up data were available for 116 patients (follow-up: 69%). Of the remainder, 23 patients underwent revisional surgery and 29 were lost to follow-up. For the entire cohort, the mean excess weight loss (EWL) was 76% (0-149) at 5 years and 67% (4-135) at 8 years, respectively. Of the 116 patients with 8 years of follow-up, 82 patients had>50% EWL at 8 years (70.7%). Percentages of co-morbidities resolved were hypertension, 59.4%; type 2 diabetes, 43.4%; and obstructive sleep apnea, 72.4%. Twenty-three patients had revisional surgery for weight regain (n = 14) or for severe reflux (n = 9) at a mean period of 50 months (9-96). Twelve patients underwent resleeve gastrectomy, 6 patients underwent conversion to a bypass, and 5 patients to duodenal switch (1 single anastomosis duodeno-ileostomy). A total of 31% of patients reported gastroesophageal reflux symptoms at 8 years.

CONCLUSIONS

At 8 years postoperatively, the LSG as a definitive bariatric procedure remained effective for 59% of cases. The results appear to be more favorable especially for the non-super-obese patients and primary procedures. LSG is a well-tolerated bariatric procedure with low long-term complication rates.

Operative Treatments for Reflux After Bariatric Surgery: Current and Emerging Management Options

Gastroesophageal reflux disease (GERD) is a common disorder that has a well-established connection with obesity. To ameliorate the morbidity associated with obesity, bariatric procedures have become an established pathway to accomplish sustained weight loss. In some procedures, such as with the Roux-en-Y gastric bypass surgery, weight loss is also accompanied by the resolution of GERD symptoms. However, other popular bariatric surgeries, such as the sleeve gastrectomy, have a controversial impact on their effect on reflux. Consequently, increased attention has been given to the development of strategies for the management of de novo or recurrent reflux after bariatric surgery. This article aims to discuss medical and surgical strategies for reflux after bariatric surgery, and their outcomes.

Laparoscopic management of severe reflux after sleeve gastrectomy using the LINX® system: Technique and one year follow up case report

INTRODUCTION

Management of severe reflux after sleeve gastrectomy (SG) usually requires converting to Roux-en-y gastric bypass (RYGB). We present a case of managing this problem using the LINX^® system.

PRESENTATION OF CASE

In February 2015, we performed a laparoscopic placement of LINX^® system to treat severe reflux after sleeve gastrectomy on a 25-year-old female. The operative time was 47min. There were no intra or postoperative complications. The hospital stay was one day. The postoperative UGI showed no reflux. Ten days after surgery her Quality of life score (QOL) changed from 64/75 to 7/75 after the LINX^® placement. One year later the patient continued to enjoy no reflux and stayed off medication.

DISCUSSION

Reflux after sleeve gastrectomy is usually managed by conversion to RYGB by most surgeons. This case report opens the door for an alternative management of this problem while maintaining the original sleeve gastrectomy. This technique is reasonably easy to perform in comparison to the conversion to RYGB with less potential post-operative complications. A one year follow up showed good control of reflux without medication.

CONCLUSION

Laparoscopic placement of the LINX^® system to correct severe reflux after sleeve gastrectomy is a safe alternative procedure to conversion to a RYGB.

Preoperative endoscopy may reduce the need for revisional surgery for gastro-oesophageal reflux disease following laparoscopic sleeve gastrectomy

Laparoscopic sleeve gastrectomy is a safe and effective bariatric operation, but postoperative reflux symptoms can sometimes necessitate revisional surgery. Roux-en-Y gastric bypass is the preferred operation in morbidly obese patients with gastro-oesophageal reflux disease. In 2011, we introduced preoperative endoscopy to assess for hiatus hernia or evidence of oesophagitis in conjunction with an assessment of gastro-oesophageal reflux symptoms for all patients undergoing bariatric surgery with a view to avoid sleeve gastrectomy for these patients. A prospectively maintained database was used to identify patients who underwent sleeve gastrectomy before and after we changed the unit policy. The need for revisional surgery in patients with troublesome gastro-oesophageal reflux disease was examined. Prior to 2011, 130 patients underwent sleeve gastrectomy, and 11 (8.5%) of them required conversion to Roux-en-Y gastric bypass for symptomatic reflux disease. Following the policy change, 284 patients underwent sleeve gastrectomy, and to date, only five (1.8%) have required revisional surgery (p = 0.001). Baseline demographics were comparable between the groups, and average follow-up period was 47 and 33 months, respectively, for each group. Preoperative endoscopy and a detailed clinical history regarding gastro-oesophageal reflux symptoms may improve patient selection for sleeve gastrectomy. Avoiding sleeve gastrectomy in patients with reflux disease and/or hiatus hernia may reduce the incidence of revisional surgery.

Sleeve gastrectomy and anti-reflux procedures

BACKGROUND

Obesity is an epidemic in the USA that continues to grow, becoming a leading cause of premature avoidable death. Bariatric surgery has become an effective solution for obesity and its comorbidities, and one of the most commonly utilized procedures, the sleeve gastrectomy, can lead to an increase in gastroesophageal reflux following the operation. While these data are controversial, sometimes operative intervention can be necessary to provide durable relief for this problem.

METHODS

We performed an extensive literature review examining the different methods of anti-reflux procedures that are available both before and after a sleeve gastrectomy.

RESULTS

We reviewed several different types of anti-reflux procedures, including those that supplement the lower esophageal sphincter anatomy, such as magnetic sphincter augmentation and radiofrequency ablation procedures. Re-operation was also discussed as a possible treatment of reflux in sleeve gastrectomy, especially if the original sleeve becomes dilated or if a conversion to a Roux-en-Y gastric bypass or biliopancreatic diversion is deemed necessary. Sleeve gastrectomy with concomitant anti-reflux procedure was also reviewed, including the anti-reflux gastroplasty, hiatal hernia repair, and limited fundoplication.

CONCLUSION

A number of techniques can be used to mitigate the severity of reflux, either by maintaining the normal anatomic structures that limit reflux or by supplementing these structures with a plication or gastroplasty. Individuals with existing severe reflux should not be considered for a sleeve gastrectomy. New techniques that incorporate plication at the time of the index sleeve gastrectomy show some improvement, but these are in small series that will need to be further evaluated. The only proven method of treating intractable reflux after sleeve gastrectomy is conversion to a Roux-en-Y gastric bypass.

Revaluation of the efficacy of magnetic sphincter augmentation for treating gastroesophageal reflux disease

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.

Magnetic Sphincter Augmentation for Gastroesophageal Reflux at 5 Years: Final Results of a Pilot Study Show Long-Term Acid Reduction and Symptom Improvement

Background: As previously reported, the magnetic sphincter augmentation device (MSAD) preserves gastric anatomy and results in less severe side effects than traditional antireflux surgery. The final 5-year results of a pilot study are reported here.

Patients and Methods: A prospective, multicenter study evaluated safety and efficacy of the MSAD for 5 years. Prior to MSAD placement, patients had abnormal esophageal acid and symptoms poorly controlled by proton pump inhibitors (PPIs). Patients served as their own control, which allowed comparison between baseline and postoperative measurements to determine individual treatment effect. At 5 years, gastroesophageal reflux disease (GERD)-Health Related Quality of Life (HRQL) questionnaire score, esophageal pH, PPI use, and complications were evaluated.

Results: Between February 2007 and October 2008, 44 patients (26 males) had an MSAD implanted by laparoscopy, and 33 patients were followed up at 5 years. Mean total percentage of time with pH <4 was 11.9% at baseline and 4.6% at 5 years (P < .001), with 85% of patients achieving pH normalization or at least a 50% reduction. Mean total GERD-HRQL score improved significantly from 25.7 to 2.9 (P < .001) when comparing baseline and 5 years, and 93.9% of patients had at least a 50% reduction in total score compared with baseline. Complete discontinuation of PPIs was achieved by 87.8% of patients. No complications occurred in the long term, including no device erosions or migrations at any point.

Conclusions: Based on long-term reduction in esophageal acid, symptom improvement, and no late complications, this study shows the relative safety and efficacy of magnetic sphincter augmentation for GERD.