Linx or Nissen Fundoplication?

Digestive health
1

Hi everyone,

Hope you are all fine, my problem started last January (I mentioned everything about it in a previous post). after I struggled to get anything done with the NHS, I decided to go privately. I have seen 3 consultants, one in London, and two where I lived in Leicester. The one in London (British hernia centre) asked me to do a PH manometry test and based on the results he will decide what type of Nissen Fundoplication suregery I will need to help curing my GERD. one of the consultants I have seen in Leicester (where I live) said that there is nothing wrong with me!! and my hiatus hernia is small in size and shouldn't cause any problem! and I should carry on taking 30 mg lansoprazole twice a day (one in the morning and one in the evening) and thats it! my present consultant asked me to do a PH manometry test and I did and the results where positive (I had acid reflux in my oesophagus and therefore he suggested the LINX procedure. The procedure cost is expensive. 

I feel so worried and confused about which procedure I should go for, shall I go with the traditional fundoplication or the new procedure (LINX)? part of my confusion is because I don't know if I will ever be ok again and feel normal again! I feel bloated after I eat or drink anything! is this GERD and hiatus hernia? I feel pain in the middle of my back some times this pain is so bad that I have to sit down and bend my head down, is this GERD and hiatus hernia? I feel pain in my chest (had a lot of test done to my heart and all negative) is this GERD and hiatus hernia? my hiatus hernia was found during an endoscopy and a CT Scan done at a local hospiatl few months ago. But the NHS report said it is a small hiatus hernia and my GP says it should not cause any problems! The CT Scan also found that I have a fatty liver (non alcoholic fatty liver). I have been on PPI (Lansoprazole) since 2014. 

I hope someone here can give some advise. Thank you very much.

2

Don't know who you're seeing in Leicester. The two names I'd recommend there are John DeCaestecker & Janusz Jankowski. In London, I guess you ay have seen Laurence Lovatt and Rehan Haidry?

My views on Linx vs Nissen are summarised below:

LINX pros:

It's ring of magnetic beads help close the lower oesophageal sphincter.

The surgery for this is slightly less invasive and slightly shorter than for LNF and there is less (internal) healing for the body to do. It has been available for nearly 15 years. The operation is minimal and patients can go home the next day with some able to go home the same day. You can eat normally afterwards.

If it doesn't work or goes wrong, it can be removed and LNF performed instead.

A "long term" study over 6 years (with a mean implantation time of 3 years) of 100 recipients showed 85% of them no longer required daily PPIs for acid reflux and were glad they had had the procedure.

LINX cons:

It costs over twice as much as LNF.

It cannot be used in everybody (depends on presence of Barrett's and hiatus hernia). It doesn't repair a hiatus hernia.

If needed, MRI scans can only be at low power. MRI can displace magnets or create induction heating.

63% of recipients experience swallowing difficulties. A solid enough bolus propelled with sufficient peristalsis is required to open the device.

LINX unknowns:

Will it migrate or erode the adventia (outer wall of oesophagus) over time? 40 years ago, a new device was being enthusiastically embraced. Angelchik was effectively a broad gel rubber band / collar attached around the oesophagus that kept the oesophagus closed by elasticity. However over a long period, it's movement against the adventia caused gradual erosion. Migration and erosion issues occurred causing a clamour of patients having it removed.

LNF pros:

It is the gold standard for reflux reduction surgery.

Nissen fundoplications have been used for 60 years with surgeons becoming more expert and techniques improving all the time. It has been performed laparoscopically for the over 20 years.

The operation is minimal with patients usually able to go home the next day (and some on the same day as their operation).

It uses natural body tissue with similar elasticity to the organ it surrounds.

A recent study of nearly 200 patients who had LNF 20 years ago found 94% satisfaction with it.

There is no risk of erosion or migration.

Any hiatus hernia will be corrected and the Nissen wrap prevents it from recurring.

It can be performed if the patient has Barrett's.

LNF cons:

85% of patients experience problems with burping or vomitting whilst the scar tissue heals.

50% of patients have swallowing difficulties while the scar tissue heals. Soft foods are required at first but you can eat normally within a few weeks.

In the 20 year study, the wrap had failed in 18% of patients, when it can be redone. (Newer techniques mean that failure rates are now estimated to be only around 5%.)

NHS is far more likely to provide Nissen. LINX is too expensive.

There are very many people with hiatus hernias that cause no problems. However if frequent reflux is an issue, LNF should be considered. PPIs only control acid not reflux.

3

Hi,

Thank you very much for your reply, I am really grateful. I have seen mr. Chris Sutton in Leicester, and he is convinced that Linx is the best procedure for me. At London (British hernia centre) I have seen mr. K moorthy who asked me to do a ph test and then come back to him. I have done the ph test in Leicester at Glenfield hospital and the results were positive.

4

Chris Sutton is now at Southampton.

The other surgeons here aren't so convinced but they're also trialling endostim which could be promising.

But we have some of the best laparoscopic surgeons at Southampton specialising in upper GI procedures (including one who "invented" laparoscopic oesophagectomy for cancer patients when others said it couldn't be done! )

5

Hi Barretts

I have followed you posts in this area for a while and found them extremely well informed and helpful.

I have suffered from reflux for circa 10 years taking a low dose of ppi over that period. Condition has deteriorated and recently diagnosed with a small hernia and short segment barrets (1.5cm)

I have suffered a number of other symptoms over the years which I believe are linked to the reflux problem ( bruxism being one) and have lost 2 stone in  12 months (not by choice)

The GI consultant surgeon I am under is not worried about the barrets having put me o a surveillance program (endoscope every 2 years) and a mega dose of esomeprazolo (nexium 2 x 40mg per day)

I am keen to consider the surgical options but have encountered great reluctance from the medical profession who are pushing the medication route.

I am not happy with the medication route as it is only partially effective and is not addressing the core problem (mechanical defect in LES function)

I am inclined to push towards LNF procedure and I have noted your comments on this versus Linx. However , the Endostim procedure also appears interesting in that it deals with the LES failure and does not alter the anatomy.

From what you know , do you think that the Endostim may be the future for anti reflux surgery.

Do you know anybody who has had it

Would it be suitable for my condition ( reflux, 1.5cm barrets and a small hernia)

 

6

Endostim certainly looks promising but it is still early days.

I don't know where you live. Are you UK? Unless I have missed a recent announcement, it is not yet approved by FDA for use in US, though it does have CE approval for Europe but is stll considered experimental so you wouldn't get it under NHS unless part of a trial.

There are two surgeons at Southampton now qualifed to implant it: Chris Sutton and Tim Underwood. They think it shows promise but so far insufficient recipients to tell. (I think Tim has only so far performed one implantation of the device. Not sure how many Chris may have implanted before hs move to Southampton.)

I don't know anyone who has had it.

You can find the page on Endostm in the www DownWithAcid org uk book including links to clinical trials findings. The 2015 paper evaluating 2  years of Lower Esophageal Sphincter - Electrical Stimulation Treatment (LES-ES), concluded, “LES-EST is safe and effective for treating patients with GERD over a period of 2 years. LES-EST resulted in a significant and sustained improvement in GERD symptoms, and esophageal acid exposure and eliminated PPI use in majority of patients (16 of 21). Further, LES-EST was not associated with any gastrointestinal side effects or adverse events.”

You would need to discuss your partyicular case with a surgeoon qualified to implant the device to see whether you may be a suitable candidate.

7

Hi Barrets

Thanks for that info. I live in the UK ( N Ireland). My symptoms are moderately under control at the minute on 80mg of  esomeprazolo per day.(though far from perfect)  I am on a 3 month review with a good upper gi surgeon.

I had been pretty determined that one way or another I would have LNF procedure . Current moderation in symptoms may have bought me some time to consider options , particularly Endostim  which looks promising in terms of what it does ( ie directly address the LES deficiency). The clinical studies on the Endostim website look impressive ( as one might expect) However , there is not enough evidence about just yet. I am not so confident that it would be a absolutely  effective in stopping reflux as LNF. I have thought about going to Germany to follow it up. The are some online details from an American lady who has gone this route.

One thing I have noted from a number of the contributors to these discussions is a general difficulty patients have in encountered in progressing the surgical route in the UK , even when the clinical protocols and patient desire point that way.

I have found these patient forums useful as I have been very much alone in navigating the NHS system with this problem. Reflux/Hernia/Barrets conditions can be particularly horrible for a certain % of patients. I certainly was not aware of the progressive nature of it .