Anti-Reflux Surgery (LINX)

Definition- Non-anatomical altering, life style anti-reflux surgery with or without synchronous hiatus hernia repair with the use of prosthetic implant

LINX is a valid alternative to fundoplication in selected patients with symptomatic reflux with equivalent outcomes and safety

Anti-Reflux surgeons should be aware of LINX outcomes and limitations compared to fundoplication and advise patients if asked LINX providers should have received appropriate training and mentorship

Completion of 2-day industry In-Hospital Training program (Virtual) with expert LINX surgeons

  • Criteria for course

    • Performing anti-reflux and foregut surgeries regularly.

    • Performing a minimum of 10 laparoscopic fundoplication procedures (over the last 12 months).

    • Access & experience in pre-operative diagnostic work-up including OGD, pH monitoring, Manometry & Barium contrast study.

    • Works in collaboration with GI physician and multi-disciplinary team

  1. Observe procedure where possible (COVID compliant)

  2. Offer of proctorship to support first 2 cases using virtual technology to remote support during pandemic where face to face is not possible.

 

LINX providers should be performing >10 procedures per year

LINX should be offered as an alternative option to fundoplication surgery in eligible patients

- patients in whom the primary symptom is volume reflux/regurgitation

- a confirmed diagnosis of acid reflux and adequate symptom control with medical therapy but do not wish to continue with long term therapy

- patient with breakthrough symptoms despite maximum medical therapy

- a confirmed diagnosis of acid reflux and symptoms that respond to medical therapy but who are intolerant of medication side effects

- atypical symptoms such as aspiration, cough or hoarse voice and confirmed evidence of GORD (these patients as a group have less successful outcomes than patients with typical symptoms)

As minimum pass complex/equivocal patients through a hiatal MDT* prior to surgery, best practice to discuss all patients prior to surgery.

Enter data into a registry to audit outcomes

Not recommended with hiatal hernia > 3 cm (unless provider high volume/experienced)

Surgery not recommended with BMI >35

Surgery not recommended in age <21

Surgery not recommended in active smoker

Surgery not recommended with significant history of dysphagia

Laparoscopic conversion to open < 2%

Less than 24 stay for > 90%

Readmission rates within 30 days <5%

Re-operation rate within 30 days (acute complications) <2%

Re-operation for device herniation (within 1 year) <10%

Long term device erosion <1%

>80% of patients should not require regular anti-acid medication at 5 years after surgery

 

Morbidity <5%

Mortality < 0.1%

Minimum investigation set

OGD

pH analysis

High Resolution Manometry-     Mean contractile amplitude of >30 mm Hg in 70% of swallows is recommended prior to magnetic sphincter augmentation

Other investigations to consider in patients with additional upper gastrointestinal symptoms such as bloating, nausea, vomiting, and early satiety: Contrast swallow/gastric emptying study

Atypical symptoms: ENT or respiratory opinion sort pre-operatively