Anti-Reflux Surgery (LINX)
Definition- Non-anatomical altering, life style anti-reflux surgery with or without synchronous hiatus hernia (hiatus hernia <3 cm) with the use of prosthetic implant
LINX is a valid alternative to fundoplication in patients with symptomatic reflux with equivalent outcomes and safety and maybe superior in some patients
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 Nissen 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
Observe procedure where possible (COVID compliant)
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 preforming >15 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 (these patients as a group have less successful outcomes than patients with typical symptoms)
Pass patients through a hiatal MDT prior to surgery
Enter data into a registry to audit outcomes
Not recommended with hiatal hernia > 3 cm
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 < 5%
Less than 24 stay for > 90%
Readmission rates after 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%
Mortality < 0.1%
Minimum investigation set
High Resolution Manometry- Mean contractile amplitude of >30 mm Hg in 70% of swallows OR a average DCI of >450 mmHg/s/cm for more than 50% 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
Patients with a history of eating disorders are relatively contraindicated due to potential poor compliance with oesophageal physiotherapy diet after surgery leading to a higher risk of post operative problems.
Atypical symptoms: ENT or respiratory opinion sort pre-operatively
Please also see the European Foregut Society recommendations on sizing the LINX prosthesis.
Below are Upper Units that provide NHS LINX