Laparoscopic Nissen Fundoplication Versus Magnetic Gastroesophageal Sphincter Augmentation: Comparison of Patient Reported Outcomes and Costs

Boris Zevin, MD, PhD, Jeffrey W Hazey, MD, Kyle A Perry, MD. The Ohio State University

Introduction: Magnetic sphincter augmentation with the LINX device is a novel surgical approach for lower esophageal sphincter dysfunction. The objective of this study was to compare patient reported outcomes and in-hospital costs for laparoscopic Nissen fundoplication (LNF) and LINX procedure in patients with symptomatic gastroesophageal reflux disease (GERD).

Methods: A retrospective case-control study was performed for consecutive patients undergoing LNF and LINX procedure between March 2013 and July 2015 at a tertiary academic center. Pre and post-operative patient reported outcomes for GERD symptoms and quality of life were assessed with Gastroesophageal Reflux Disease Health-Related Quality of Life (GERD-HRQL) questionnaire and GERD symptom score (GERSS).  The total, direct and indirect in-hospital cost per LNF case and LINX case were obtained. Parametric data were analyzed using t-test and non-parametric data were analyzed using Mann-Whitney U test. Significance was set to p < 0.05.

Results: Forty-five patients underwent LNF and 25 patients underwent LINX procedure. Median duration of follow-up was 5 (4-8) weeks.  Age, gender, ASA and pre-operative DeMeester scores were equivalent between the groups.  Pre-operatively, patients undergoing LNF had a higher BMI (30.1 ± 4.8 vs 26.8 ± 4.9 kg/m2, p<0.01) and more severe symptoms of GERD (GERD-HRQL: 33.5 ± 9.1 vs 26.0 ± 9.3, p<0.01 and GERSS: 44.3 ± 15.7 vs 34.5 ± 16.3, p<0.01) than LINX patients. The duration of surgery (90.2 ± 25.1 vs 62.6 ± 21.9 min, p<0.01) and hospital stay (1.2 ± 0.6 vs 0.6 ± 0.6 days, p<0.01) were greater for LNF versus LINX.  Significant improvement in GERD symptoms was seen after LNF (GERD-HRQL: 33.5 ± 9.1 vs 8.9 ± 11.7, p<0.01 and GERSS: 44.3 ± 15.7 vs 13.9 ± 18.0, p<0.01) and LINX (GERD-HRQL: 26.0 ± 9.3 vs 11.7 ± 12.7, p<0.01 and GERSS: 34.5 ± 16.3 vs 17.6 ± 18.1, p<0.01).  Post-operatively, resolution of GERD symptoms was seen in patients undergoing LNF and LINX (GERD-HRQL: 8.9 ± 11.7 vs 11.7 ± 12.7, p=0.34 and GERSS: 13.9 ± 18.0 vs 17.6 ± 18.1, p=0.37). The total in-hospital cost was $7,336 USD ($3,279 direct cost, $4,056 indirect cost) per LNF case and $13,011 USD ($8,524 direct cost, $4,488 indirect cost) per LINX case.

Conclusion:  Resolution of GERD symptoms was seen after laparoscopic Nissen fundoplication and laparoscopic magnetic sphincter augmentation with the LINX device; however, the LINX procedure was more expensive. Studies with long-term follow-up are needed to determine the cost effectiveness of the LINX procedure.

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