Russell B Hawkins, MD, Camille G Dessaigne, MD, Alexander L Ayzengart, MD, MPH, FACS. University of Florida Health
Background: The obesity epidemic continues to worsen. Bariatric surgery remains the most effective way to achieve weight loss and resolution of comorbidities. Laparoscopic sleeve gastrectomy has become the most common bariatric operation due to excellent efficacy and low morbidity and mortality. The most common complication of sleeve gastrectomy is gastroesophageal reflux disease (GERD), which can adversely impact the quality of life and lead to additional esophageal complications. Recently, esophageal magnetic sphincter augmentation (LINX®) has become an acceptable alternative to fundoplication for certain patients with GERD. The use of LINX® in patients who previously underwent laparoscopic sleeve gastrectomy was described in a case series in 2015. The known complications of these devices include dysphagia, need for endoscopic dilation, and device erosion. The complication profile of LINX® in the setting of sleeve gastrectomy has not been reported heretofore.
Methods: We present a case of a patient with prior sleeve gastrectomy who received a LINX® device one year after her bariatric operation due to severe GERD refractory to medical management. Initial evaluation demonstrated a hypotensive lower esophageal sphincter and hiatal hernia, but no evidence of stricture or twisting. Soon after LINX® implantation, the patient developed progressive dysphagia and worsened reflux. Repeat evaluation showed esophagitis, a moderate stricture with angulation at the incisura, and a large amount of retained food.
Discussion: The patient was recommended conversion to Roux-en-Y gastric bypass, but was deemed to be a poor candidate due to heavy smoking. Thus, laparoscopic removal of the LINX® device was performed with hiatal hernia repair and gastric stricturoplasty. Post-operative fluoroscopic evaluation revealed improvement in the stricture, but persistent gastroesophageal reflux. The patient experienced a significant improvement in her symptoms of dysphagia, nausea, and vomiting. However, once smoking cessation is achieved, she may still need a conversion to Roux-en-Y gastric bypass in order to address persistent GERD.
Conclusion: Conversion to Roux-en-Y gastric bypass remains the standard approach to treatment of GERD post sleeve gastrectomy. New approaches to this problem, including placement of LINX®, are promising but have not been evaluated for long-term safety and efficacy in the setting of prior bariatric surgery. Careful diagnostic evaluation prior to placement of magnetic sphincter augmentation device should be routinely undertaken. Postoperatively, close long-term follow up is imperative, particularly in patients with prior sleeve gastrectomy. Presence of LINX® in a patient with prior bariatric surgery may lead to worsening symptoms if complications of initial operation are present.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 84777
Program Number: P457
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
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