Steven Leeds, MD, Marc Ward, MD. Baylor University Medical Center at Dallas
INTRODUCTION: Magnetic sphincter augmentation (MSA) of the lower esophageal sphincter (LES) by LINX implantation is a highly effective GERD treatment. Reports describe significant improvements in GERD-HRQL, normalization of esophageal acid exposure, and freedom from PPIs for more than 85% of carefully-selected GERD patients at 5 years after MSA. However, many key technical aspects of LINX implantation are not standardized. The purpose of this study was to determine how often surgical experts agree on technical aspects of the MSA procedure.
METHODS AND PROCEDURES: We created a survey form comprising 12 questions on various technical aspects of the MSA procedure including patient selection criteria, hiatal dissection and repair procedures, criteria for selecting the proper site for placement, and criteria for the ideal appearance of the MSA implant after placement. We obtained a list of MSA procedure preceptor surgeons from the LINX manufacturer (Ethicon, Somerville, NJ), and sent the survey to those surgical experts. Consensus on individual questions was defined as ≥70% agreement among the responding surgeons.
RESULTS: We sent the survey to 37 surgical experts, and 24 responded. The mean number of MSA procedures performed by the responders was 210 (range 10 – 600). There was consensus on 4 questions: 1) hiatal hernia size is not a contraindication to MSA implantation, 2) tension at the crural closure does not influence the decision to implant the device, 3) LES muscle has no characteristic laparoscopic appearance, and 4) the posterior vagus nerve is one important landmark for localizing the LES. Consensus was not achieved for the other 8 questions that included criteria for the ideal location for LINX placement, criteria for ideal appearance of the LINX with regard to the LES, the need for circumferential mobilization of the esophagus, criteria for determining the adequacy of mediastinal dissection, and the critical anatomical landmarks needed to ensure proper device placement. Notably, for the question “What do you consider the ideal location for LINX placement with respect to the LES?”, 38% responded middle, 29% proximal, 25% distal, 4% immediately proximal and 4% immediately distal.
CONCLUSIONS: There is poor consensus among surgical experts on key technical aspects of MSA including what is the ideal anatomic location for LINX implantation. It is not clear how this variability in technical aspects of the procedure might influence its outcomes. Our results highlight the need for an expert consensus conference to standardize key technical aspects of the operation.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95445
Program Number: P525
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster