Search

Hypothesis: Magnetic Sphincter Augmentation device causes fibrosis at the distal esophagus which prevents reflux even after device removal Background: Gastroesophageal reflux disease (GERD) affects over 20 million people in the United States. If left untreated, chronic reflux of gastric contents into the distal esophagus may result in benign or malignant esophageal strictures, causing varying degrees of dysphagia. We currently offer interventions which artificially create a narrowing at the distal esophagus to prevent complications of GERD. Magnetic Sphincter Augmentation device (MSA), or LINX, creates such a narrowing of the distal esophagus at the level of the LES. Individuals intolerant of this device need surgical removal which leaves scarring at the site of implantation. Methods: There were 118 MSA devices placed at our institution between 2017 and 2021. During this time, 8 out of 118 (6.7%) patients needed to have their LINX removed due to side effects attributed to the implant. Causes for removal included esophageal perforation, dysphagia or hypersensitivity related chest pressure presumably caused by the device. Patients, who have had the LINX device removed, were followed for recurrence of reflux using Barium Swallow imaging, endoscopic findings and GERD-HRQL scores. Results: The longer the MSA implants remained before removal, the more extensive the scar tissue encountered at site of excision. Five of eight patients (62%) experienced improvement in their GERD-HRQL scores after removal of the MSA device when compared to results before LINX implantation. The residual band of scar tissue observed after device removal appeared to control reflux by restricting the relaxation of the esophageal outlet. Conclusions: These results indicate that fibrosis at the site of MSA device removal improves heartburn symptoms in a majority of patients. We do not recommend fundoplication at time of LINX removal as symptoms of GERD may be adequately controlled by scar tissue at the LES.

Background: Optimal management of gastroesophageal reflux disease (GERD) requires a concerted team of physicians rather than an individual approach. While an integrated approach to GERD has previously been proposed, the practical execution of such a “center of excellence” (COE) has not been described, particularly in a community setting. Ranging from initial consultation and diagnosis to surgical intervention for complex disease, such an approach is likely to provide optimal care and provide surveillance for patients with a complex disease process of GERD.Methods: We report our approach to implement an integrated heartburn center (HBC) and our experience with the first cohort of patients. Patients treated in the HBC were followed for 2 years from initial consultation to completion of their appropriate treatment plan, including anti-reflux surgery. The performance prior to the HBC set-up was compared to that post-HBC. Performance was measured in terms of volume of patients referred, referral patterns, length of stay (LOS), and patient health-related quality of life (HRQL) pre- and post-surgery.Results: Setting up the HBC resulted in referrals from multiple avenues, including primary care physicians (PCPs), emergency departments (EDs), and gastroenterologists (GIs). There was a 75% increase in referrals compared to pre-center patient volumes. Among the initial cohort of 832 patients presenting to the HBC, 20% had been on PPIs for ≥12 years. Thirty-eight patients were found to have Barrett's esophagus (4.6%) (up to 10 times the general population prevalence). Two patients had dysplasia. Seven patients (0.8%) received radiofrequency ablation (RFA) for Barrett's esophagus and two patients received endoscopic mucosal resection (EMR) for Barrett's esophagus-related dysplasia. The most common comorbidities were chronic pulmonary disease (16.8%) and diabetes without complications (10.6%). Patients received treatment for newly identified comorbid conditions, including early maladaptive schemas (EMS) and generalized anxiety disorder (GAD) (n = 7; 0.8%). Fifty cases required consultation with various specialists (6.0%) and 34 of those (4.1%) resulted in changes in care. Despite the significant increase in patient referrals, conversion rates from diagnosis to anti-reflux surgery remained consistent at ~25%. Overall HRQL improved year-over-year, and LOS was significantly reduced with potential cost savings for the larger institution.Conclusions: While centralization of GERD care is known to improve outcomes, in this case study we demonstrated the clinical success and commercial viability of centralizing GERD care in a community setting. The integrated GERD service line center offered a comprehensive, multi-specialty, and coordinated patient-centered approach. The approach is reproducible and may allow hospitals to set up their own heartburn COEs, strengthening patient-community relationships and establishing scientific and clinical GERD leadership.