My name is Gerrit Sonnabend, and I am a German medical journalist. My specialty is laryngopharyngeal reflux (LPR). Many people ask themselves: Should I have surgery to treat my LPR?
If the answer is yes, then the next and even more complicated question pops up: Which surgery is the right one for me?
Let’s have a look at the three most common surgeries for LPR:
The Stretta procedure is not at all the first operation that most people think of against reflux. Chances are you – or even your physician – have never heard of it.
The reason why I list Stretta first is that it should be the first line of defense if lifestyle and diet modifications do not resolve your LPR symptoms.
The Stretta procedure is about 10 years old. It is not really a surgery. You do not cut open patients. Instead, it is an endoscopic treatment. That means the surgeon inserts a device into your esophagus through your mouth. This device contains soft needles which send a (low) electrical current into your lower esophageal sphincter (LES). The LES is the valve between your stomach and your esophagus.
In the months after the treatment, your LES becomes stronger and thicker. The muscle inside of the valve grows. At the same time, transient lower esophageal sphincter relaxations (TLESRs) are reduced. That means your sphincter opens up less often during digestion. The result is: less reflux.
It is not 100% clear yet why the Stretta procedure strengthens the LES. You’ve probably heard that electricity is used in many treatments to strengthen muscles. It is theorized that by using an electrical current on the LES, it causes inflammation. Your body removes this inflamed tissue and builds stronger and thicker versions instead. A very similar thing happens when you do weight lifting. The stress you put on the muscle destroys some tissue, and your body reacts by healing it and making it stronger in the process.
The Stretta procedure has no instant effect. Your body will build up muscle mass for a few months after the treatment. On top of that comes that LPR takes time to resolve. You can expect symptoms to improve for up to 1 year after treatment. However, many people already see big improvements after just 2-4 months.
Stretta does not alter the function of your sphincter. It just makes it stronger. That is the reason why the complication rate is way lower than for other operations.
The procedure does not limit your options to do further surgical treatments: You can still do a LINX or a fundoplication on top of the Stretta if your symptoms do not resolve. You can also do a second Stretta to grow the sphincter muscle even more.
Interestingly, you can even do the Stretta AFTER an already performed fundoplication or LINX implantation. That is because Fundoplication and LINX work from the outside of the sphincter while the Stretta strengthens the sphincter itself. The combination of Stretta and another surgery is more effective against LPR than any procedure alone.
You can also read more about this in my interview with Dr. Mark Noar on Refluxgate.
The Fundoplication is a procedure in which the upper part of the stomach is wrapped around the lower esophageal sphincter. It tightens that valve.
There are different types of fundoplication. They differ by how complete the wrap around the LES is. For laryngopharyngeal reflux, the most common type by far is the Nissen Fundoplication, which means a complete 360 degree wrap. This is the tightest form and the most effective.
The fundoplication is the oldest surgery against reflux which means there are many experienced surgeons. That is why most physicians will recommend the Nissen to reflux patients. You can do it literally everywhere in the world.
Results against LPR are good, but not perfect. Not everybody’s symptoms are resolved, but most show great improvement.
The fundoplication has common side effects. The biggest one is bloating. In laryngopharyngeal reflux, gas rises from the stomach to the airways. After a fundoplication, that gas is trapped in your stomach and intestines. This can be very painful for some people. Others do not experience negative symptoms at all.
Once you have a fundoplication, you cannot just undo it. It would be a very difficult surgery that often leads to a damaged vagus nerve. Such damage can lead to paralysis of your gastrointestinal system and much worse problems than you had before.
However, if you are having problems with a Nissen fundoplication it is possible to change it into a less tight form, like the Toupet fundoplication. This lessens the side effects. However, it will also be less effective against the reflux.
The LINX device is an implant against reflux. It is a band of permanently magnetic beads that is surgically placed around the lower esophageal sphincter. It strengthens the LES from the outside.
The LINX is quite new. It has been on the market for about 5 years.
Other than the fundoplication it is a rather physiological option. Your sphincter still works the same way it did before. It just gets a little push from outside, so it does not have to do all the work by itself. That is why belching and burping is still possible.
On the other hand that also means it is less tight. There is also the problem that the LINX tends to get stuck in scars that keep it in a wrong position. That means instead of opening and closing as it should, it might get stuck in the open position. Instead of helping the LES to close it instead forces it open.
The opposite can happen as well. Patients might have trouble swallowing anything at all. Also, some patients see their motility go down over time. That means the esophagus stops working correctly and swallowing becomes further impaired. The device is just 5 years old; time will tell how big of an issue the motility will become.
So, how effective is the LINX against LPR?
Studies show that LINX and Fundoplication are comparable in resolving symptoms of GERD. However, there are no numbers out yet for LPR.
I tried to get the manufacturer of the device – Thorax Medical – for an interview. But they just ignored my emails and phone calls. There are many surgeons who implant the device against LPR and it works for many patients. But maybe a fundoplication is more effective against LPR, which is why the manufacturer does not want to publish the numbers. We will see once independent studies are published.
The great advantage with the LINX is that it is removable. That gives you an option for action in case the device is causing more problems than it is worth. Many negative side effects are likely to reverse after removal of the LINX. You could even do a fundoplication after the removal.
If you want to do anything surgical, the Stretta should be the first thing to consider. Technically, it is not even a surgery as no cutting is involved – only electrical stimulation of the lower esophageal sphincter. Many patients get better this way. If the first treatment fails, a second Stretta procedure or another surgery are possible. You can even do a Stretta procedure AFTER a fundoplication or LINX if you still experience LPR symptoms. The disadvantage is that it can take up to one year to see all the benefits of the Stretta procedure.
The Fundoplication is the most established surgery and the most effective against LPR. However, it fundamentally changes how your sphincter works by creating a wrap around it. It also has the strongest side effect and is not removable.
The LINX is a new device which is popular with patients as it is removable. However, its effectiveness with LPR is unclear and it often does not work well because it might get stuck in the wrong position. Most experts say that if you’re going to have surgery, it’s better to do an effective one – and that would be Stretta or Fundoplication.