LPR Surgery – An Ultimate Option That Often Fails

Surgery can be very efficient for laryngopharyngeal reflux (LPR) but always bears the risk of complications. Operating is, therefore, the last option to consider for the treatment of LPR and is only recommended in extreme cases.

Moreover, the success rate of surgery for LPR is much lower than for classical reflux (GERD). Because silent reflux is gaseous, it is more difficult to stop than liquid reflux.

Fundoplication – the most established surgery against reflux

Nissen fundoplication is the most established surgery for reflux. Studies have shown that it is also efficient for the treatment of LPR.[1],[2]

During fundoplication surgery, the upper part of the stomach is wrapped around the esophagus, forming a loop. This compresses the lower esophageal sphincter (the valve between the stomach and esophagus), thereby preventing reflux.

The success rate of Nissen fundoplication that is reported in studies varies. One reason for this is that experts cannot agree on diagnostic criteria and how to select patients that would profit from a surgery. Some studies might have included patients that do not actually have LPR but just similar symptoms.

One study showed that LPR symptoms improved in 75% of patients.[3] This does not mean that symptoms disappeared, though; they were just reduced. The study did not report on the number of cases in which symptoms completely disappeared. Another study assessed in detail to what extent symptoms improved. On a scale from 0–45, symptoms decreased from, on average, 31.7 (severe symptoms) down to 10 (light symptoms).[4]

While Nissen fundoplication can help patients with silent reflux, the success rate is not overwhelming.

At first glance, the average success rate seems promising. By having a closer look at the data, though, you quickly realize that some patients benefit a lot, while other patients do not benefit at all from this surgery. Symptoms may even become worse in some patients, or new problems may show up.

Bottom line: Nissen fundoplication can be an option for extreme cases, but for most patients, less extreme treatment approaches are recommended.

Side effects of fundoplication

A bloated belly and swallowing problems are common side effects of fundoplication. Around 10% of patients have a bloated belly after undergoing Nissen fundoplication.[5]

Vagus nerve damage also occurs more frequently than previously thought. Because this nerve controls digestion, damage to it can affect digestive organs and aggravate problems such as reflux.[6],[7],[8],[9]

Studies have shown that vagus nerve damage occurs in 10–42% of fundoplication surgeries. Usually, this damage won’t completely destroy the function of the nerve, but it can be enough damage to cause symptoms.[10],[11],[12],[13]

LINX device

A LINX device is implanted around the esophagus at the position of the lower esophageal sphincter. LINX is a magnetic ring in which small magnets are aligned like pearls on a string, thereby supporting the closure of the valve.

LINX is popular among patients because it is supposed to be easy to remove. This is appealing to many people to have a way out in case they get problems. However, what is often not made clear is that the LINX can cause permanent tissue damage of the esophagus and around it, even after removing the device. The scar tissue that the LINX device forms around the esophagus can also interfere with further surgeries after removing the device (such as fundoplication) and reduce their success rates.

Doctors’ opinions about LINX vary. Some support it vigorously, while others criticize it heavily. In contrast to fundoplication, LINX is marketed and produced by a medical device manufacturer, so there is a lot of marketing involved in the process.

Swallowing problems, impairment of esophageal function through scar tissue, and pooling effects (accumulation of saliva in the esophagus) are frequent symptoms occurring with LINX.

There are hardly any data about LINX success rates for LPR. Available data refer to classic reflux symptoms, which are easier to control. The company has not shared any clear data about LPR, and they refused my interview requests. Not being willing to share information about a product is not a good sign.

I know many surgeons who have stopped implanting LINX and instead solely offer fundoplication.

I am still curious as to whether improved versions of the device will be developed in the future that may be useful for LPR.

Alternatives to surgery

Surgery is only necessary in extreme cases. Reflux can usually be controlled by less extreme treatment options.

One promising approach is making dietary changes. A change in eating behavior can minimize the rise of acidic gases from the stomach and reduce the activation of pepsin.

Pepsin is a digestive enzyme from the stomach that is carried along with the reflux to the throat and airways, where it causes damage. It is inactive at a high pH but can be activated by acidic reflux or by acidity in food.

My online course for the treatment of LPR explains in detail how you can stop airway reflux and the activation of pepsin by making dietary changes.


References

[1] van der Westhuizen L, Von SJ, Wilkerson BJ, Johnson BL, Jones Y, Cobb WS, Smith DE. Impact of Nissen fundoplication on laryngopharyngeal reflux symptoms. Am Surg. 2011;77(7):878-82.

[2] Carroll TL, Nahikian K, Asban A, Wiener D. Nissen Fundoplication for laryngopharyngeal reflux after patient selection using dual pH, full column impedance testing: A pilot study. Ann Otol Rhinol Laryngol. 2016;125(9):722-8.

[3] van der Westhuizen L, Von SJ, Wilkerson BJ, Johnson BL, Jones Y, Cobb WS, Smith DE. Impact of Nissen fundoplication on laryngopharyngeal reflux symptoms. Am Surg. 2011;77(7):878-82.

[4] Carroll TL, Nahikian K, Asban A, Wiener D. Nissen Fundoplication for laryngopharyngeal reflux after patient selection using dual pH, full column impedance testing: a pilot study. Ann Otol Rhinol Laryngol. 2016;125(9):722-8.

[5] Carlson MA, Frantzides CT. Complications and results of primary minimally invasive antireflux procedures: a review of 10,735 reported cases. J Am Coll Surg. 2001;193(4):428-39.

[6] Lindeboom MY, Ringers J, van Rijn PJ, Neijenhuis P, Stokkel MP, Masclee AA. Gastric emptying and vagus nerve function after laparoscopic partial fundoplication. Ann Surg. 2004;240(5):785–790.

[7] van Rijn S, Roebroek YG, Conchillo JM, Bouvy ND, Masclee AA. Effect of vagus nerve injury on the outcome of antireflux surgery: an extensive literature review. Dig Surg. 2016;33(3):230-9.

[8] van Rijn S, Rinsma NF, van Herwaarden-Lindeboom MY, Ringers J, Gooszen HG, van Rijn PJ, Veenendaal RA, Conchillo JM, Bouvy ND, Masclee AA. Effect of vagus nerve integrity on short and long-term efficacy of antireflux surgery. Am J Gastroenterol. 2016 Apr;111(4):508-15.

[9] DeVault KR, Swain JM, Wentling GK, Floch NR, Achem SR, Hinder RA. Evaluation of vagus nerve function before and after antireflux surgery. J Gastrointest Surg. 2004 Nov;8(7):883-8.

[10] Lindeboom MY, Ringers J, van Rijn PJ, Neijenhuis P, Stokkel MP, Masclee AA. Gastric emptying and vagus nerve function after laparoscopic partial fundoplication. Ann Surg. 2004;240(5):785–790.

[11] van Rijn S, Roebroek YG, Conchillo JM, Bouvy ND, Masclee AA. Effect of vagus nerve injury on the outcome of antireflux surgery: an extensive literature review. Dig Surg. 2016;33(3):230-9.

[12] van Rijn S, Rinsma NF, van Herwaarden-Lindeboom MY, Ringers J, Gooszen HG, van Rijn PJ, Veenendaal RA, Conchillo JM, Bouvy ND, Masclee AA. Effect of Vagus Nerve integrity on short and long-term efficacy of antireflux surgery. Am J Gastroenterol. 2016 Apr;111(4):508-15.

[13] DeVault KR, Swain JM, Wentling GK, Floch NR, Achem SR, Hinder RA. Evaluation of vagus nerve function before and after antireflux surgery. J Gastrointest Surg. 2004 Nov;8(7):883-8.

Gerrit Sonnabend
 

Gerrit is a German data scientist & medical publisher. His formal education is in qualitative research. He had severe reflux himself. Read more about him here.