Dealing with excessive heartburn? You’re not alone. More than 60 million Americans suffer from acid reflux. Let’s quickly get to the point. We’re talking about GastroEsophageal Reflux Disease (GERD) and its treatment options. Our reviews of scientific research publications leads us to conclude that, if you suffer from serious unrelenting heartburn, you should consult a doctor who offers the LINX Reflux Management System, EsophyX, or Laparoscopic Nissen Fundoplication surgery. Read on to find out why.
| Medical Management: Antacids, PPIs, H2 Blockers | Laparoscopic Nissen Fundoplication (LNF) | EsophyX TIF | Stretta Therapy | LINX Reflux Management System | |
|---|---|---|---|---|---|
| Suitable Candidates | Mild Occasional Gerd | Chronic Gerd | Chronic Gerd | Chronic Gerd | Chronic Gerd |
| Age Group | 2+ | 2+ | 18+ | 18+ | 21+ |
| Invasiveness | Not Invasive. Just swallow medications. | Moderate. Requires laparoscopic surgery | Minimal. Endoscopic | Minimal. Endoscopic | Moderate Requires Laparoscopic surgery |
| Out/Inpatient | Outpatient | Inpatient | Outpatient | Outpatient | Inpatient |
| FDA Approval | Yes | Yes | Yes | Yes | Yes |
| Effectiveness of Treatment | Less effective than LNF, EsophyX, Stretta & LINX | Most effective | Most effective | Most effective (based on limited available information) | Most effective |
| Anesthesia Required | No | Yes | Yes | Yes | Yes |
| Recovery Period | Fast | Slower than Meds, EsophyX, Stretta & LINX | Slower than Meds & LNF. | Slower than EsophyX & LNF. | Slowest |
| Side Effects/Complications of the Treatment | Diarrhea, dizziness, headache, rashes and tiredness. | Bleeding, difficulty swallowing & belching, infection. | Gas-bloat syndrome, difficulty swallowing & belching, diarrhea, vagal nerve injury, & gastric issues. | Chest/throat pain, bleeding, difficulty burping & accidental tearing of esophageal lining | Post-operative pain, temporary bloating. |
| Durability of the Treatment | H2 – Up to 12 Hours Antacids – Up to 2 Hours PPIs – Up to 24 Hours | Up to 20 years | Up to 6 years (With PPIs) | 4-10 years | 5+ years |
| Future Treatment Limitations | No | No | No | No | No |
This time Patient9 is talking about “GastroEsophageal Reflux Disease” or “GERD” for short, which causes moderate to severe heartburn pretty regularly.
Most of us have experienced heartburn after a big meal or food that’s too spicy for us. Usually, we disregard it as a common feeling that’ll go away. However, if you suffer from these symptoms at least twice a week, it might be more than a simple heartburn. It might be GERD.
Gastroesophageal Reflux Disease is a condition in which the esophagus – the tube that carries food and liquids from the mouth to the stomach – becomes irritated or inflamed due to acid backing up from the stomach. Because of GERD, the esophagus is consistently troubled by acid that contains fluid and bile.
Common symptoms include heartburn, difficulty in swallowing, and regurgitation. However, if left untreated, GERD can be associated with severe symptoms such as chest pain, asthma, pneumonia, hoarseness, damage to the esophagus, development of Barrett’s esophagus, and cancer.
Increasingly prevalent, GERD may affect as many as 1 in 5 Americans.
The worst part? Since it is mostly a lifelong condition that needs constant management, the chances for a relapse are quite high even after getting treated.
Current GERD Treatment Options
Lifestyle Modifications & Prescription Medications/Medical Management
Like all medical conditions, GERD treatment depends on the frequency as well as the severity of the symptoms. The first plan of action is trying to incorporate lifestyle changes that may reduce symptoms. These changes include recommending weight loss if the patient is overweight, quitting smoking if the patient smokes, avoiding big meals in the evening, avoiding immediately lying down after eating, and elevating your head while sleeping.
There are many over-the-counter GERD medications that you can try. There are antacids to relieve mild heartburn and other GERD symptoms. Then there are “H2 blockers”, which lower the amount of acid that your stomach makes. These help heal the esophagus, but not as well as proton pump inhibitors (PPIs). PPIs work similar to H2 blockers, but are better in lowering the amount of acid produced in the stomach and can also heal the esophageal lining in some people with GERD.
If the symptoms remain after a two or three-month medical treatment course, GERD is typically classified as “medically refractory”. When that is the case, doctors may consider surgical options.
Laparoscopic Nissen Fundoplication (LNF)
Laparoscopic Nissen Fundoplication is a surgery that improves GERD symptoms by tightening the junction between the esophagus and the stomach to prevent acid coming up from the stomach and back into the esophagus. The upper part of the stomach is wrapped around the lower entire esophageal sphincter (a valve made of muscle) to strengthen the sphincter and prevent reflux. Surgeons perform two types of Nissen fundoplication surgery:
- Laparoscopic procedures that use tiny incisions, cameras and instruments
- Open procedures that involve larger incisions for greater surgeon access inside the body
Laparoscopic procedures are favored upon the latter, as it includes faster recovery, smaller scars/incisions, decreased respiratory complications, and reduced morbidity.
It has one seemingly minor complication, though. After a Nissen Fundoplication, patients are sometimes unable to pass gas from the stomach (burp), which leads to a feeling of being bloated
Transoral Incisionless Fundoplication (TIFs)
TIF is an advanced procedure that provides a way to treat GERD without surgery. A doctor inserts a TIF device with an endoscope that is advanced through your mouth and down your esophagus while you are under anesthesia. Doctors often recommend TIF instead of Laparoscopic Nissen Fundoplication when they want to avoid its unwanted side effects, such as:
- Trouble swallowing
- Difficulty in eating that can last several months
- Trapped air that results in bloating
- Hernia at the incision location
TIF can also be used to repair a failed valve created with Nissen fundoplication. TIF can deliver excellent results without the incision and scars of Laparoscopic Nissen fundoplication.
What Happens in a TIF?
Once the anesthesia has knocked you out, your doctor will insert an endoscopic device through your mouth to view your esophagus and stomach. The doctor will then use special tools to wrap the top part of your stomach around the esophagus. Finally, the doctor will deploy special fasteners to secure the newly created valve that offers a stronger barrier so the acid doesn’t come up and cause GERD symptoms.
TIF Implantable Devices
We talked about TIF including the insertion of a device, right? Well, there are several devices that have been introduced as part of TIF procedures, and we’ll be talking about three of them. EsophyX, Stretta, and LINX.
EsophyX - Manufactured by EndoGastric Solutions, Inc.
The EsophyX device is inserted into the esophagus using an endoscope. It is then placed in the esophageal sphincter muscle, making it act as a valve that prevents acid reflux. The procedure is safe, effective and doesn’t involve scarring or incisions.
Who is it intended for?
The TIF procedure with the EsophyX device may be appropriate if the patient:
- Is 18+
- Experiences chronic symptomatic GERD.
- Requires and responds to medical therapy.
- Has a hiatal hernia <= 2cm.
- Has a BMI (Body Mass Index) of less than 35.
How effectively does it improve GERD symptoms?
EsophyX is safe and is known to improve symptoms and quality of life in most patients with persistent GERD symptoms despite PPI therapy, based on evidence from five research systematic reviews. Network meta-analysis (a systematic review of multiple research studies) also suggests that EsophyX is as effective as LINX for improving the patient’s quality of life.
What’s involved in the procedure and recovery?
The EsophyX TIF procedure is done under general anesthesia and takes less than an hour. The recovery period is relatively shorter, with many patients returning home the next day and returning to normal activities within a few days.
Long term adverse events can occur in 15% to 20% of patients, including gas-bloat syndrome, dysphagia, inability to belch, diarrhea, vagal nerve injury, and gastric dysmotility.
How durable is the treatment?
Researches have shown that the EsophyX has achieved lasting elimination of daily reliance on PPIs for many patients, which makes this an effective and durable treatment option.
Will the option you choose prevent you from having to undergo other treatment options in the future?
Some patients have reported that their symptoms have returned 6-12 months after the EsophyX TIF procedure. The lack of more studies and long-term outcomes acts as a barrier to the wider adoption of the device as a treatment for GERD patients.
Stretta - Manufactured by Restech Reflux Solutions
The Stretta endoscopic system (Mederi Therapeutics, Inc.) is a patented device that uses radiofrequency pulses to treat patients with GERD who have not experienced successful outcomes with proton pump inhibitors (PPIs).
Manufactured by Restech Reflux Solutions, its low-frequency pulses are delivered to the muscle tissue of the lower esophageal sphincter, which strengthens it without harming nearby tissue. Like EsophyX, the Stretta procedure is non-invasive. Research to date suggests Stretta compares favorably to both EsopyX and Linx, but the body of scientific evidence to substantiate that is not yet sufficient.
Who is it intended for?
Stretta provides a safe, easy, and effective treatment for patients who cannot tolerate PPIs, do not have complete resolution of symptoms from PPIs, or simply don’t want to pop a pill every morning for the rest of their lives.
The Stretta treatment therapy is not recommended for:
- Patients under the age of 18
- Pregnant women
- Patients with hiatal hernia >2 cm
- Patients with esophageal nerve damage (Achalasia)
How effectively does it improve GERD symptoms?
Data available at the time of publication suggests that Stretta is a commonly used, minimally invasive treatment option for GERD – and has been proven safe and effective in more than 60 clinical studies and 25,000 procedures. Studies also show that Stretta effectively resolves reflux symptoms and improves the quality of life for up to 10 years. Comparisons of Stretta to other TIF options or LNF are not yet statistically sound for us to draw conclusions.
What’s involved in the procedure and recovery?
Generally, the Stretta procedure is outpatient and very safe. It usually takes between 40-60 minutes, with the patient under general anesthesia. Medication is given to help prevent pain as well as to calm the patient. It is expected for the patient to have recovered enough to resume normal activities by the next day.
Common complications can include chest or throat pain, which can be eliminated with liquid painkillers and medication. Additional complications (not so common) may include bleeding at the surgery site, difficulty in burping, and accidental tearing of the lining of the esophagus.
How durable is the treatment?
Studies show that patients experience significant and lasting symptom relief from 4-10 years, without the higher complication rates of surgery or the higher costs.
Will choosing Stretta now prevent you from receiving other treatment options in the future?
The procedure can be repeated if necessary. In fact, most patients show better responses to two treatments instead of one. Therefore, while it may help you steer clear from PPIs, it might be a possibility that you have to repeat the Stretta treatment.
LINX - Manufactured by Ethicon US, LLC.
LINX Reflux Surgery Animation
LINX is an implantable medical device that involves a minimally invasive, surgical procedure. How this one works is ingenious.
LINX uses a small, flexible band of beads that is looped around the exterior of the esophagus. The beads in the band each have a magnet inside and what happens is that the magnetic attraction between the beads helps the sphincter remain closed enough to prevent reflux. Now you might be thinking that this might even hinder eating and drinking. However, that’s not what happens: swallowing actually breaks the magnetic bond, so food and liquids can pass as usual.
Who is it intended for?
Patients who still suffer from chronic GERD symptoms despite medical therapy are the best candidates. It is recommended for patients with:
- A BMI of less than 35
- Persistent reflux symptoms even with PPIs
- Hiatal Hernia <2cm
How effectively does it improve GERD symptoms?
LINX is known to significantly improve quality of life, offering a lasting resolution of symptoms such as regurgitation, gas, bloating, and bothersome heartburn. It also directly reduces PPI usage. In fact, one research study suggests that the LINX implant works better than Nissen fundoplication, with the added benefit of less bloating.
What are the associated costs of the procedure?
The LINX implant is placed laparoscopically under general anesthesia with the treatment lasting less than an hour. Patients can typically go home either the same day or within 24 hours without dietary restrictions. Because implanting LINX does not change the structure of the esophagus or other nearby organs, side effects such as difficulty belching, bloating and swallowing are less of a problem than with surgeries that wrap stomach tissue around the esophagus to prevent reflux.
However, because the implant can trigger metal detectors or pose a serious hazard during MRI, clinicians provide patients with a LINX Implant Card to notify others that they have received an implant.
How durable is the treatment?
Studies show that the treatment shows sustained improvement in quality of life for at least 5 years, making it a durable treatment option.
Will the option you choose prevent you from having to undergo other treatment options in the future?
It is unlikely that patients will require medication for acid reflux after the LINX procedure. The intent is for the LINX device to be permanent. However, if need be, Nissen Fundoplication can still be an option after the LINX procedure.
What would we do?
Now that you have a general idea of the kind of treatments that are offered for GERD, we hope you are able to have a more informed and helpful conversation with your doctor.
If your heartburn is frequent, and diet modifications and medications are not working for you, you’ll either want to choose traditional treatment options such as Laparoscopic Nissen Foundation or opt for innovative options such as implantable devices.
EsophyX is a fairly simple non-invasive procedure with a quick recovery. However, LINX is only minimally invasive yet more effective at keeping your GERD symptoms controlled for a longer period of time. LINX, however, also promises the least chance of adverse effects. Stretta appears promising as well, but the scientific literature is not yet strong enough to determine how it compares to Linx or EsophyX.
But again, our purpose is not to tell you which treatment to go for. Our purpose is to equip you with enough information to help you make the decision that is best for you. No matter how many doctors and clinicians you consult, only you know your symptoms best, which makes you the best person to make the decision.
Frequently Asked Questions
What is the innovative treatment for GERD?
The LINX device is surgically implanted around near the lower esophageal end. It is used to treat gastroesophageal reflux disease (GERD) in people who still have symptoms despite using medical therapy (acid tablets such as proton pump inhibitor medicines) to control their reflux.
What new technology cures GERD without surgery?
The Stretta device provides radiofrequency (RF) energy to the lower esophageal sphincter (LES) muscle and gastric cardia at low power and low temperature. This energy remodels the tissue, which results in better barrier function and fewer random relaxations that trigger reflux symptoms.
What is the life expectancy of GERD?
While GERD might be a severe disruption in your life, it does not inevitably shorten your life. Those who can effectively control their symptoms will have a better and more fulfilling life.
Is GERD considered a disability?
If your gastroesophageal reflux disease (GERD) is not adequately controlled by available treatments or has resulted in major consequences, you may be eligible for long-term disability (LTD) or Social Security Disability benefits for GERD.
Does drinking water help acid reflux?
Water. In general, drinking water can help balance the pH of an especially acidic meal, potentially lowering the incidence of acid reflux. Drinking mineral water with a high hydrogen carbonate level has been shown in studies to help reduce the frequency and severity of acid reflux.
Selected References
- Guidozzi, N, Wiggins, T, Ahmed, AR, Hanna, GB, and Markar, SR. Laparoscopic magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: systematic review and pooled analysis. Dis Esophagus . 2019;32(9).
- Huang, X, Chen, S, Zhao, H, Zeng, X, Lian, J, Tseng, Y, and Chen, J. Efficacy of transoral incisionless fundoplication (TIF) for the treatment of GERD: a systematic review with meta-analysis. Surg Endosc . 2017;31(3):1032-1044.
- Stanak, M, Erdos, J, Hawlik, K, and Birsan, T. Novel Surgical Treatments for Gastroesophageal Reflux Disease: Systematic Review of Magnetic Sphincter Augmentation and Electric Stimulation Therapy. Gastroenterology Res . 2018;11(3):161-173.
- Telem, DA, Wright, AS, Shah, PC, and Hutter, MM. SAGES technology and value assessment committee (TAVAC) safety and effectiveness analysis: LINX((R)) reflux management system. Surg Endosc . 2017;31(10):3811-3826.
- McCarty, TR, Itidiare, M, Njei, B, and Rustagi, T. Efficacy of transoral incisionless fundoplication for refractory gastroesophageal reflux disease: a systematic review and meta-analysis. Endoscopy . 2018;50(7):708-725.
- Chen, MY, Huang, DY, Wu, A, Zhu, YB, Zhu, HP, Lin, LM, and Cai, XJ. Efficacy of Magnetic Sphincter Augmentation versus Nissen Fundoplication for Gastroesophageal Reflux Disease in Short Term: A Meta-Analysis. Can J Gastroenterol Hepatol 2017;2017:9596342.
- Testoni, S, Hassan, C, Mazzoleni, G, Antonelli, G, Fanti, L, Passaretti, S, Correale, L, Cavestro, GM, et al. Long-term outcomes of transoral incisionless fundoplication for gastro-esophageal reflux disease: systematic-review and meta-analysis. Endosc Int Open. 2021;9(2):E239-e246.
- Skubleny, D, Switzer, NJ, Dang, J, Gill, RS, Shi, X, de Gara, C, Birch, DW, Wong, C, et al. LINX((R)) magnetic esophageal sphincter augmentation versus Nissen fundoplication for gastroesophageal reflux disease: a systematic review and meta-analysis. Surg Endosc 2017;31(8):3078-3084.
- Bell, R, Lipham, J, Louie, B, Williams, V, Luketich, J, Hill, M, Richards, W, Dunst, C, et al. Laparoscopic magnetic sphincter augmentation versus double-dose proton pump inhibitors for management of moderate-to-severe regurgitation in GERD: a randomized controlled trial. Gastrointest Endosc . 2018.
- Bell, R, Lipham, J, Louie, BE, Williams, V, Luketich, J, Hill, M, Richards, W, Dunst, C, et al. Magnetic Sphincter Augmentation Superior to Proton Pump Inhibitors for Regurgitation in a 1-Year Randomized Trial. Clin Gastroenterol Hepatol . 2019.
- Ayazi, S, Zheng, P, Zaidi, AH, Chovanec, K, Salvitti, M, Newhams, K, Hoppo, T, and Jobe, BA. Clinical Outcome and Predictors of Favorable Result after Laparoscopic Magnetic Sphincter Augmentation: Single Institution Experience with over 500 Patients. J Am Coll Surg . 2020.
- Xie, P, Yan, J, Ye, L, Wang, C, Li, Y, Chen, Y, and Li, G. Efficacy of different endoscopic treatments in patients with gastroesophageal reflux disease: a systematic review and network meta-analysis. Surg Endosc . 2021;35(4):1500-1510.
- Chandan, S, Mohan, BP, Khan, SR, Jha, LK, Dhaliwal, AJ, Bilal, M, Aziz, M, Canakis, A, et al. Clinical efficacy and safety of magnetic sphincter augmentation (MSA) and transoral incisionless fundoplication (TIF2) in refractory gastroesophageal reflux disease (GERD): a systematic review and meta-analysis. Endosc Int Open. 2021;9(4):E583-e598.
- Richter, JE, Kumar, A, Lipka, S, Miladinovic, B, and Velanovich, V. Efficacy of Laparoscopic Nissen Fundoplication vs Transoral Incisionless Fundoplication or Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease: A Systematic Review and Network Meta-analysis. Gastroenterology . 2018;154(5):1298-1308.e1297.
- Obuobi, RB, Viswanath, Y, Sathasivam, R, Bussa, G, Gill, T, Reddy, A, Shanmugam, V, Gilliam, A, and Thambi, P. Trans-oral incisionless fundoplication vs stretta, two recognized endoluminal anti-reflux therapies; a systematic review and metaanalysis.ISJ . 2018;5(3).
- Smith, CD, Ganz, RA, Lipham, JC, Bell, RC, and Rattner, DW. Lower Esophageal Sphincter Augmentation for Gastroesophageal Reflux Disease: The Safety of a Modern Implant. J Laparoendosc Adv Surg Tech A. 2017;27(6):586-591.
