Gut | 2019
PTU-057\u2005LINX®magnetic sphincter augmentation: azithromycin and high dose proton pump inhibitors can identify reversible oesophageal hypomotility
Abstract
Introduction Oesophageal hypomotility, which can accompany gastro-oesophageal reflux disease, is a contraindication to LINX ® magnetic sphincter augmentation (Torax Medical). This device is employed in a minimally invasive anti-reflux procedure and involves implanting a bracelet of magnetic beads around the gastro-oesophageal junction to augment lower oesophageal sphincter function. The manufacturer has shown using oesophageal manometry, that a pressure of ≥28 mmHg is required to open the bracelet and allow normal swallowing. Consequently, for patients in whom the mean distal oesophageal amplitude (MDA) is <28 mmHg, surgery is contra-indicated and this increasingly requested treatment option denied to patients. We took a group of patients being considered for LINX but with an MDA below the opening threshold of the device, or a mean distal contractile integral (DCI) of <100 mmHg.cm.s, and tested if combined azithromycin (AZI) and proton pump inhibitor (PPI) therapy can improve contractility to the point that these patients could proceed with surgery. Methods 18 patients (12 female, mean age 55.8) underwent a pre-LINX assessment with high resolution impedance manometry and were found to have hypomotility (MDA<28 mmHg or DCI<100 mmHg.cm.s). They were then given a four-week course of high dose twice daily PPI, combined with AZI 250 mg taken every other day. A repeat manometry study was then performed whilst on medication. Changes to the mean MDA of all subjects, the ratio of those with MDA below or above 28 mmHg, and the mean DCI, were assessed. Results Data were assessed with Wilcoxon signed-rank and McNemar’s tests. The MDA improved from a mean of 21.3 to 33.9 (p<0.01). The DCI improved from a mean of 40.7 to 217.1 (p<0.01). The ratio of those with MDA ≥28 mmHg improved from 1/18 to 11/18 (p<0.01). Conclusion We summarise that using a pre-operative protocol of concomitant AZI and PPIs can significantly improve contractility in a proportion of patients with GORD. This protocol distinguishes these patients as having a reversible hypomotility, and therefore allows them to proceed to LINX implantation. Further investigation is required to evaluate whether this improvement is due to a change in reflux induced dysmotility, the prokinetic effects of AZI, or a combination of both.