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Page 2 of 5 Bell et al. Mini-invasive Surg 2022;6:43 https://dx.doi.org/10.20517/2574-1225.2022.30

cases and held together by individual wires to allow limited expansion of the bracelet, is placed
laparoscopically around the lower esophageal sphincter and acts like a pressure-relief valve to strengthen the
[1]
LES and control reflux . As a pressure-relief valve, a certain esophageal body peristaltic amplitude is
required to open the valve and allow passage of swallowed food. Instrumental to training in LINX was
understanding reflux and esophageal physiology, enlisted gastroenterologists in their surgeon training to
provide expertise and openly discuss the known barriers to GI adoption of antireflux surgeries. LINX
opened a dialogue between gastroenterologists and surgeons. Many of the device studies have included
[1-4]
investigators from both specialties . This positive discussion between the specialties was incorporated as a
manifesto in the initial concept that a foregut society must be multispecialty - a disruptive stance correlated
with disruptive technology.

Gastroenterologists’ hesitancy in referring patients for surgical treatment has some basis - most antireflux
procedures are performed by general surgeons without specialty expertise. Traditional surgical training
includes antireflux surgery as part of the general curriculum, so that “any Tom, Dick, or Harry think they
can do it (This is one of John Lipham’s favorite quotes)”. Most general surgery is extirpative. No other GI
procedure reconstructs a functional element of the body in a highly variable clinical environment based on
preoperatively determined physiologic parameters. Torax, by seeking out surgeons with specific foregut
expertise to be trained in LINX, fostered a culture of intellectual and technical specialization.

My colleague and co-author of this paper love analogies. Discussing LINX and American Foregut Society
(AFS): “The LINX device and the American foregut society are similar and construct. The individual
members of the society are the titanium casing. Our experiences and knowledge of the rare earth magnets.
And the society is the strut that bonds the beads together. As an individual, the bead accomplishes nothing.
But when combined with all the elements (as does the LINX device), a unification of purpose and
achievement is accomplished. The satisfaction of being part of a community is achieved, and patients win”.

The LINX as an implantation technology is also a targeted problem with traditional fundoplication -
alteration of normal anatomy with resultant side effects. Traditional fundoplication creates a
supraphysiologic flap valve and alters gastric anatomy, both of which have a role in the recognized side
effects of excess gas, bloating, diarrhea, inability to belch and vomit. Providing more physiologic venting, it
paved the way for the acceptance of surgical treatment of gastroesophageal reflux disease (GERD) by both
patients and gastroenterologists. This has culminated in recognizing LINX as an appropriate GERD
treatment in the most recent ACG guidelines and AGA technical updates on GERD .
[5,6]

The need to foster collaboration and expertise was concretely reaffirmed when Ethicon (who acquired
Torax Medical) was approached by the AFS and became the first industry sponsor of the nascent society.

The other technology-dependent GERD procedure that has fostered collaboration and expertise is transoral
fundoplication using the EsophyX device. The EsophyX is a 56 French flexible device inserted transorally
over an endoscope. A combination of a helical retractor and retroflexed tissue mold coapt the proximal
stomach to the distal esophagus, then polypropylene H-shaped fasteners are deployed over a wire to secure
and fuse the coapted tissues. The first human trials, performed in Europe, required both a GI to perform the
[7]
endoscopy and a surgeon to use the device . A new pathway was created to engage the gastroenterologist in
the patient procedure, the surgeon in discussing patient selection beforehand, and both in evaluating the
new technology. Subsequent introduction in the USA, where much upper endoscopy is performed by
surgeons, trended toward primary surgeon use without obligating the gastroenterologist to be in the
operating room. Gastroenterologists did embrace the lack of side effects of a purely transoral approach.