Louie, Brian E.

Background: Magnetic sphincter augmentation (MSA) via the surgical placement of a LINX ® device (LINX ® Reflux Management System, Torax Medical, Shoreview, MN, USA) is an increasingly performed minimally invasive outpatient anti-reflux procedure with a low erosion rate. The most common initial approach to eroded LINX ® devices is endoscopic removal. Often endoscopy centers do not have specialized devices to cut through the newer, more durable LINX ® systems. In this paper we describe a unique approach for removal of a LINX ® with intraluminal erosion using a commonly stocked mechanical biliary lithotripsy device. Case description: A 63-year-old male with a history of GERD and symptomatic type III paraesophageal hernia (PEH) underwent a robotic PEH repair with magnetic sphincter augmentation (1.5T, 17 bead) at an outside hospital. He developed an acute recurrence of his PEH, and subsequent upper endoscopy and contrast esophagram four weeks postoperatively revealed a gastric erosion of the LINX device, which had migrated 6 cm onto the stomach. Attempted endoscopic LINX ® removal using the OVESCO remove DC Cutter device was unsuccessful. Using principles of prior endoscopic bariatric lap band foreign body removal, the entire LINX ® device was successfully removed with the described biliary lithotriptor technique. Conclusion: Using a common biliary mechanical lithotriptor device and a guidewire to transect the newer 1.5T LINX ® Reflux Management System is a safe, effective and familiar technique for endoscopic removal of an eroded MSA device.

Abstract OBJECTIVES Complete thymectomy is a key component of the optimal treatment for myasthenia gravis. Unilateral, minimally invasive approaches are increasingly utilized with debate about the optimal laterality approach. A right-sided approach has a wider field of view, while a left-sided approach accesses potentially more thymic tissue. We aimed to assess the impact of laterality on perioperative and medium-term outcomes, and to identify predictors of a ‘good outcome’ using standard definitions. METHODS We performed a multicentre review of 123 patients who underwent a minimally invasive thymectomy for myasthenia gravis between January 2000 and August 2015, with at least 1-year follow-up. The Myasthenia Gravis Foundation of America standards were followed. A ‘good outcome’ was defined by complete stable remission/pharmacological remission/minimal manifestations 0, and a ‘poor outcome’ by minimal manifestations 1–3. Univariate and multivariable logistic regression analyses were performed to assess factors associated with a ‘good outcome’. RESULTS Ninety-two percent of thymectomies (113/123) were robotic-assisted. The left-sided approach had a shorter median operating time than a right-sided: 143 (interquartile range, IQR 110–196) vs 184 (IQR 133–228) min, P = 0.012. At a median of 44 (IQR 27–75) months, the left-sided approach achieved a ‘good outcome’ (46%, 31/68) more frequently than the right-sided (22%, 12/55); P = 0.011. Multivariable analysis identified a left-sided approach and Myasthenia Gravis Foundation of America class I/II to be associated with a ‘good outcome’. CONCLUSIONS A left-sided thymectomy may be preferred over a right-sided approach in patients with myasthenia gravis given the shorter operating times and potential for superior medium-term symptomatic outcomes. A lower severity class is also associated with a ‘good outcome’.