Severe Dysphagia is Rare After Magnetic Sphincter Augmentation

Impact of Change in Sizing Protocol on Outcome of Magnetic Sphincter Augmentation

OBJECTIVE

To evaluate and compare magnetic sphincter augmentation (MSA) device sizing protocols on postoperative outcomes and dysphagia.

BACKGROUND

Among predictors of dysphagia after MSA, device size is the only factor that may be modified. Many centers have adopted protocols to increase device size. However, there are limited data on the impact of MSA device upsizing protocols on surgical outcomes.

METHODS

Patients who underwent MSA were implanted with 2 or 3 beads above the sizing device's pop-off point (POP). Clinical and objective outcomes >1 year after surgery were compared between patients implanted with POP+2-versus-POP+3 sizing protocols. Multiple subgroups were analyzed for the benefit of upsizing. Preoperative and postoperative characteristics were compared between the size patients received, regardless of protocol.

RESULTS

A total of 388 patients were implanted under POP+2 and 216 under POP+3. At a mean of 14.2 (7.9) months, pH normalization was 73.6% and 34.1% required dilation, 15.9% developed persistent dysphagia, and 4.0% required removal. The sizing protocol had no impact on persistent dysphagia ( P =0.908), pH normalization ( P =0.822), or need for dilation ( P =0.210) or removal ( P =0.191). Subgroup analysis found that upsizing reduced dysphagia in patients with <80% peristalsis (10.3% vs 31%, P =0.048) or distal contractile integral >5000 (0% vs 30.4%, P =0.034). Regardless of sizing protocol, as device size increased there was a stepwise increase in the percent male sex ( P <0.0001), body mass index >30 ( P <0.0001), and preoperative hiatal hernia >3 cm ( P <0.0001), Los Angeles grade C/D esophagitis ( P <0.0001), and DeMeester score ( P <0.0001). Increased size was associated with decreased pH normalization ( P <0.0001) and need for dilation ( P =0.043) or removal ( P =0.014).

CONCLUSIONS

Upsizing from POP+2 to POP+3 does not reduce dysphagia or affect other MSA outcomes; however, patients with poor peristalsis or hypercontractile esophagus do benefit. Regardless of sizing protocol, preoperative clinical characteristics varied among device sizes, suggesting size is not a modifiable factor, but a surrogate for esophageal circumference.

New Developments in Anti-Reflux Surgery: Where Are We Now?

Background

Gastroesophageal reflux disease is one of the most common chronic diseases, affecting up to 28% of the western population. Therapeutic management ranges from conservative measures to endoscopic or surgical interventions. Laparoscopic Nissen fundoplication (LNF) still is considered as gold standard, but alternative procedures have been developed and evaluated within the past years.

Summary

Magnetic sphincter augmentation (MSA), which aims to be a less disruptive and possibly more standardized laparoscopic procedure than LNF, shows satisfying results regarding short- and long-term follow-up as well as comorbidities. Alternatives, such as the RefluxStop™ procedure or Transoral incisionless fundoplication (TIF), combined with laparoscopic hiatal hernia repair (cTIF) show promising results for short-term follow-up, nevertheless further studies regarding long-term follow-up are necessary.

Key Message

Although there definitely are upcoming and promising trends in upper GI surgery, LNF still represents today's gold standard and MSA is an equivalent alternative. RefluxStop™ and cTIF show promising results, nevertheless, further studies are necessary.

Magnetic sphincter augmentation in the management of gastro-esophageal reflux disease: a systematic review and meta-analysis

BACKGROUND

Magnetic sphincter augmentation (MSA) through placement of the LINX device is an alternative to fundoplication in the management of gastro-esophageal reflux disease (GERD). This systematic review and meta-analysis aimed to assess efficacy, quality of life, and safety in patients that underwent MSA, with a comparison to fundoplication.

METHODS

A literature search of MEDLINE, Embase, Emcare, Scopus, Web of Science, and Cochrane library databases was performed for studies that reported data on outcomes of MSA, with or without a comparison group undergoing fundoplication, for GERD from January 2000 to January 2023. Meta-analysis was performed using random-effect models and between-study heterogeneity was assessed.

RESULTS

Thirty-nine studies with 8075 patients were included: 6983 patients underwent MSA and 1092 patients had laparoscopic fundoplication procedure. Ten of these studies (seven retrospective and three prospective) directly compared MSA with fundoplication. A higher proportion of individuals successfully discontinued proton-pump inhibitors ( P <0.001; WMD 0.83; 95% CI: 0.72-0.93; I2 =96.8%) and had higher patient satisfaction ( P <0.001; WMD 0.85; 95% CI: 0.78-0.93; I2 =85.2%) following MSA when compared to fundoplication. Functional outcomes were better after MSA than after fundoplication including ability to belch ( P <0.001; WMD 0.96; 95% CI: 0.93-0.98; I2 =67.8) and emesis ( P <0.001; WMD 0.92; 95% CI: 0.89-0.95; I2 =42.8%), and bloating ( P =0.003; WMD 0.20; 95% CI: 0.07-0.33; I2 =97.0%). MSA had higher rates of dysphagia ( P =0.001; WMD 0.41; 95% CI: 0.17-0.65; I2 =97.3%) when compared to fundoplication. The overall erosion and removal rate following MSA was 0.24% and 3.9%, respectively, with no difference in surgical reintervention rates between MSA and fundoplication ( P =0.446; WMD 0.001; 95% CI: -0.001-0.002; I2 =78.5%).

CONCLUSIONS

MSA is a safe and effective procedure at reducing symptom burden of GERD and can potentially improve patient satisfaction and functional outcomes. However, randomized controlled trials directly comparing MSA with fundoplication are necessary to determine where MSA precisely fits in the management pathway of GERD.

Current Trends in the Management of Hiatal Hernia: A Literature Review of 10 Years of Data

Hiatal hernia (HH) is commonly detected during endoscopic examinations and is associated with gastroesophageal reflux disease. In recent years, there have been significant advancements in diagnosing and treating HH. Surgical techniques for HH repair include open surgery, various laparoscopic procedures, transoral incisionless fundoplication, and magnetic sphincter augmentation (MSA). Laparoscopic Nissen fundoplication is often considered the standard for treating gastroesophageal reflux disease-related HH due to its effectiveness. Other procedures, such as Toupet and Dor fundoplications, may be suited for patients with specific conditions, such as impaired esophageal motility. Newer approaches, including the MSA system and mesh repair, focus on patient-specific treatments to achieve the best outcomes. This review synthesizes the literature from 2014 to 2024 to provide an overview of current trends in HH management.

MAGNETIC SPHINCTER AUGMENTATION DEVICE FOR GASTROESOPHAGEAL REFLUX DISEASE: EFFECTIVE, BUT POSTOPERATIVE DYSPHAGIA AND RISK OF EROSION SHOULD NOT BE UNDERESTIMATED. A SYSTEMATIC REVIEW AND META-ANALYSIS

BACKGROUND

Magnetic ring (MSA) implantation in the esophagus is an alternative surgical procedure to fundoplication for the treatment of gastroesophageal reflux disease.

AIMS

The aim of this study was to analyse the effectiveness and safety of magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD).

METHODS

A systematic literature review of articles on MSA was performed using the Medical Literature Analysis and Retrieval System Online (Medline) database between 2008 and 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.

RESULTS

A total of 22 studies comprising 4,663 patients with MSA were analysed. Mean follow-up was 27.3 (7-108) months. The weighted pooled proportion of symptom improvement and patient satisfaction were 93% (95%CI 83-98%) and 85% (95%CI 78-90%), respectively. The mean DeMeester score (pre-MSA: 34.6 vs. post-MSA: 8.9, p=0.03) and GERD-HRQL score (pre-MSA: 25.8 vs. post-MSA: 4.4, p<0.0001) improved significantly after MSA. The proportion of patients taking proton pump inhibitor (PPIs) decreased from 92.8 to 12.4% (p<0.0001). The weighted pooled proportions of dysphagia, endoscopic dilatation and gas-related symptoms were 18, 13, and 3%, respectively. Esophageal erosion occurred in 1% of patients, but its risk significantly increased for every year of MSA use (odds ratio - OR 1.40, 95%CI 1.11-1.77, p=0.004). Device removal was needed in 4% of patients.

CONCLUSIONS

Although MSA is a very effective treatment modality for GERD, postoperative dysphagia is common and the risk of esophageal erosion increases over time. Further studies are needed to determine the long-term safety of MSA placement in patients with GERD.

Safety profile of magnetic sphincter augmentation for gastroesophageal reflux disease

Background

The magnetic sphincter augmentation (MSA) procedure is an effective treatment for gastroesophageal reflux disease (GERD). Adverse events requiring MSA device removal are rare, but the true prevalence and incidence may be underestimated.

Methods

Retrospective study on a prospectively collected database. Patients who underwent MSA procedure between March 2007 and September 2021 in two tertiary-care referral centers for esophageal surgery were included. The trend of MSA explant, the changes in the sizing technique and crura repair over the years, the technique of explant, and the clinical outcomes of the revisional procedure were reviewed.

Results

Out of 397 consecutive patients, 50 (12.4%) underwent MSA removal, with a median time to explant of 39.5 [IQR = 53.7] months. Main symptoms leading to removal were dysphagia (43.2%), heartburn (25%), and epigastric pain (13.6%). Erosion occurred in 2.5% of patients. Smaller (12- and 13-bead) devices were the ones most frequently explanted. The majority of the explants were performed laparoscopically with endoscopic assistance. There was no perioperative morbidity, and the median length of stay was 2.8 ± 1.4 days. After 2014, changes in sizing technique and crura repair resulted in a decreased incidence of explants from 23% to 5% (p < 0.0001). Multivariate analysis confirmed the protective role of added bead units [HR 0.06 (95% CI = 0.001-0.220); p < 0.000].

Conclusion

Oversizing and full mediastinal dissection with posterior hiatoplasty may improve the outcomes of the MSA procedure and possibly reduce removal rates.

Is magnetic sphincter augmentation indicated in patients with laryngopharyngeal reflux?

Up to 30% of patients with gastroesophageal reflux disease (GERD) suffer from laryngopharyngeal reflux (LPR) with symptoms, as chronic cough, laryngitis, or asthma. Besides life-style modifications and medical acid suppression, laparoscopic fundoplication is an established treatment option. Treatment-related side effects after laparoscopic fundoplication have to be weighted against LPR symptom control in 30-85% of patients after surgery. Magnetic sphincter augmentation (MSA) is described as an effective alternative to fundoplication for surgical treatment of GERD. However, evidence on the efficacy of MSA in patients with LPR is very limited. Preliminary data on the results of MSA treating LPR symptoms in patients with acid and weakly acid reflux are promising; showing comparable results to laparoscopic fundoplication by providing the potential of decrease side effects.

Real-world evidence with magnetic sphincter augmentation for gastroesophageal reflux disease: a scoping review

Background

The burden of gastroesophageal reflux disease (GERD) is high, with up to 30% of the Western population reporting reflux-related symptoms with or without hiatal hernia. Magnetic sphincter augmentation (MSA) is a standardized laparoscopic procedure for patients who are dissatisfied with medical therapy and for those with early-stage disease who would not usually be considered ideal candidates for fundoplication. The MSA device is manufactured in different sizes and is designed to augment the physiologic barrier to reflux by magnetic force.

Methods

An extensive scoping review was performed to provide a map of current evidence with respect to MSA, to identify gaps in knowledge, and to make recommendations for future research. All the authors contributed to the literature search in PubMed and Web of Science and contributed to summarizing the evidence.

Results

Magnetic sphincter augmentation, especially in combination with crural repair, is effective in reducing GERD symptoms, proton pump inhibitor use, and esophageal acid exposure, and in improving patients’ quality of life. Safety issues such as device erosion or migration have been rare and not associated with mortality. The MSA device can be removed laparoscopically if necessary, thereby preserving the option of fundoplication or other therapies in the future. Contraindication to scanning in high-power Tesla magnetic resonance systems remains a potential limitation of the MSA procedure. High-resolution manometry and functional lumen imaging probes appear to be promising tools to predict procedural outcomes by improving reflux control and reducing the incidence of dysphagia.

Conclusion

A consensus on acquisition and interpretation of high-resolution manometry and impedance planimetry data is needed to gain better understanding of physiology, to improve patient selection, and to pave the way for a personalized surgical approach in antireflux surgery.