The role of magnetic sphincter augmentation in the treatment of gastroesophageal reflux disease

Abstract

Purpose of reviewMagnetic sphincter augmentation (MSA) has been designed as a less disruptive and more standardized laparoscopic surgical procedure than fundoplication for patients with early stage gastroesophageal reflux disease (GERD). We analyzed the more recent literature in search of updates regarding indications, technique, perioperative management, and long-term outcomes.Recent findingsOver the years, the procedure of MSA has evolved to including full hiatus repair rather than relying on the preservation of the phreno-esophageal ligament. Restoring the mechanical synergy between the lower esophageal sphincter and the crural diaphragm has the potential to further enhance the antireflux barrier. The adoption of this approach has led to expand the indications from early stage disease to different scenarios including patients with high esophageal acid exposure, atypical symptoms, large hiatal hernias, Barrett's esophagus, postbariatric surgery, and previously failed fundoplication.SummaryMSA has a favorable side-effect profile and is highly effective in reducing typical reflux symptoms, medication dependency, and esophageal acid exposure. Excellent outcomes have been confirmed over a 12-year follow-up, indicating that the operation has the potential to prevent GERD progression. Further studies are needed to confirm the cost-effectiveness of this procedure in patients with more advanced disease-stage and prior gastric surgery. A randomized control trial comparing MSA with fundoplication could raise the level of evidence and the strength of recommendation.

Magnetic Sphincter Augmentation for Hiatus Hernia and De Novo Gerd after Sleeve Gastrectomy

“…Since then, the indications for this technique have expanded to include patients with large (>3 cm) HH and severe GERD including Barrett’s esophagus. 10 The use of MSA in patients with prior LSG was first described in a case series, 8 but concomitant HH repair was not mentioned. Subsequent reports confirmed feasibility and safety of MSA performed as a remedial procedure or concurrent with LSG and RYGB, with improvement of GERD-HRQL scores in the short-term follow-up.…”

Effect of Increased Intra-abdominal Pressure on the Esophagogastric Junction

“… 43 This could explain why the outcomes of current antireflux procedures, such as magnetic sphincter augmentation, are improved by routine mediastinal dissection and posterior crural repair. 30 , 44 , 45 , 46 Disruption of the EGJ frequently occurs in patients with central obesity which is associated with increased IAP. 26 This could also explain why Roux-en-Y gastric bypass is considered more effective than fundoplication in reducing GERD symptoms and recurrence rates in morbid obese patients.…”

“…Rather, increased IAP is part of a spectrum of pathophysiological mechanisms including transient LES relaxations, impairment of esophageal clearance, increased thoracoabdominal pressure gradient,42 and the gastric acid pocket 43. This could explain why the outcomes of current antireflux procedures, such as magnetic sphincter augmentation, are improved by routine mediastinal dissection and posterior crural repair 30,44,45,46. Disruption of the EGJ frequently occurs in patients with central obesity which is associated with increased IAP 26.…”

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

“…Magnetic sphincter augmentation (MSA-Linx™ Reflux Management System; Johnson & Johnson, New Brunswick, NJ, USA) is a minimally invasive procedure designed to provide a permanent solution to GERD. The Linx procedure can be used with the intent to prevent progression of early-stage GERD or to treat more advanced disease associated with hiatus hernia [24]. The Linx is a mechanical device designed to augment the physiologic barrier to reflux by magnetic force.…”