Magnetic Sphincter Augmentation and Postoperative Dysphagia: Characterization, Clinical Risk Factors, and Management

Abstract

Introduction Magnetic sphincter augmentation (MSA) results in less severe side effects compared with Nissen fundoplication, but dysphagia remains the most common side effect reported by patients after MSA. This study aimed to characterize and review the management of postoperative dysphagia and identify the preoperative factors that predict persistent dysphagia after MSA. Material and Methods This is a retrospective review of prospectively collected data of patients who underwent MSA between 2013 and 2018. Preoperative objective evaluation included upper endoscopy, esophagram, high-resolution impedance manometry (HRIM), and esophageal pH testing. Postoperative persistent dysphagia was defined as a postoperative score of > 3 for the dysphagia-specific item within the GERD-HRQL at a minimum of 3 months following MSA. A timeline of dysphagia and dilation rates was constructed and correlated with the evolution of our patient management practices and modifications in surgical technique. Results A total of 380 patients underwent MSA, at a mean (SD) follow up of 11.5 (8.7) months, 59 (15.5%) patients were experiencing persistent dysphagia. Thirty-one percent of patients required at least one dilation for dysphagia or chest pain and the overall response rate to this procedure was 67%, 7 (1.8%) patients required device removal specifically for dysphagia. Independent predictors of persistent dysphagia based on logistic regression model included (1) absence of a large hernia (OR 2.86 (95% CI 1.08-7.57, p = 0.035)); (2) the presence of preoperative dysphagia (OR 2.19 (95% CI 1.05-4.58, p = 0.037)); and (3) having less than 80% peristaltic contractions on HRIM (OR 2.50 (95% CI 1.09-5.73, p = 0.031)). Graded cutoffs of distal contractile integral (DCI), mean wave amplitude, DeMeester score, sex, and body mass index were evaluated within the model and did not predict postoperative dysphagia. Frequent eating after surgery, avoidance of early dilation, and increase in the size of the LINX device selected decreased the need for dilation. Conclusion In a large cohort of patients who underwent MSA, we report 15.5% rate of persistent postoperative dysphagia. The overall response rate to dilation therapy is 67%, and the efficacy of dilation with each subsequent procedure reduces. Patients with normal hiatal anatomy, significant preoperative dysphagia, and less than 80% peristaltic contractions of the smooth muscle portion of the esophagus should be counseled that they have an increased risk for persistent postoperative dysphagia.

Efficacy of Magnetic Sphincter Augmentation Across the Spectrum of GERD Disease Severity

“…The attractive force between closed beads is roughly 40 g and exponentially decreases to 7g at full separation. A fibrous capsule will encase the MSA device in the weeks to months following surgery, adding another variable to its resistive potential(33,34). The data in the present study supports that the circumferential nature of MSA is superior to partial fundoplication while limiting the side-effects of Nissen fundoplication.One key feature which separates antireflux potential of Nissen fundoplication from Toupet fundoplication and MSA is the relative contributions native GEJ.…”

Six to 12-year outcomes of magnetic sphincter augmentation for gastroesophageal reflux disease

“…It should be noted that, during the study period, the sizer instrument has been replaced with a more user-friendly device in an attempt to improve the reproducibility of measurements. Furthermore, it has become clear over time that it is wiser to oversize by increasing 3 beads from the point of sizer release, and to use a larger MSA device to minimize dysphagia and decrease the likelihood of removal 19,20 . In our cohort of patients followed for 6-12 years, the overall estimated probability of MSA explant was 0.1 (Fig.…”

Clinical Outcomes and Predictors of Favorable Result after Laparoscopic Magnetic Sphincter Augmentation: Single-Institution Experience with More than 500 Patients

“…In a recent publication, our group reported that the change in sizing protocol, in addition to introduction of postoperative diet modification and avoiding early dilation, results in decreases in the dysphagia rate and need for dilation. 34 Although the clinical benefits of MSA are well established, the cost associated with the device has been perceived as a drawback by payers and this has slowed the widespread dissemination of this technique. A recent study by our group examined the economic impact of introducing MSA for the primary treatment of GERD.…”