The failure pattern for the magnetic sphincter augmentation device: a single-institution case series with literature...

Magnetic sphincter augmentation (MSA) is an effective surgical treatment for GERD. Removal rates are reported around 4-6%, with dysphagia being the most common indication for removal. This rate has increased over time, and the pattern of device failure has not been well established. This study characterizes a consistent pattern of MSA slippage or migration and contextualizes this within the existing literature on MSA failure.

This is a single-institution retrospective review of patients who underwent MSA placement and device removal between 2014 and 2024. Radiographic and endoscopic images and operative reports were reviewed for the presence of pre-operative and post-operative hiatal hernia or device malposition. We also conducted a comprehensive review of existing literature on MSA explantation, with particular attention to device slippage, malposition, and hiatal hernia.

42 patients underwent MSA placement at our tertiary academic institution. Twelve of these, plus one patient who had MSA placed elsewhere, underwent device removal for symptoms of dysphagia and/or recurrent reflux (28%) with a median follow-up of 41.1 months. Ten of these 13 patients showed evidence of MSA slippage and/or hiatal hernia. In comparison, our literature review revealed explant rates of 0-12.6% (median 4.7%) with overall shorter terms of follow-up. Similarly, the most common reason for explantation was dysphagia, followed by recurrent or persistent reflux. However, device migration/hiatal herniation was a rare finding.

In the long-term follow-up of MSA patients with dysphagia or recurrent reflux, we observe a pattern of device slippage or migration. This pattern mirrors the failure pattern of the 360-degree fundoplication. We suspect an under-appreciation of device slippage or migration as the etiology for these symptoms. While MSA is effective, continued improvements on implantation technique, coupled with careful patient selection and lifestyle counseling, may increase its long-term success rate.