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Kitamura et al. Mini-invasive Surg 2022;6:44 https://dx.doi.org/10.20517/2574-1225.2022.27 Page 7 of 9

Re-operative rates between MSA versus LF are similar over time [22,24] .

Erosion of the MSA device also appears to be rare. In the literature, erosion rates are as high as 1.2% but
may have been influenced by early variation in surgical technique when the device first came to market. A
recent study with 5-year data reports a 0.3% erosion rate. All eroded devices in the literature have been
successfully explanted using a combination of laparoscopic and endoscopic techniques . Currently, data is
[23]
limited to short and mid-term outcomes (i.e., 5-year follow-up), and long-term adverse event rates remain
to be seen.

Cost
In 2016, Reynolds et al. performed an indirect preliminary comparative cost analysis involving 52 MSA and
[8]
67 LF patients . Total billable supply costs were higher in MSA patients (LINX® device approximate cost:
$5000); however, this was offset by shorter operative time (66 vs. 82 minutes for MSA vs. LF, respectively),
length of stay (MSA patients were discharged from the recovery room), and lower need for pharmaceuticals,
labs/tests/imaging, and room and board. Mean charges were $48,491 for MSA and $50,111 for LF. At one
year follow-up, both groups improved similarly in GERD-HRQL and PPI cessation, and MSA patients
[31]
performed better in terms of gas bloat symptoms and ability to belch or vomit .

LIMITATIONS
There are several limitations to this review. Approval of MSA is relatively recent, and the volume and
quality of direct comparative studies are low. Moreover, the majority of reported outcomes are qualitative
and based on patient-reported surveys (i.e., GERD-HQRL responses) and subject to recall bias. As
mentioned previously, long-term data remains to be seen. Further study is needed with standardized
surgical approaches and long-term follow-up to better evaluate the relationship between the MSA and
surgical wraps.

CONCLUSION
Gastrointestinal reflux disease rates and its sequelae are rising worldwide and increasingly involve younger
populations. While PPI therapy is first-line and its use seems ubiquitous, it is not without drawbacks.
Patients who partially or poorly respond to medical management alone are at increased risk for reflux
disease progression. Magnetic sphincter augmentation of the LES represents a reasonable and viable
treatment option. There is evidence supporting the safety and efficacy of MSA for uncomplicated reflux
cases, and the superiority of MSA compared to PPIs alone for reflux-related outcomes. Compared to
surgical wraps, MSA demonstrates similar short and mid-term improvement in terms of patient satisfaction,
PPI cessation, and DeMeester score. MSA may also achieve better postoperative gas bloat symptoms and
preserve the ability to belch or vomit compared to surgical wraps. However, interpretation of the available
data is made with caution, as no comparative randomized control trials exist between MSA and surgical
wraps. Additionally, follow-up in all published studies to date is no longer than five years. At present, for
appropriately selected patients, MSA is at least non-inferior to surgical wraps, and represents a reasonable
and viable intermediary treatment option. However, further study is needed to compare both the benefits
and adverse effects of MSA more appropriately versus surgical wraps.

DECLARATIONS
Authors’ contributions
Made substantial contributions to the literature review, writing, and editing: Kitamura RK
Made substantial contributions to the design, review, and writing of the manuscript: Kenric MM