Vol.:(0123456789) 1 3 Surgical Endoscopy https://doi.org/10.1007/s00464-020-08013-5 2020 SAGES ORAL More beads, more peristaltic reserve, better outcomes: factors predicting postoperative dysphagia after magnetic sphincter augmentation Rebeca Dominguez‑Profeta 1  · Joslin N. Cheverie 1  · Rachel R. Blitzer 1  · Arielle M. Lee 1  · Lauren McClain 1  · Ryan C. Broderick 1  · Bryan J. Sandler 1  · Garth R. Jacobsen 1  · Santiago Horgan 1  · David C. Kunkel 2 Received: 19 May 2020 / Accepted: 16 September 2020 © Springer Science+Business Media, LLC, part of Springer Nature 2020 Abstract Introduction Magnetic sphincter augmentation (MSA) ofers a minimally invasive anti-refux alternative to fundoplication for gastroesophageal refux disease. The most common side efect of MSA is dysphagia, which may require dilation or even device removal. The incidence of dysphagia may be reduced by MSA sizing and preoperative motility studies. Multiple rapid swallows (MRS) is a provocative maneuver during high-resolution esophageal manometry (HRM) that assesses peristaltic reserve. We evaluated factors predicting development of dysphagia following MSA. Materials and methods A retrospective review of a prospectively maintained database identifed patients undergoing MSA. Preoperative work-up included barium swallow, esophagogastroduodenoscopy, and esophageal manometry. Peristaltic aug- mentation was defned as a ratio > 1 of the distal contractile integral (DCI) following MRS and the mean DCI of the 10 baseline wet swallows during manometry. Demographics, MSA implant size, and postoperative symptom data were gathered on all patients. Results Sixty-eight patients underwent MSA. Mean age was 51.7 years, average BMI was 25.8 kg/m 2 . 15 (22.1%) of patients had severe dysphagia requiring endoscopic dilation. Peristaltic augmentation with MRS was signifcantly higher in patients without dysphagia (46.1% vs 6.3% p = 0.026). 33.3% of patients requiring dilatation exhibited complete absence of smooth muscle contraction following MRS (DCI = 0). The ratio of the DCI of MRS/wet swallows predicting dysphagia following MSA was 0.56. Patients with a small (12–14 beads) versus a larger MSA implant (15–17 beads) had a signifcantly higher rate of postoperative dysphagia (58.5% vs 30.0% p = 0.026). Conclusion Adequate peristaltic reserve and larger device size correlate with decreased incidence of dysphagia following MSA implantation without compromising the anti-refux barrier. Routine assessment of peristaltic reserve during preopera- tive HRM should be considered prior to MSA placement. Keywords Gastroesophageal refux disease (GERD) · Magnetic sphincter augmentation · Dysphagia · High-resolution manometry Gastroesophageal refux disease (GERD) is the most prev- alent foregut pathology in the Western world, afecting nearly 25% of the adult population in the U.S. [1]. While lifestyle modifcation and medical management with proton pump inhibitors (PPI) are considered frst-line treatment for GERD, approximately 30–40% of patients have persistent or progressive symptoms despite maximal medical therapy [2]. Laparoscopic fundoplication is the gold standard in the surgical management of GERD with reported reduction of symptoms and PPI use up to 91% postoperatively [3, 4]. Magnetic sphincter augmentation (MSA) using the LINX™ Refux Management System has emerged as an alternative to fundoplication. An implantable ring of magnetic beads placed at the distal aspect of the LES acts as a physiologic sphincter, with minimal disruption of native anatomy [5]. and Other Interventional Techniques * Rachel R. Blitzer rrblitzer@gmail.com 1 Division of Minimally Invasive Surgery, Department of Surgery, Center for the Future of Surgery, University of California, San Diego, CA, USA 2 Division of Gastroenterology, Department of Medicine, University of California, San Diego, CA, USA