Interventional procedure overview of laparoscopic insertion of a magnetic ring for gastro-oesophageal reflux disease

Indications and current treatment

Gastro-oesophageal reflux disease (GORD) is a common condition in which acid from the stomach flows back up into the oesophagus. It is usually caused by the sphincter at the lower end of the oesophagus becoming weakened. Symptoms of GORD can be directly related to reflux episodes (such as heartburn, regurgitation, chest pain and nausea) or be caused by complications of the disease (such as dysphagia and respiratory difficulties). Repeated episodes of GORD can damage the lining of the oesophagus and lead to oesophageal ulceration, oesophageal stricture and Barrett's oesophagus.

NICE's guideline on GORD and dyspepsia in adults: investigation and management describes managing GORD in adults. The standard treatments for symptomatic GORD are lifestyle modification and drug therapy. People may be offered antireflux surgery (usually laparoscopic fundoplication) or bariatric surgery if their symptoms do not improve, or they develop complications despite medication or an intolerance to medication. Endoscopic interventions (such as endoscopic radiofrequency ablation at the esophagogastric junction) and electrical stimulation of the lower oesophageal sphincter (LOS) can also be used.

What the procedure involves

The aim of laparoscopic insertion of a magnetic ring for GORD is to relieve reflux-related symptoms without impeding the ability to swallow, belch or vomit.

The procedure is done under general anaesthesia. Using a laparoscopic approach, a specially designed sizing tool is loosely wrapped around the distal oesophagus to assess the size of implant needed. The sizing tool is then removed, and the implant is placed at the gastro-oesophageal junction, with the posterior vagus nerve trunk located outside the magnetic ring. The ends of the implant are secured together to hold it in place. Intraoperative endoscopy may be used to help identify the anatomic gastro-oesophageal junction and to assess device position.

The implant consists of a ring of interlinked beads, each with a weak magnetic force that holds the beads together to keep the distal oesophagus closed. When the person swallows, the magnetic force is overcome, allowing the ring to open. After swallowing, magnetic attraction brings the beads together and the distal oesophagus is again closed.

Outcome measures

The DeMeester score is a composite score of the acid exposure during a prolonged ambulatory pH monitoring to categorise patients as GORD + or GORD -. The parameters that constitute the score are number of reflux episodes, number of episodes longer than 5 minutes, longest reflux duration, total percentage of monitoring time with pH below 4, and the percentage of time with pH below 4 in an upright position and supine position, respectively. The DeMeester score is the sum of the scores calculated for each of the 6 parameters. A score more than 14.7 is considered abnormal acid reflux, scores between 14.7 and 100 are regarded as mild-to-moderate GORD, and a score greater than 100 is regarded as severe GORD.

The GORD health-related quality of life (HRQL) scale measures symptomatic outcomes and therapeutic effects in patients with GORD. The scale has 10 items, and each item is scored from 0 to 5, with 0 indicating no symptoms and 5 presenting symptoms being incapacitating (unable to do daily activities).