A budget impact analysis of a magnetic sphincter augmentation device for the treatment of medication-refractory mechanical gastroesophageal reflux disease: a United States payer perspective

Long-term outcomes of magnetic sphincter augmentation in sleeve gastrectomy and Roux-en-Y gastric bypass patients: a comprehensive analysis

INTRODUCTION

Management of gastroesophageal reflux disease after bariatric procedures can be challenging. There are very few long-term studies in this arena. This study aims to evaluate the long-term outcomes of the magnetic sphincter augmentation (MSA) reflux management system in a cohort of bariatric patients who had previously undergone sleeve gastrectomy and Roux-en-Y gastric bypass, with a focus on assessing gastroesophageal reflux disease (GERD) scores, medication use, and patient-reported symptoms.

METHODS

We conducted a retrospective chart review of 16 consecutive bariatric patients who received MSA implants following sleeve gastrectomy (n = 14) or gastric bypass (n = 2) surgeries. Data were collected regarding BMI, GERD quality of life assessments (GERD-HRQL), reflux symptoms, and use of PPIs in the sleeve/RGB patients through an extended period with a mean follow-up of 48 months.

RESULTS

Patients were followed up for a range of .5-84 months. Preoperative assessments included upper gastrointestinal imaging (UGI), high-resolution manometry, Bravo pH studies, and esophagogastroduodenoscopy (EGD). Three patients exhibited reflux on UGI, and 13/13 patients had positive Bravo studies preoperatively. Sixteen patients had a lower esophageal sphincter (LES) pressure under 18 mmHg, and eight patients had biopsy-proven esophagitis. Long-term outcomes are as follows. Daily PPI use fell from 88 to 25% at greater than three years. GERD-HRQL scores fell from 50.6 at baseline (range 27-70) and normalized at long-term follow-up. GERD symptom of regurgitation completely resolved. At long term, two patients had dysphagia and two patients had ongoing reflux. No adverse events were noted.

CONCLUSION

This is the first long-term outcomes study of magnetic sphincter augmentation placement after bariatric surgery. Our study showed the majority of patients had long-term improvement in GERD-HRQL scores and resolution/ relief of their reflux symptoms, with decreased use of PPIs. MSA is a safe, effective and durable management tool for reflux after bariatric surgery in carefully selected patients.

The role of magnetic sphincter augmentation (MSA) in the gastroesophageal reflux disease (GERD) treatment pathway: the gastroenterology perspective

Magnetic sphincter augmentation (MSA) is a surgical intervention for well-characterized gastroesophageal reflux disease (GERD), where the esophagogastric junction barrier is augmented using a bracelet of magnetized titanium beads. MSA could be an attractive option for patients with documented GERD who wish to avoid long-term pharmacologic therapy or whose symptoms are not adequately managed with lifestyle modifications and pharmacologic therapy. The 'ideal' MSA patient is one with prominent regurgitation, without dysphagia or esophageal motor dysfunction, with objective evidence of GERD on upper endoscopy and/or ambulatory reflux monitoring. Appropriate candidates with significant hiatus hernia may pursue MSA with concomitant hiatus hernia repair. The increasing adoption of MSA in the GERD treatment pathway reflects research that shows benefits in long-term outcomes and healthcare costs compared with other established therapies in appropriate clinical settings.

Current management of gastro-oesophageal reflux disease-treatment costs, safety profile, and effectiveness: a narrative review

Background

The purpose of this study was to review the current management of gastro-oesophageal reflux disease (GORD), including treatment costs, safety profile and effectiveness.

Methods

A literature review was performed of randomized-controlled trials, systematic reviews, Cochrane reports and National/Societal guidelines of the medical, endoscopic and surgical management of GORD. Proton pump inhibitor (PPI) prescribing patterns and expenditure were reviewed in different countries, including Australia, Canada, New Zealand, UK and USA.

Results

Proton pump inhibitors (PPIs) are primarily indicated for control of GORD, Helicobacter pylori eradication (combined with antibiotics), preventing NSAID-induced gastrointestinal bleeding and treating peptic ulcer disease. There is widespread overprescribing of PPIs in Western and Eastern nations in terms of indication and duration, with substantial expense for national health providers. Despite a favourable short-term safety profile, there are observational associations of adverse effects with long-term PPIs. These include nutrient malabsorption, enteric infections and cardiovascular events. The prevalence of PPI use makes their long-term safety profile clinically relevant. Cost-benefit, symptom control and quality-of-life outcomes favour laparoscopic fundoplication rather than chronic PPI treatment. Laparoscopic fundoplication in long-term management of PPI-responsive GORD is supported by SAGES, NICE and ACG, and PPI-refractory GORD by AGA and SAGES guidelines. The importance of establishing a definitive diagnosis prior to invasive management is emphasized, especially in PPI-refractory heartburn.

Conclusions

We examined evidence-based guidelines for PPI prescribing and deprescribing in primary care and hospital settings and the need for PPI stewardship and education of health professionals. This narrative review presents the advantages and disadvantages of surgical, endoscopic and medical management of GORD, which may assist in shared decision making and treatment choice in individual patients.This paper was presented (GS020) at the 88th RACS Annual Scientific Conference, 6-10 May, 2019.

Effect of the transcutaneous electrical stimulation system on esophageal-acid exposure in patients non-responsive to once-daily proton-pump inhibitor: proof-of-concept study

Background

Gastroesophageal reflux disease (GERD) is a common disorder. Overall, ≤35% of GERD patients fail the standard dose of proton-pump-inhibitor (PPI) treatment. Due to the high prevalence and low satisfaction rate with treatment failure, there is an unmet need for new treatment. Our aim was to evaluate whether the use of the transcutaneous electrical stimulation system (TESS) can reduce esophageal-acid exposure in GERD patients unresponsive to standard-dose PPI.

Methods

We enrolled 10 patients suffering from heartburn and regurgitation with an abnormal esophageal-acid exposure (off PPIs) who failed standard-dose PPI. After the placement of a wireless esophageal pH capsule, all patients were treated with TESS. The primary end point was the reduction in the baseline (pretreatment) 24-hour percent total time pH <4 and/or DeMeester score by 50%.

Results

Seven GERD patients (five females and two males, aged 49.3 ± 10.1 years) completed the study. At baseline, the mean percent total time pH <4 was 12.0 ± 4.9. Following TESS, the mean percent total time pH <4 dropped to 5.5 ± 3.4, 4.5 ± 2.6, 3.7 ± 2.9, and 4.4 ± 2.5 on Days 1, 2, 3, and 4, respectively. At baseline, the mean DeMeester score was 39.0 ± 18.5. After TESS, the mean DeMeester score dropped to 15.8 ± 9.2, 13.2 ± 6.8, 11.2 ± 9.4, and 12.0 ± 6.8 on Days 1, 2, 3, and 4, respectively.

Conclusion

TESS is a safe and potentially effective modality in reducing esophageal-acid exposure in GERD patients unresponsive to standard-dose PPI. A larger and prospective controlled study is needed to verify these preliminary results.

Magnetic sphincter augmentation versus fundoplication for gastroesophageal reflux disease: pros and cons

PURPOSE OF REVIEW

The purpose of this magnetic sphincter augmentation (MSA) year in review article is to provide a clear understanding for the current state of MSA literature in 2019, and contrast MSA outcomes with traditional fundoplication.

RECENT FINDINGS

Continued work was performed in 2019 to expand patient populations eligible for MSA including those with hiatal hernia, post-bariatric patients, patients necessitating a thoracic approach, and patients with esophageal intestinal metaplasia. Additionally, a large systematic review reinforced earlier findings comparing laparoscopic fundoplication to MSA. This study demonstrated equivalency over many different operative outcomes, with MSA patients having less bloating while also retaining the ability to belch and vomit. Furthermore, independent research teams found a modest cost savings for MSA over laparoscopic fundoplication with budget analysis.

SUMMARY

MSA is a safe and efficacious procedure originally approved for patients with medically refractory, uncomplicated gastroesophageal reflux disease. The accumulating body of evidence suggests patients with intestinal metaplasia or hiatal hernias can safely and effectively undergo MSA, whereas further research will be required before MSA is widely used for post-bariatric patients or for patients requiring a transthoracic surgical approach. MSA is equivalent or superior to laparoscopic fundoplication in all surgical outcomes measured thus far.