Acid-suppression medications are rst-line and the predominant treatment for patients with GERD [3]. The mechanism of medical acid suppression is to decrease the acid content and pH of the reuxate with a corresponding improvement in clini­cal symptoms and reux esophagitis [3]. Proton pump inhibitors (PPIs) effectively change the character of reuxate but do not always stop reux entirely. Regurgitation of non-acid reuxate (including bile and other gastric contents) often continues [5]. PPI therapy has been associated with adverse events including Clostridium difcile infection, osteoporosis and pathologic bone fractures, dementia, renal insufciency, myocardial infarction, and B12 deciency [6]. Despite ongoing medical therapy, many patients with GERD remain dissatised with their GERD symptom control [7, 8]. Surgical intervention should be offered to patients with medically refractory GERD symptoms, complications as a result of GERD, or to those having a desire to stop acid-suppression therapy due to cost or concern for side effects [2]. Laparoscopic Nissen fundoplication (LNF) is the primary intervention for GERD and has been demonstrated to provide an effective alternative to medical therapy with greater

quality of life in patients with medically refractory symptoms [9]. Despite high estimates on the number of people who qualify for antireux surgery, it is estimated that less than 1% undergo such a procedure [10]. For many patients, potential side effects of a fundoplication including dysphagia, bloating, and an inability to belch or vomit serve as a major deterrent. In addition, it has been demonstrated that approximately 10% of patients to undergo fundoplication undergo a reoperative procedure, most often secondary to fundoplication failure [11]. Magnetic sphincter augmentation (MSA) is a promising new surgical treatment for GERD with several potential advantages when compared to a fundoplication. The LINX® Reux Management System (Torax Medical, Inc., Shoreview, MN, USA) is a magnetic sphincter augmentation device for GERD that was approved by the US Food and Drug Administration (FDA) in 2012.

The LINX® MSA device is composed of a ring of titanium beads that slide inde­pendently on titanium wires. The beads have neodymium iron boron magnetic cores coated with titanium. The inter-bead attraction provides augmentation of the lower esophageal sphincter (LES) at rest, while having the mobility to expand to accom­modate a physiologic bolus such as during swallowing. The device’s design utilizes the inter-bead attraction to augment the LES when challenged with low-pressure reuxate; however, higher physiologic challenges, such as with swallowing, vomit­ing, or belching, are able to overcome the inter-bead attraction.

The LINX® device was rst approved by the FDA after nearly a decade of develop­ment and animal studies [12, 13]. The device was rst implanted in a porcine model, which provided preliminary evidence of safety and feasibility. Animals implanted with the device were able to eat normally, gain weight appropriately, and there were no incidents of device erosion. This study was followed by a feasibility clinical trial in humans published in 2008 [14]. In this prospective multicenter trial, 41 patients underwent placement of an MSA device at the esophagogastric junction. Inclusion criteria included patients with clinically signicant reux symptoms at least par­tially treated with proton pump inhibitors (PPIs), abnormal esophageal acid expo­sure, and normal esophageal contractility. Notable exclusion criteria included patients with a hiatal hernia >3cm, esophagitis Grade C or D, or a BMI >35kg/m2. All patients in this study had clinical improvement in their symptoms and 80% demonstrated pH normalization.