MAGNETIC SPHINCTER AUGMENTATION DEVICE FOR GASTROESOPHAGEAL REFLUX DISEASE: EFFECTIVE, BUT POSTOPERATIVE DYSPHAGIA AND RISK OF EROSION SHOULD NOT BE UNDERESTIMATED. A SYSTEMATIC REVIEW AND META-ANALYSIS

Valinoti, Agustin Cesar; Angeramo, Cristian Agustin; Dreifuss, Nicolas; Herbella, Fernando Augusto Mardiros; Schlottmann, Francisco

doi:10.1590/0102-672020230063e1781

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ABCD. Arquivos Brasileiros de Cirurgia Digestiva (São Paulo)

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Review Article • ABCD, arq. bras. cir. dig. 36 • 2023 • https://doi.org/10.1590/0102-672020230063e1781 copy

MAGNETIC SPHINCTER AUGMENTATION DEVICE FOR GASTROESOPHAGEAL REFLUX DISEASE: EFFECTIVE, BUT POSTOPERATIVE DYSPHAGIA AND RISK OF EROSION SHOULD NOT BE UNDERESTIMATED. A SYSTEMATIC REVIEW AND META-ANALYSIS

DISPOSITIVO MAGNÉTICO NO ESFINCTER PARA DOENÇA DO REFLUXO GASTROESOFÁGICO: EFICAZ, MAS A DISFAGIA PÓS-OPERATÓRIA E O RISCO DE EROSÃO NÃO DEVEM SER SUBESTIMADOS. UMA REVISÃO SISTEMÁTICA E META-ANÁLISE

Authorship SCIMAGO INSTITUTIONS RANKINGS

ABSTRACT

BACKGROUND:

Magnetic ring (MSA) implantation in the esophagus is an alternative surgical procedure to fundoplication for the treatment of gastroesophageal reflux disease.

AIMS:

The aim of this study was to analyse the effectiveness and safety of magnetic sphincter augmentation (MSA) in patients with gastroesophageal reflux disease (GERD).

METHODS:

A systematic literature review of articles on MSA was performed using the Medical Literature Analysis and Retrieval System Online (Medline) database between 2008 and 2021, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A random-effect model was used to generate a pooled proportion with 95% confidence interval (CI) across all studies.

RESULTS:

A total of 22 studies comprising 4,663 patients with MSA were analysed. Mean follow-up was 27.3 (7–108) months. The weighted pooled proportion of symptom improvement and patient satisfaction were 93% (95%CI 83–98%) and 85% (95%CI 78–90%), respectively. The mean DeMeester score (pre-MSA: 34.6 vs. post-MSA: 8.9, p=0.03) and GERD-HRQL score (pre-MSA: 25.8 vs. post-MSA: 4.4, p<0.0001) improved significantly after MSA. The proportion of patients taking proton pump inhibitor (PPIs) decreased from 92.8 to 12.4% (p<0.0001). The weighted pooled proportions of dysphagia, endoscopic dilatation and gas-related symptoms were 18, 13, and 3%, respectively. Esophageal erosion occurred in 1% of patients, but its risk significantly increased for every year of MSA use (odds ratio — OR 1.40, 95%CI 1.11–1.77, p=0.004). Device removal was needed in 4% of patients.

CONCLUSIONS:

Although MSA is a very effective treatment modality for GERD, postoperative dysphagia is common and the risk of esophageal erosion increases over time. Further studies are needed to determine the long-term safety of MSA placement in patients with GERD.

HEADINGS:
Gastroesophageal Reflux; Esophagus; Laparoscopy

Author	Year	Type of study	Patients (n)	Pre-MSA
Author	Year	Type of study	Patients (n)	Median follow-up time (months)	GERD- HRQL score	Use of PPI	DeMeester score	Median operative time (min)
Lipham et al.³²32 Lipham JC, DeMeester TR, Ganz RA, Bonavina L, Saino G, Dunn DH, et al. The LINX® reflux management system: confirmed safety and efficacy now at 4 years. Surg Endosc. 2012;26(10):2944-9. https://doi.org/10.1007/s00464-012-2289-1 https://doi.org/10.1007/s00464-012-2289-...	2012	R	44	44	25.7	100	NR	40
Lipham et al.³³33 Lipham JC, Taiganides PA, Louie BE, Ganz RA, DeMeester TR. Safety analysis of first 1000 patients treated with magnetic sphincter augmentation for gastroesophageal reflux disease. Dis Esophagus. 2015;28(4):305-11. https://doi.org/10.1111/dote.12199 https://doi.org/10.1111/dote.12199...	2015	R	1048	44	NR	NR	NR	NR
Sheu et al.⁴⁹49 Sheu EG, Nau P, Nath B, Kuo B, Rattner DW. A comparative trial of laparoscopic magnetic sphincter augmentation and Nissen fundoplication. Surg Endosc. 2015;29(3):505-9. https://doi.org/10.1007/s00464-014-3704-6 https://doi.org/10.1007/s00464-014-3704-...	2015	R	12	7	NR	NR	NR	NR
Ganz et al.²⁵25 Ganz RA, Edmundowicz SA, Taiganides PA, Lipham JC, Smith CD, DeVault KR, et al. Long-term outcomes of patients receiving a magnetic sphincter augmentation device for gastroesophageal reflux. Clin Gastroenterol Hepatol. 2016;14(5):671-7. https://doi.org/10.1016/j.cgh.2015.05.028 https://doi.org/10.1016/j.cgh.2015.05.02...	2016	P	100	60	27	100	NR	NR
Reynolds et al.⁴¹41 Reynolds JL, Zehetner J, Nieh A, Bildzukewicz N, Sandhu K, Katkhouda N, et al. Charges, outcomes, and complications: a comparison of magnetic sphincter augmentation versus laparoscopic Nissen fundoplication for the treatment of GERD. Surg Endosc. 2016;30(8):3225-30. https://doi.org/10.1007/s00464-015-4635-6 https://doi.org/10.1007/s00464-015-4635-...	2016	R	52	12	17	NR	NR	66
Rona et al.⁴⁵45 Rona KA, Reynolds J, Schwameis K, Zehetner J, Samakar K, Oh P, et al. Efficacy of magnetic sphincter augmentation in patients with large hiatal hernias. Surg Endosc. 2017;31(5):2096-102. https://doi.org/10.1007/s00464-016-5204-3 https://doi.org/10.1007/s00464-016-5204-...	2017	R	140	20	18.6	NR	39.3	NR
	2017	R	52	20	20.5	NR	52.4	NR
Czosnyka et al.¹⁶16 Czosnyka NM, Buckley FP, Doggett SL, Vassaur H, Connolly EE, Borgert AJ, et al. Outcomes of magnetic sphincter augmentation – a community hospital perspective. Am J Surg. 2017;213(6):1019-23. https://doi.org/10.1016/j.amjsurg.2016.09.044 https://doi.org/10.1016/j.amjsurg.2016.0...	2017	R	102	7.6	NR	NR	NR	49
Buckley et al.¹⁴14 Buckley 3rd FP, Bell RCW, Freeman K, Doggett S, Heidrick R. Favorable results from a prospective evaluation of 200 patients with large hiatal hernias undergoing LINX magnetic sphincter augmentation. Surg Endosc. 2018;32(4):1762-8. https://doi.org/10.1007/s00464-017-5859-4 https://doi.org/10.1007/s00464-017-5859-...	2018	P	200	8.6	26	87	NR	81
Prakash et al.⁴⁰40 Prakash D, Campbell B, Wajed S. Introduction into the NHS of magnetic sphincter augmentation: an innovative surgical therapy for reflux – results and challenges. Ann R Coll Surg Engl. 2018;100(4):251-6. https://doi.org/10.1308/rcsann.2017.0224 https://doi.org/10.1308/rcsann.2017.0224...	2018	R	47	36	25.8	100	34.1	74
Louie et al.³⁴34 Louie BE, Smith CD, Smith CC, Bell RCW, Gillian GK, Mandel JS, et al. Objective evidence of reflux control after magnetic sphincter augmentation: one year results from a post approval study. Ann Surg. 2019;270(2):302-8. https://doi.org/10.1097/SLA.0000000000002789 https://doi.org/10.1097/SLA.000000000000...	2019	P	200	12	26	NR	33.4	NR
Antiporda et al.⁴4 Antiporda M, Jackson C, Smith CD, Bowers SP. Short-term outcomes predict long-term satisfaction in patients undergoing laparoscopic magnetic sphincter augmentation. J Laparoendosc Adv Surg Tech A. 2019;29(2):198-202. https://doi.org/10.1089/lap.2018.0598 https://doi.org/10.1089/lap.2018.0598...	2019	R	98	46	25	NR	33.8	NR
Tatum et al.⁵⁰50 Tatum JM, Alicuben E, Bildzukewicz N, Samakar K, Houghton CC, Lipham JC. Minimal versus obligatory dissection of the diaphragmatic hiatus during magnetic sphincter augmentation surgery. Surg Endosc. 2019;33(3):782-8. https://doi.org/10.1007/s00464-018-6343-5 https://doi.org/10.1007/s00464-018-6343-...	2019	R	96	18.5	NR	NR	31.2	56.4
	2019	R	86	12.5	NR	NR	19.9	69.3
Ward et al.⁵⁵55 Ward MA, Ebrahim A, Kopita J, Arviso L, Ogola GO, Buckmaster B, et al. Magnetic sphincter augmentation is an effective treatment for atypical symptoms caused by gastroesophageal reflux disease. Surg Endosc. 2020;34(11):4909-15. https://doi.org/10.1007/s00464-019-07278-9 https://doi.org/10.1007/s00464-019-07278...	2020	R	86	12	38.79	100	NR	NR
Tsai et al.⁵²52 Tsai C, Steffen R, Kessler U, Merki H, Lipham J, Zehetner J. Postoperative dysphagia following magnetic sphincter augmentation for gastroesophageal reflux disease. Surg Laparosc Endosc Percutan Tech. 2020;30(4):322-6. https://doi.org/10.1097/SLE.0000000000000785 https://doi.org/10.1097/SLE.000000000000...	2020	R	118	7.8	42.3	91.6	NR	NR
Riva et al.⁴³43 Riva CG, Siboni S, Sozzi M, Lazzari V, Asti E, Bonavina L. High-resolution manometry findings after Linx procedure for gastro-esophageal reflux disease. Neurogastroenterol Motil. 2020;32(3):e13750. https://doi.org/10.1111/nmo.13750 https://doi.org/10.1111/nmo.13750...	2020	P	45	12	19	66.7	NR	NR
Dunn et al.²⁰20 Dunn CP, Henning JC, Sterris JA, Won P, Houghton C, Bildzukewicz NA, et al. Regression of Barrett’s esophagus after magnetic sphincter augmentation: intermediate-term results. Surg Endosc. 2021;35(10):5804-9. https://doi.org/10.1007/s00464-020-08074-6 https://doi.org/10.1007/s00464-020-08074...	2020	R	87	35	20.5	NR	34	60
Ferrari et al.²³23 Ferrari D, Asti E, Lazzari V, Siboni S, Bernardi D, Bonavina L. Six to 12-year outcomes of magnetic sphincter augmentation for gastroesophageal reflux disease. Sci Rep. 2020;10(1):13753. https://doi.org/10.1038/s41598-020-70742-3 https://doi.org/10.1038/s41598-020-70742...	2020	R	124	108	NR	NR	NR	NR
	2020	R	211	108	NR	NR	NR	NR
Dominguez-Profeta et al.¹⁹19 Dominguez-Profeta R, Cheverie JN, Blitzer RR, Lee AM, McClain L, Broderick RC, et al. More beads, more peristaltic reserve, better outcomes: factors predicting postoperative dysphagia after magnetic sphincter augmentation. Surg Endosc. 2021;35(9):5295-302. https://doi.org/10.1007/s00464-020-08013-5 https://doi.org/10.1007/s00464-020-08013...	2020	R	68	NR	NR	97.1	52.9	NR
Allman et al.³3 Allman R, Speicher J, Rogers A, Ledbetter E, Oliver A, Iannettoni M, et al. Fundic gastropexy for high risk of recurrence laparoscopic hiatal hernia repair and esophageal sphincter augmentation (LINX) improves outcomes without altering perioperative course. Surg Endosc. 2021;35(7):3998-4002. https://doi.org/10.1007/s00464-020-07789-w https://doi.org/10.1007/s00464-020-07789...	2021	R	86	NR	NR	89.5	40.9	NR
	2021	R	51	NR	NR	96.1	40.3	NR
Ayazi et al.⁷7 Ayazi S, Zheng P, Zaidi AH, Chovanec K, Salvitti M, Newhams K, et al. Clinical outcomes and predictors of favorable result after laparoscopic magnetic sphincter augmentation: single-institution experience with more than 500 patients. J Am Coll Surg. 2020;230(5):733-43. https://doi.org/10.1016/j.jamcollsurg.2020.01.026 https://doi.org/10.1016/j.jamcollsurg.20... ^* * Studies with two groups of individuals undergoing MSA procedure.	2020	R	553	10.3	33.8	NR	33.9	NR
Bonavina et al.¹¹11 Bonavina L, Horbach T, Schoppmann SF, DeMarchi J. Three-year clinical experience with magnetic sphincter augmentation and laparoscopic fundoplication. Surg Endosc. 2021;35(7):3449-58. https://doi.org/10.1007/s00464-020-07792-1 https://doi.org/10.1007/s00464-020-07792... ^* * Studies with two groups of individuals undergoing MSA procedure.	2021	P	465	36	22	97.8	NR	43
Schwameis et al.⁴⁸48 Schwameis K, Ayazi S, Zheng P, Grubic AD, Salvitti M, Hoppo T, et al. Efficacy of magnetic sphincter augmentation across the spectrum of gerd disease severity. J Am Coll Surg. 2021;232(3):288-97. https://doi.org/10.1016/j.jamcollsurg.2020.11.012 https://doi.org/10.1016/j.jamcollsurg.20...	2021	R	274	13.6	NR	88.1	22.8	NR
	2021	R	60	13.6	NR	93	79.2	NR

Author	Year	Type of study	Patients (n)	Post-MSA
Author	Year	Type of study	Patients (n)	Symptom improvement (%)	Patient satisfaction (%)	GERD- HRQL score	Use of PPI	DeMeester score	Dysphagia (%)	Endoscopic dilation (%)	Erosion (%)	Removal (%)
Lipham et al.³²32 Lipham JC, DeMeester TR, Ganz RA, Bonavina L, Saino G, Dunn DH, et al. The LINX® reflux management system: confirmed safety and efficacy now at 4 years. Surg Endosc. 2012;26(10):2944-9. https://doi.org/10.1007/s00464-012-2289-1 https://doi.org/10.1007/s00464-012-2289-...	2012	R	44	NR	87.5	3.3	20	NR	43	NR	0	6.8
Lipham et al.³³33 Lipham JC, Taiganides PA, Louie BE, Ganz RA, DeMeester TR. Safety analysis of first 1000 patients treated with magnetic sphincter augmentation for gastroesophageal reflux disease. Dis Esophagus. 2015;28(4):305-11. https://doi.org/10.1111/dote.12199 https://doi.org/10.1111/dote.12199...	2015	R	1048	NR	NR	NR	NR	NR	1.7	5.6	0.1	3.4
Sheu et al.⁴⁹49 Sheu EG, Nau P, Nath B, Kuo B, Rattner DW. A comparative trial of laparoscopic magnetic sphincter augmentation and Nissen fundoplication. Surg Endosc. 2015;29(3):505-9. https://doi.org/10.1007/s00464-014-3704-6 https://doi.org/10.1007/s00464-014-3704-...	2015	R	12	NR	NR	NR	NR	NR	83	50	0	NR
Ganz et al.²⁵25 Ganz RA, Edmundowicz SA, Taiganides PA, Lipham JC, Smith CD, DeVault KR, et al. Long-term outcomes of patients receiving a magnetic sphincter augmentation device for gastroesophageal reflux. Clin Gastroenterol Hepatol. 2016;14(5):671-7. https://doi.org/10.1016/j.cgh.2015.05.028 https://doi.org/10.1016/j.cgh.2015.05.02...	2016	P	100	NR	92.9	4	15.3	NR	6	NR	0	7
Reynolds et al.⁴¹41 Reynolds JL, Zehetner J, Nieh A, Bildzukewicz N, Sandhu K, Katkhouda N, et al. Charges, outcomes, and complications: a comparison of magnetic sphincter augmentation versus laparoscopic Nissen fundoplication for the treatment of GERD. Surg Endosc. 2016;30(8):3225-30. https://doi.org/10.1007/s00464-015-4635-6 https://doi.org/10.1007/s00464-015-4635-...	2016	R	52	NR	90	4	15	NR	46	19	NR	0
Rona et al.⁴⁵45 Rona KA, Reynolds J, Schwameis K, Zehetner J, Samakar K, Oh P, et al. Efficacy of magnetic sphincter augmentation in patients with large hiatal hernias. Surg Endosc. 2017;31(5):2096-102. https://doi.org/10.1007/s00464-016-5204-3 https://doi.org/10.1007/s00464-016-5204-...	2017	R	140	91.3	NR	5.6	26.6	NR	NR	17.9	NR	2.1
	2017	R	52	98.1	NR	3.6	9.6	NR	NR	13.5	NR	0
Czosnyka et al.¹⁶16 Czosnyka NM, Buckley FP, Doggett SL, Vassaur H, Connolly EE, Borgert AJ, et al. Outcomes of magnetic sphincter augmentation – a community hospital perspective. Am J Surg. 2017;213(6):1019-23. https://doi.org/10.1016/j.amjsurg.2016.09.044 https://doi.org/10.1016/j.amjsurg.2016.0...	2017	R	102	NR	NR	NR	NR	NR	NR	9	NR	1
Buckley et al.¹⁴14 Buckley 3rd FP, Bell RCW, Freeman K, Doggett S, Heidrick R. Favorable results from a prospective evaluation of 200 patients with large hiatal hernias undergoing LINX magnetic sphincter augmentation. Surg Endosc. 2018;32(4):1762-8. https://doi.org/10.1007/s00464-017-5859-4 https://doi.org/10.1007/s00464-017-5859-...	2018	P	200	NR	NR	2	6	NR	6	10	0	1
Prakash et al.⁴⁰40 Prakash D, Campbell B, Wajed S. Introduction into the NHS of magnetic sphincter augmentation: an innovative surgical therapy for reflux – results and challenges. Ann R Coll Surg Engl. 2018;100(4):251-6. https://doi.org/10.1308/rcsann.2017.0224 https://doi.org/10.1308/rcsann.2017.0224...	2018	R	47	NR	83.3	4.5	16.7	NR	NR	4.2	NR	0
Louie et al.³⁴34 Louie BE, Smith CD, Smith CC, Bell RCW, Gillian GK, Mandel JS, et al. Objective evidence of reflux control after magnetic sphincter augmentation: one year results from a post approval study. Ann Surg. 2019;270(2):302-8. https://doi.org/10.1097/SLA.0000000000002789 https://doi.org/10.1097/SLA.000000000000...	2019	P	200	NR	80	4	12.6	12	36.6	7.1	0.5	2.5
Antiporda et al.⁴4 Antiporda M, Jackson C, Smith CD, Bowers SP. Short-term outcomes predict long-term satisfaction in patients undergoing laparoscopic magnetic sphincter augmentation. J Laparoendosc Adv Surg Tech A. 2019;29(2):198-202. https://doi.org/10.1089/lap.2018.0598 https://doi.org/10.1089/lap.2018.0598...	2019	R	98	NR	77	5	28	NR	9.2	13.3	1.02	5.1
Tatum et al.⁵⁰50 Tatum JM, Alicuben E, Bildzukewicz N, Samakar K, Houghton CC, Lipham JC. Minimal versus obligatory dissection of the diaphragmatic hiatus during magnetic sphincter augmentation surgery. Surg Endosc. 2019;33(3):782-8. https://doi.org/10.1007/s00464-018-6343-5 https://doi.org/10.1007/s00464-018-6343-...	2019	R	96	NR	NR	NR	23.4	NR	67	16.3	NR	8.3
	2019	R	86	NR	NR	NR	19	NR	55.3	15.5	NR	3.7
Ward et al.⁵⁵55 Ward MA, Ebrahim A, Kopita J, Arviso L, Ogola GO, Buckmaster B, et al. Magnetic sphincter augmentation is an effective treatment for atypical symptoms caused by gastroesophageal reflux disease. Surg Endosc. 2020;34(11):4909-15. https://doi.org/10.1007/s00464-019-07278-9 https://doi.org/10.1007/s00464-019-07278...	2020	R	86	NR	87	6.53	9	NR	NR	3.5	NR	5.8
Tsai et al.⁵²52 Tsai C, Steffen R, Kessler U, Merki H, Lipham J, Zehetner J. Postoperative dysphagia following magnetic sphincter augmentation for gastroesophageal reflux disease. Surg Laparosc Endosc Percutan Tech. 2020;30(4):322-6. https://doi.org/10.1097/SLE.0000000000000785 https://doi.org/10.1097/SLE.000000000000...	2020	R	118	NR	NR	5.3	4.8	NR	67.8	16.9	NR	2.5
Riva et al.⁴³43 Riva CG, Siboni S, Sozzi M, Lazzari V, Asti E, Bonavina L. High-resolution manometry findings after Linx procedure for gastro-esophageal reflux disease. Neurogastroenterol Motil. 2020;32(3):e13750. https://doi.org/10.1111/nmo.13750 https://doi.org/10.1111/nmo.13750...	2020	P	45	NR	NR	3	22	NR	53.7	NR	NR	NR
Dunn et al.²⁰20 Dunn CP, Henning JC, Sterris JA, Won P, Houghton C, Bildzukewicz NA, et al. Regression of Barrett’s esophagus after magnetic sphincter augmentation: intermediate-term results. Surg Endosc. 2021;35(10):5804-9. https://doi.org/10.1007/s00464-020-08074-6 https://doi.org/10.1007/s00464-020-08074...	2020	R	87	NR	NR	4	29.3	13.7	1.08	NR	NR	NR
Ferrari et al.²³23 Ferrari D, Asti E, Lazzari V, Siboni S, Bernardi D, Bonavina L. Six to 12-year outcomes of magnetic sphincter augmentation for gastroesophageal reflux disease. Sci Rep. 2020;10(1):13753. https://doi.org/10.1038/s41598-020-70742-3 https://doi.org/10.1038/s41598-020-70742...	2020	R	124	NR	NR	21	NR	31.3	0.8	0	0	2.4
	2020	R	211	NR	NR	19.5	NR	24.8	2.4	0	2.8	13.3
Dominguez-Profeta et al.¹⁹19 Dominguez-Profeta R, Cheverie JN, Blitzer RR, Lee AM, McClain L, Broderick RC, et al. More beads, more peristaltic reserve, better outcomes: factors predicting postoperative dysphagia after magnetic sphincter augmentation. Surg Endosc. 2021;35(9):5295-302. https://doi.org/10.1007/s00464-020-08013-5 https://doi.org/10.1007/s00464-020-08013...	2020	R	68	NR	NR	NR	7.1	NR	47.1	22.1	NR	4.4
Allman et al.³3 Allman R, Speicher J, Rogers A, Ledbetter E, Oliver A, Iannettoni M, et al. Fundic gastropexy for high risk of recurrence laparoscopic hiatal hernia repair and esophageal sphincter augmentation (LINX) improves outcomes without altering perioperative course. Surg Endosc. 2021;35(7):3998-4002. https://doi.org/10.1007/s00464-020-07789-w https://doi.org/10.1007/s00464-020-07789...	2021	R	86	100	NR	NR	4.4	NR	7.5	2.9	NR	NR
	2021	R	51	98	NR	NR	10.2	NR	26.5	18.4	NR	NR
Ayazi et al.⁷7 Ayazi S, Zheng P, Zaidi AH, Chovanec K, Salvitti M, Newhams K, et al. Clinical outcomes and predictors of favorable result after laparoscopic magnetic sphincter augmentation: single-institution experience with more than 500 patients. J Am Coll Surg. 2020;230(5):733-43. https://doi.org/10.1016/j.jamcollsurg.2020.01.026 https://doi.org/10.1016/j.jamcollsurg.20... ^* * Studies with two groups of individuals undergoing MSA procedure.	2020	R	553	84	NR	7.2	6.3	NR	16.8	30.5	0	6.7
Bonavina et al.¹¹11 Bonavina L, Horbach T, Schoppmann SF, DeMarchi J. Three-year clinical experience with magnetic sphincter augmentation and laparoscopic fundoplication. Surg Endosc. 2021;35(7):3449-58. https://doi.org/10.1007/s00464-020-07792-1 https://doi.org/10.1007/s00464-020-07792... ^* * Studies with two groups of individuals undergoing MSA procedure.	2021	P	465	93.1	NR	4.6	24.2	NR	3.8	NR	NR	2.4
Schwameis et al.⁴⁸48 Schwameis K, Ayazi S, Zheng P, Grubic AD, Salvitti M, Hoppo T, et al. Efficacy of magnetic sphincter augmentation across the spectrum of gerd disease severity. J Am Coll Surg. 2021;232(3):288-97. https://doi.org/10.1016/j.jamcollsurg.2020.11.012 https://doi.org/10.1016/j.jamcollsurg.20...	2021	R	274	NR	NR	NR	6.9	NR	14.2	32.8	NR	5.1
	2021	R	60	NR	NR	NR	15	NR	10	25	NR	3.3

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[1] Correspondence: Francisco Schlottmann. E-mail: fschlottmann@hotmail.com