Laparoscopic insertion of a magnetic ring for gastro-oesophageal reflux disease

Evidence-based recommendations on laparoscopic insertion of a magnetic ring for gastro-oesophageal reflux disease. This involves placing a ring of beads outside of the food pipe, just above the stomach. Magnets inside the beads hold them together to keep the food pipe closed but are weak enough to move apart to allow food or liquid to be swallowed. The aim is to prevent acid reflux.

# Recommendations
Evidence on the safety and efficacy of laparoscopic insertion of a magnetic ring for gastro-oesophageal reflux disease (GORD) is adequate to support using this procedure provided that standard arrangements are in place for clinical governance, consent and audit. Find out what standard arrangements mean on the NICE interventional procedures guidance page.
Patient selection, and the procedure, should be done by clinicians who have specific training in the procedure, and experience in upper gastrointestinal laparoscopic surgery and managing GORD.# The condition, current treatments and procedure

# The condition
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.

# Current treatments
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 anti-reflux surgery (usually laparoscopic fundoplication) if their symptoms do not improve, or if they develop complications despite medication or they have an intolerance to medication. Endoscopic interventions (such as endoscopic radiofrequency ablation at the gastrooesophageal junction) and electrical stimulation of the lower oesophageal sphincter can also be used.

# The procedure
The aim of laparoscopic insertion of a magnetic ring for GORD is to relieve reflux-related symptoms (such as heartburn or regurgitation) 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 placed 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 and reduces reflux. 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.