Endoscopic removal of a magnetic sphincter augmentation device eroded into the esophagus using a mechanical lithotriptor

Abstract

Background and Aims

Device erosion is a rare, serious adverse event of magnetic sphincter augmentation (MSA) device implantation for gastroesophageal reflux disease (GERD), occurring in 0.3% of cases. Limited literature exists regarding endoscopic approaches to device removal, making evidence-based guidance challenging. We describe an endoscopic technique for removal of an eroded MSA device using a mechanical lithotriptor under fluoroscopic guidance.

Methods

Upper endoscopy was used to visualize 2 beads of the MSA device at the gastroesophageal junction. A 0.035-inch, 450-cm guidewire was advanced past the device via balloon catheter and retrieved on the opposite side, forming a loop between 2 beads. A rescue biliary mechanical lithotriptor passed over the wire was torqued to sever the metal link between the beads. The separated device fragments were removed via snare. Fluoroscopy confirmed complete extraction.

Results

Postprocedure, the patient experienced self-resolving substernal pain without radiographic evidence of perforation. She was observed overnight and discharged the next day on a staged diet plan without recurrence of symptoms including GERD or dysphagia.

Conclusions

Endoscopic removal of an eroded MSA device using a mechanical lithotriptor is feasible, effective, and safe. This approach broadens the management options for MSA erosion and emphasizes the value of innovation in complex GERD cases.

Case description

Case

Device erosion is a rare but serious adverse event of magnetic sphincter augmentation (MSA) device implantation for gastroesophageal reflux disease (GERD), occurring in approximately 0.3% of cases.¹ To our knowledge, limited literature exists regarding endoscopic approaches to MSA device removal, making evidence-based guidance challenging.²

This case involved an 82-year-old woman with longstanding GERD who underwent laparoscopic hiatal hernia repair with fundoplication in 2012. After her hernia recurred in 2017, she underwent robotic reoperation and placement of a 17-bead MSA device. She was asymptomatic until 6 months prior to her presentation in 2025, when she developed severe dysphagia to both solids and liquids, as well as recurrent reflux. CT imaging at an outside hospital demonstrated vertical displacement of the device, and upper endoscopy revealed that the device had partially eroded into the lumen of the distal esophagus (Fig. 1). She was referred to our center for evaluation. Based on prior experience with eroded gastric bands, we elected for an endoscopic removal approach using a mechanical biliary lithotriptor.

Figure 1.

Vertically displaced magnetic sphincter augmentation device on coronal plane CT scan.

Procedure

The procedure was performed with the patient under general anesthesia with carbon dioxide insufflation and under fluoroscopic guidance. Upper endoscopy was performed; 2 beads of the MSA device were visualized at the gastroesophageal junction causing significant edema and near-complete obstruction of the distal esophagus (Fig. 2). Through the working channel of a diagnostic upper endoscope, a 0.035-inch, 450-cm guidewire was advanced past the device on 1 side with a balloon catheter and retrieved on the opposite side of the beads with a snare, forming a loop between the 2 beads. The endoscope was then removed along with the wire tip, leaving the wire looped around the MSA device with both ends free at the mouth (Fig. 3).

Figure 2.

Eroded magnetic sphincter augmentation beads in the esophageal lumen near the gastroesophageal junction.

Figure 3.

Mechanical lithotriptor in position prior to magnetic sphincter augmentation disruption.

A rescue biliary mechanical lithotriptor was passed over the wire ends. Approximation of the tip of the metal sheath with the MSA device was confirmed by reintroduction of the upper endoscope along the device. Under fluoroscopic and endoscopic guidance, steady torque was applied to the wire by rotating the handle of the lithotriptor slowly to sever the metal link between the beads (Fig. 4). The separated device fragments were removed with a snare, and complete extraction of the MSA device was confirmed fluoroscopically (Figs. 5 and 6) (Video 1, available online at www.videogie.org). If transection cannot be achieved, there is a risk of wire-sheath entrapment. To mitigate this, we used controlled tension and gradual cranking and kept the sheath tip closely apposed to the device (not buried in tissue). The total procedure duration was 27 minutes. Periprocedural antibiotics were not administered.

Figure 4.

Successful disruption of magnetic sphincter augmentation device.

Figure 5.

Snare retrieval of disrupted magnetic sphincter augmentation components.

Figure 6.

No residual evidence of the magnetic sphincter augmentation device or perforation on esophagogram.

Outcome

After the procedure, the patient experienced substernal pain without radiographic evidence of perforation (esophagogram did not reveal contrast extravasation), and luminal narrowing was noted at the gastroesophageal junction consistent with the edema seen during endoscopy (Fig. 6). Overnight, she was observed in the hospital, and her substernal pain self-resolved. She was discharged the next day on a staged diet plan. Following removal, her symptoms resolved without dysphagia. Repeat endoscopy 8 months later showed normal esophagus, previous fundoplication, and mild gastritis (Figs. 7 and 8).

Figure 7.

Repeat upper endoscopy showing normal gastroesophageal junction.

Figure 8.

Repeat upper endoscopy showing a normal cardia and gastroesophageal junction (retroflexed view).

Erosion of MSA devices, although rare, can result in significant symptoms as it did for this patient, and traditionally requires surgical removal. Limited endoscopic approaches have been reported, including use of direct-current cutting systems (eg, Ovesco retrieval system [Ovesco Endoscopy AG, Tübingen, Germany], loop cutter [Olympus Corporation, Tokyo, Japan]) and mechanical lithotripsy-based transection.3, 4, 5 In this case, we selected a mechanical lithotriptor approach because it is commonly available in endoscopy units and avoids thermal injury. This case demonstrates a safe, effective endoscopic alternative using a mechanical lithotriptor to disrupt and retrieve the device with fluoroscopic guidance, offering a less-invasive management option in appropriately selected patients.

Disclosure

All authors disclosed no financial relationships.

Supplementary data

Video 1

Endoscopic removal of an eroded magnetic sphincter augmentation device using a mechanical lithotriptor under fluoroscopic guidance.