S4167 Endoscopic Removal of a Magnetic Sphincter Augmentation Device Eroded Into the Esophagus Using a Mechanical Lithotripter

Introduction: Device erosion is a rare but serious complication 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 MSA device removal, making evidence-based guidance challenging. We present a case of successful endoscopic removal of an eroded MSA device using a biliary lithotriptor and balloon catheter wire, adding to the sparse reports supporting this minimally invasive technique. Case Description/Methods: An 82-year-old woman with longstanding gastroesophageal reflux disease underwent laparoscopic hiatal hernia repair with fundoplication in 2012, followed by robotic reoperation and placement of a #17 MSA device in 2017 for hernia recurrence. She remained asymptomatic until 6 months prior to presentation in 2025, when she developed severe dysphagia and recurrent reflux. Computed tomography imaging demonstrated vertical displacement of the device, and upper endoscopy revealed partial erosion of the device into the esophageal lumen. She was referred to our center for evaluation. Upon endoscopy, 2 beads of the MSA device were visualized causing near-complete obstruction at the gastroesophageal junction. A 0.035-inch, 450 cm guidewire was advanced past the device with a balloon catheter and retrieved on the opposite side, forming a loop between 2 beads. A biliary mechanical lithotripter was passed over the wire and under fluoroscopic and endoscopic guidance, applied torque to sever the metal link between the beads. The separated device fragments were removed with a snare, and complete extraction was confirmed fluoroscopically. Post-procedure, 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. Discussion: Erosion of MSA devices, though rare, can result in significant symptoms and traditionally requires surgical removal. This case demonstrates a safe, effective endoscopic alternative utilizing a mechanical lithotripter to disrupt and retrieve the device with fluoroscopic guidance, offering a less invasive management option in appropriately selected patients. Endoscopic removal of an eroded MSA device using a mechanical lithotripter is feasible, effective, and may reduce the need for surgical reoperation. This approach broadens the management options for MSA erosion and emphasizes the value of innovation in treating complex cases of gastroesophageal reflux disease. Watch the video: https://tinyurl.com/25ACGS4167