Magnetic compression anastomosis – the future of GI surgery

For nearly two decades, Professor Michel Gagner (Professor of Surgery in Montreal, Canada) has been working on new technologies to eliminate the limitations and complications associated with staplers and sutures. His innovative solution is magnetic compression anastomosis. In this interview he discusses the evolution of the technology, the positive outcomes, the latest data to be presented in Malaga and why he believes it could revolutionise the future if gastro-intestinal (GI) surgery...

“The idea of using magnetic compression to form as anastomosis has been 19 years in the making. In 2007, I left Cornell University where I was Professor of Surgery and decided to join two engineers and create a startup called Endometabolic Solutions (EMS). We initially had prototypes of anastomosis by compression using elastic bands and did series of animals and it worked well,” he explained. “Then, in the evolution of trying to find a way to make this minimally invasive endoscopic, we came up with the idea of trying some magnets."

In 2008, the first magnet prototype was developed, a square with four self-folding magnets and was successfully carried out in canine models. However, due to the World Financial Crisis in 2008, the company struggled to find investors.  Subsequently, the company was closed and Professor Gagner bought back the patents to the technology.

“I had to wait more than a decade before I decided to start this again, because for whatever reason, timing is everything. In 2019, we had a meeting in New York City with Thierry Thaure initially looking at creating a new company. Thierry was an engineer himself as well as a medtech entrepreneur with experience at Cephea Valve Technologies / Abbott, Intuitive Surgical, Accuray, Origin Medsystem, EndoGastric Solutions and Guidant. I asked him to take care of the day to day operations. So, in May 2020 we restarted everything and established GT Metabolic Solutions.”

However, fate again step in the way, as the Covid pandemic Swept across the globe.

“At the time of the pandemic, all I could do was animal work alone with a lot of masks. Todd Krinky, an engineer from Minneapolis, and who was the initial engineer with us at EMS, joined GT Metabolic, and helped us develop new prototypes that were 3cm and made of titanium. This was in the summer of 2020 and our first human case was performed in November 2021.”

Although the team were delighted with the initial results, they carried out further adjustments tweaking the force, length and the different variables surrounding the surrounding height, etc.

“The outcomes from the first five patients were fantastic and we carried out some additional studies in Europe, mainly in Belgium and Madrid, and then in Canada. With the collection of those patients, we were able to submit our application to the FDA. But, I was not totally happy with 3cms, so we increased the size of the magnet from 3 to 4cm and 4 to 5cm. Version two of the magnet was modified to be thinner, not as wide and had an absorbable membrane instead of titanium, so it was lighter and could be swallowed. Now, we had a magnet that could be swallowed or even two magnets in sequence.”

The company now has FDA approval in the US for the 3cm, 4cm and 5cm magnets and has its manufacturing plant in Minneapolis, MN, and an administrative office is in Silicon Valley, San Jose, CA. The small bowel magnets are also approved in Canada, several countries in South America including Chile, Argentina and Colombia, with approval pending in Ecuador, Costa Rica, Dominican Republic and Mexico. In addition, the magnets are approved in Qatar, Kuwait, Saudi Arabia and the UAE. The company has applied for the CE Mark in Europe, as well as Taiwan and several countries in North Africa.

Natural compression anastomosis

Professor Gagner explained that the principle of compression anastomosis is that the tissue (in the stomach, small bowel, colon etc) is slowly compressed and what lies between the compression will become necrotic. At the same time, the tissue outside of the compression begins the healing process.

“It’s just like cut on a wound, there's collagen deposition - which is essentially the cement of tissue between tissues - and slowly it gets stronger and stronger. Crucially, there is no foreign body - no staples, no sutures in the surrounding of the compression - so the result is pure deposition, pure healing without interference. When you look at the data from our animal models - whether it's primates, rabbits or rats - if you use magnets the burst pressure of compression anastomosis is much higher than if you use staples or sutures. So, magnet anastomosis is stronger. As this is a natural healing process, you do not see as much granulation tissue inflammation and there is superb architecture in the healing and the layers are all aligned perfectly.”

The procedure

During the procedure, the patient swallows the first magnet in the outpatient department. The magnet travels into the stomach and the duodenum and reaches the ligament of Treitz in about two hours. Once the patient is under anaesthesia in theatre, a marker is placed in the ileum 250cm from cecum laparoscopically.

Next, the laparoscopic positioning device (LPD) is used to capture the magnet and direct it distally through the jejunal lumen to the marked position in the ileum, 250cm from the ileocecal valve. At the same time, the second magnet is transported orogastrically by a flexible endoscopic catheter into the antrum and then is brought into the duodenum ~2cm after the pylorus. This is the intended magnet fusion site. The distal magnet in the ileum is then elevated antecolic and brought together with the second magnet in the post-pyloric duodenum.

The second (proximal) magnet is released to self-align with the first (distal) magnet through the intestinal walls. The endoscope and LPD are withdrawn and Peterson’ s defect closed. In several days, the two magnets are fully fused after compressing and sloughing the tissue between them. The magnets detach several weeks later from the duodeno-ileal site and are expressed naturally.

Subsequently, food flows through the duodenal lumen and also through the patent anastomosis into the ileal lumen. The results show that anastomosis is extremely durable after 3-4 weeks (depending on the tissue thickness). After the procedure, patients are carefully monitored with special attention to hemodynamic conditions and cardiac rhythm for a minimum of 24 hours. Successful placement of the MAGNET System is confirmed radiologically by abdominal x-ray, and fluoroscopically, using barium or gastrographin on postoperative day 1. Patients meet with a dietician or nutritionist prior to discharge to review the post-procedure diet.

“There are actually several ways you can deliver the magnets, for example you can deliver the distal magnet by a very long endoscope to the small bowel, or if you do colonic anastomosis, you can deliver the magnets by colonoscopy from the bottom up. You can also do an enterotomy. If I find that for whatever reason, the swallowing or the endoscopy will be difficult because there's multiple surgeries, adhesions and/or difficult anatomy, I can quickly make a small enterotomy less than a centimetre (about 8mm) and then drop the magnet from the trocar, and then put them together. There's actually five or six ways to put these magnets in various ways. And that’s important because all patients are different.”

Professor Gagner noted that there are several contraindications to this type of surgery, most notably the presence of a pacemaker. In addition, any narrowing in the GI tract is a potential contraindication, and therefore he said patients with inflammatory bowel disease, previous multiple small bowel surgery or colon surgery, a severe diverticular disease that could narrow the exit of the colon, etc, should not undergo this procedure.

IFSO-EC

During the IFSO-EC 2026 meeting in Malaga, Professor Gagner is delighted that several papers will be presented highlighting the benefits and positive outcomes from magnetic compression anastomosis.

“Dr Martin Fried is presenting one of our abstracts focusing on the comparison of magnetic jejunal bypass. It's a series that compares the laparoscopic jejunal bypass versus magnetic digital bypass. Essentially, magnetic duodeno-ileostomy (MagDI) is used for type 2 diabetes resulting in improvement in all patients with type 2 diabetes. Previously, this was performed using a stapler, in this study the procedure is performed with two swallowed 5cm magnets at two hours time difference, they join on the small bowel and then they are moved to the markings and make a ‘kissing anastomosis’.”

A second presentation will focus on magnetic jejunojejunostomy for weight regain after Roux-en-Y Gastric Bypass. This novel technique to address weight regain involves placing two kissing 5cm magnets between bowel limbs to create a side-to-side anastomosis, distalising the bypass without full transection, thereby potentially reducing malnutrition risks and mesenteric defects.

“This procedure still necessitates the closure in the mesenteric defect, but it's a side to side anastomosis and it provides safety in terms of malnutrition for minerals and vitamins. Because when you completely disconnect and transpose that distally - as opposed to a side to side where there's some flow that goes in the normal pathway versus the distal pathway - it provides some safety. We're just at the beginning of this experience and in Malaga we're presenting the technical aspects of how this is being performed. I suspect that the magnetic distalisation of the RYGB will become popular in the future because there can be a lot of weight regain after this procedure. Of course, this procedure will compete with GLP1 agonist, but for those patients who cannot tolerate them there will be another option, which is magnetic distalisation.”

The third presentation is a video presentation on magnetic gastrojejunostomy. This procedure is highlighted for its potential as a combined anti-reflux and weight-loss solution, particularly for revisions of sleeve gastrectomy. Data shows 85% resolution of GERD and 68% excess weight loss at one year.

“I believe magnetic gastrojejunostomy will be more popular than the magnetic jejunojejunostomy, because of its dual impact on GERD and weight loss. It’s a fantastic option for the revision of a gastric sleeve. In my opinion, better than a RYGB and much easier because there's no enterotomy, no cutting of the stomach and we don't want to repeat the mistakes of the mini gastric bypass. I encourage all delegates in Malaga to go see these fascinating presentations and see what this technology could offer to their patients.”

The future

“In my opinion colorectal surgery is going to be the next breakthrough area because the leakage, which is a severe complication in digestive surgery, happens mostly at the extreme of our GI tract – either in the oesophagus with high rate of leakage and/or the rectum. This occurs because of a different blood supply that is affected by the mobilisation and the transection. We have started a multi-centre trial in colon surgery at four sites in Europe and additional sites in South America and Canada.  The animal work was a real revelation for me. There are three different types of anastomosis because the tissues are slightly different, but at autopsy in the animal model, it was extremely difficult to find where the anastomosis was. There was no inflammation and minimal scar tissue, totally opposed to what we see in stapled and sutured anastomosis. I think preliminary results in humans are extremely promising, endoscopists that look from the inside could not find where the anastomosis was! This is how beautiful the anastomosis is. Looking to the future, I think colorectal surgeons will adopt magnetic anastomosis very quickly and to tell you the truth, probably every hospital in the world will be using the gastric magnet for palliation of pancreatic cancer and multiple other types of cancer. The future is exciting.”