Operator
Welcome to the Implantica Q4 2025 report presentation. For the first part of the presentation, the participants will be in listen-only mode.
During the questions and answers session, participants are able to ask questions by dialing pound key 5 on their telephone keypad. Now I will hand the conference over to the speakers: CEO Peter Forsell, CFO Andreas Öhrnberg, and Chief Corporate Affairs Officer Nicole Pehrsson.
Please go ahead.
Peter Forsell
Thank you. My name is Peter Forsell, and welcome to Implantica's Q4 2025 presentation.
For new listeners, I am surgeon, inventor of RefluxStop, and have invested more than €100 million in Implantica, and also created a successful business with the adjustable gastric band. Here you see the RefluxStop introduction tool with the device at the end.
We have a little bit closer picture here, where you see how the device looks in real life. It's 2.5 cm in size.
Currently we have 50 hospitals performing this procedure in Europe, and we have done more than 1,500 procedures. Existing surgical treatments is plagued with high complications rates.
It's actually 30 to 50% complication rate, and that's why this surgery has been heavily compressed compared to the huge market size we talk about here. Everybody in the past has believed you need to compress and support the closing of the sphincter between the stomach and esophagus.
However, it's nothing wrong with the sphincter. When you do that, try to compress, you get swallowing difficulties, you can't belch, you can't vomit, you get so-called gas bloating, because you can swallow your saliva, but nothing comes up.
With RefluxStop instead, we have showed that the sphincter is perfect. It's just a question of the anatomical and physiological region, how things are organized here.
What we realized is that in the chest you have breathings. That means the pressure is coming and going, coming and going.
That is leaking out through the big diaphragm muscle that you have that divides the chest from abdomen. These pressure variations is affecting the sphincter when that comes close to the diaphragm.
Diaphragm is a muscle that you use for breathing, it moves up and down. Therefore, it's a hole for esophagus to pass through, and that is where the pressure variation leak out.
You can compare to a harbor with a big stone wall to protect the boat from the waves, and in the opening where the boats goes in and out, it's always very streamy. What we are doing, we are free dissecting and moving the sphincter down 5 cm below the diaphragm, it's not affected so heavily by these pressure variations anymore, and we place our device on the outside of the stomach wall.
It's a little bit more sophisticated than that. It's actually three components of the anti-reflux barrier that we all correct.
That's why, in reality, if you do this operation correctly, we don't know any single patient who's not treated. Why are it now so important to have a new treatment for acid reflux?
The drugs only help 40% of the sufferers. You have drugs that diminish the acid in your stomach.
However, the acid has a purpose. It kills off bacteria, it kills off parasites.
When you don't have the acid anymore, it comes bacteria into your small intestine, who normally is sterile region, and then you get inflamed, swollen, distended, gas bloating. It's not so fun to take these drugs.
On top of that, they are really dangerous. These drugs should never have been approved if it was known what we know today.
It's a huge study from United States where they have followed 157,000 US veterans, and one out of 20 died during 10 years of PPI use. Altså, extra deaths due to PPI use, altså the medication, one out of 20 died.
That's just an incredible figure. Really, really dangerous drug to take long term.
Also, we know that both the drugs and the disease together cause cancer. It's 48,000 people only in Europe and United States who die from cancer in this region, esophageal adenocarcinoma.
That's absolutely unacceptable. When they looked at these deaths here in Sweden, they find that all the people that died from esophageal adenocarcinoma, 38% took PPI.
It was increased number even if you didn't have this disease and took PPI for other reasons, you still had an increased PPI use in the deaths here. Not good for the patients.
You can compare with breast cancer. You do anything to save lives.
Here just these people let go. It's not acceptable.
The clinical outcomes of this new treatment with RefluxStop has now reached more than five years of experience. We have built a really heavy clinical evidence.
In our pivotal study that has been used for the filing PMA to FDA, we have all patients took drugs before surgery, and only one single patient at five years was still taking drugs. When you look at the objective measurement to measure pH in lower esophagus over 24 hours, then you can see that everybody was normalized.
Between six months and five years is more or less the same. It's stable for five years, and everybody is very successfully treated.
If you compare the standard of care, who is fundoplication, where you wrap the top part of the stomach around to compress the sphincter, you can see here in orange color the complications, and in green you see our study, the pivotal study. You can then see that inability to belch, for example, 40% of the patients after five years can't vomit, can't belch.
None had that problem in our study as an example. You see to the left, every single parameter you look at, our outcome is between 93 and 100% successful.
You can read yourself because all the FDA data has now been published. They are published in Surgical Endoscopy, in American magazine for SAGES.
There you have two articles to read: one about food passageway-related events and one overall. During this time, it's like, we are building a castle of of Lego made for grown-ups.
You have several thousand of pieces, and we build step by step by step. When the castle finally is ready, then people will realize how beautiful it is.
Here you can see what we have achieved in terms of clinical evidence. We have 33 published or accepted manuscripts.
It's absolutely incredible number of articles about RefluxStop. Center after center after center pop up with their results, and it's all very, very successful clinical evidence produced.
A little bit further updates. I guess you all are waiting for FDA approval.
Are actually we. I can then tell you that we have fulfilled the pre-approval inspections from FDA.
When you reach the final stage of your PMA, FDA come out and do lots of inspections. They inspect, the hospital sites, they inspect the production sites, inspect Implantica, our quality system, how we have acted as a sponsor of this study, and so on.
All these six inspections you see here has been finalized without any major findings. The result has been given in a meeting after each of these in a successful manner for Implantica.
As we have made a modular PMA. That means we have filed in three different modules.
All modules has been reviewed by FDA. FDA has provided feedback to Implantica of these.
Two of the three modules, we have also answered on the feedback, which from our perspective means they are closed. Of course, FDA may have another opinion.
Regarding module 3, FDA required some additional tests. We got information in writing how long time this test should take at the test lab, but of course they didn't fulfill their promises and we have been a little bit of delayed.
However, this in the long run is very marginal, and we are very, very close now to finalize and also, get our FDA approval in the near term. We are preparing for the US launch, of course now pending FDA approval.
We have done lots of work preparing a very extensive plan, and we have made efforts that you could make so far. You're not allowed to start the business and visit hospitals for business, but the scientific part we are allowed, and there we have done a big effort.
We have been at all the congresses and all the important meetings in United States. And 20 surgeons has already been flown over to Europe.
They have see the procedure at two different hospitals, and they have been operated at cadaver in United States. We are targeting the first initial launch 25 to 50 centers, and the key here is the training part.
We are also made a production tool so we can produce products in United States. We have a new tool where you put silicon in in one end and out comes butscha butscha butscha products, and we can make many, many products in a short period of time.
This allows us to produce these 10,000 products we are doing right now, for the launch we expect to do a really splash in the market. That's our target for this launch.
The good thing here is that it already exists existing codes that we are targeting, both the surgeons and the hospitals will get paid with high likelihood based on these existing codes. For the product, we are targeting something called Medicare transitional pass-through payments, which is a program where you get paid for three years, meanwhile you finalize your permanent code for the implant.
Also, to explain a little bit more about the market for RefluxStop, we have two markets. One is the existing market.
In US, it's like 30,000 procedures done every year, and that's where you have most of the medical treatment, the surgeries, and and so on today. However, this is only half of the sufferers.
The other half of the sufferers is those with very severe disease, very long-term disease, where they have developed a damaged esophagus, the food transportation is damaged because the nerve ends and the muscles has been, got this acid over and over and over again. These patients, you can't operate.
Imagine that you have a very weak food transportation, and then you put a sphincter or try to close the sphincter down. It doesn't work, you know.
They they have not power enough to get the food down. It's only RefluxStop who works for these patients.
Because they are all the severe, really bad, long-term sufferers, the need for surgery is maybe 10 times larger. Instead of 30,000, here we have a need of 300,000, and still a very compressed market we talk about here.
As an endorsement for this, NHS, who runs all the public health care in UK, they have an organization called NICE, who create guidelines and evaluate new treatment. They, for nine months, have looked into RefluxStop, and their conclusion was, "We recommend RefluxStop for use for IEM subjects in the public health care in UK."
That's a fantastic reinforcement, endorsement maybe, and that means that this is something really real here. If you then look at our main device competitor, and suddenly they are withdrawing from the whole market outside US.
From end of March, this product will no longer exist except in in US. In US, this product, MSA it's called, LINX is a trademark from J&J Torax Medical.
They developed the business very, very quickly up to let's say 350 hospitals. However, you also need good results, and that has not come, to say.
They have failed in the outcome, and that's why they have like 10% of the sales left only in United States today. Also these LINX, they cannot be used for IEM sufferers.
They cannot be used for large hernias sufferers like RefluxStop. RefluxStop has like 10 times larger market size than LINX, approximately.
If we then look at the US market, this is now play with figures, you have to take it. This is not any prognostic figure or anything.
It's just a play with figures. In United States, 22.9% has acid reflux.
That's 78 million people. If we just look at those who is not treated by drugs, it's 31 million people, 40% of the sufferers.
This represent a potential market size of $290 billion. If we just play with the figures and say, okay, 1%, we take 1% of this market for surgeries, that becomes around 300,000 surgeries, 330,000 maybe surgeries.
This is approximately the message you get when you talk to US surgeons. What is now realistic if it suddenly pops up a method that actually works for treating acid reflux, then is approximately the figure you get if you talk to 10 surgeons.
I wanted to show you this figure because that's a product that could be used for some similarities with our product. This is actually a product from Inspire Medical, and this is a device who is used for snoring.
It's a surgical procedure with a little stimulator for snoring. When they come out to the market, they had one year of clinical evidence.
They do one year study in US, they get their FDA approval, but they had to complete a new market. They need to build a new market.
No one wants to start to use something without first having more evidence, long-term evidence to show. It took them four years to do around 1,000 cases and create this clinical evidence, the five-year evidence that people want to see.
After that, they took off, and they reached in their peak $8 billion valuation. You see it's just continuing to increase.
A very nice success story here. This is a little bit similarity to our IEM group, because this group has no surgery today, no treatment today, and we are building a new group of of patients for treatment.
The difference between Inspire Medical and us is that we already have five-year data. We have a massive clinical evidence and five-year data, which means that we will start and much faster get to this stage here than they did.
Here you see the 2025 AVS meeting. Actually, this was in September, not the last quarter, but I can't avoid to show this because the interest was so incredible.
We talk about hundreds of surgeons. They looked here at our five-year data, they voted at our symposium to the left, and the interest was enormous.
We are the absolutely hottest topic among surgeons in this treatment field in United States. Here you see a a very respected center in Florence in Italy who operates with robotic surgery, and it's more and more centers who try to use, or successfully use, RefluxStop with robotic surgery.
If we then look at Europe and other countries, we of course have our 50 centers approximately in in Europe, but we still have not any full reimbursement. We are still struggling, but we are coming closer and closer, and I will show you that very soon here how we are in different markets so you get a bit updated.
Regarding Canada, they have said, "If you get the US approval, we accept that for approval in Canada." Also in Japan, it's high likelihood that they will accept the US approval, we are preparing.
We have already network, surgeons, we have been at the meetings down there, we are prepared to get going also in Japan. The nice thing with Japan is that when you get approved, you also get reimbursed.
That is of course a very nice feature. If we then look at reimbursement, what is happening in Europe?
Why don't we sell tens of thousands of units instead of of what we are doing today? The answer comes here.
If you take Italy and Spain, they have so-called budget systems. That means that every year you need to apply, "I want to do RefluxStop, I want to do this and this."
The first year they say, "Okay, you can do 10 RefluxStop." Next year they say, "Okay, you do 30 RefluxStop," and so on and so on.
You you negotiate, and you increase step by step in the budget system. In December this year, we actually had two tender wins for two centers for over €1.2 million for RefluxStop surgeries.
We are getting there step by step. Also in Spain, we have this wins, tender wins, and we are not so far away from In a few years' time, it will increase more and more and more basically.
If we look in UK, as you already heard, they have endorsed NICE for NHS public hospitals that RefluxStop is used, which of course a fantastic step when we now shall also get paid. There is already an existing code that gives us part paid, but we are trying now to get fully paid here in in UK as well and to increase the market, and that also look quite promising.
In Germany, again a completely different system, we already have achieved our own OPS code, we have a code in the system to operate RefluxStop, and that's fantastic, big achievement. However, they didn't apply any money to that code, we are getting the same pay as the fundoplication procedure, although we also need to pay for the implant.
In this case, they instead have a system with so-called InEK hospitals. That's hospitals, a small selected group of hospitals that report cost.
Every cost for a procedure is reported, and based on that cost you then finally will get your pay to your code. The problem we have had is that it has been very few InEK hospitals that all do this type of surgery.
They don't do anti-reflux surgery. Finally, we have now managed, we have seven hospitals, InEK reporting hospital, we finally can get around We need around 200 surgeries in a year from this hospital to to finally get us registered and also get paid, and that we are targeting now.
We will file actually both this year and next year, but we don't expect approval until after next year's filing, which is this month next month, I think. Next month.
On top of that, we have the cost effectiveness, which we have presented at ISPOR, which showed that also in United States, society save money by operating with RefluxStop. It's more cost effective than taking drugs, it's more cost effective than doing fundoplication, than doing LINX.
That's because there is so few complications and the treatment effect is better. Just to remind new listeners, Implantica is not only about RefluxStop.
That's of course the highest priority and a blockbuster potential product. However, we also have two platform technologies that we have developed, an e-health platform and a wireless energizing platform.
These platforms are actually so unique, we think we have a potential to license this to all implant manufacturers, these platforms. We are step by step coming forward, and this will save lots of cost for society, and you will be able to do much more advanced treatment, and you can do treatment on distance.
This will actually be a complete revolution of healthcare. It will be like AI coming to your computer.
This is a new world for healthcare. We have done not less than 25,000 pages of patent on this platform technology.
You can imagine, 25,000 pages of patents. It's an incredible effort, and this is something that is enormous.
It's just that for the moment, it's RefluxStop and RefluxStop, but this will come in a later stage. Two pipeline products repeated for those who who listen to me often, but I just want to take those before we go to the finance part.
People has the stoma bag. They are maybe taken away their large intestine for some reason, and they collect the fecal matter in a plastic bag.
The business just for the plastic bags is $3 billion. It's an enormous business just for plastic bags.
Here we get the most emails from patients. They don't need this plastic bag anymore, because we have reservoir, emptying function, open, close, everything designed.
When I was a young surgeon, we actually started with this type of experimental surgery, I have a big experience of that part. We have another very humanitarian product that probably can go into the humanitarian program in United States if we are lucky, and that's UriRestore.
That's for people who can't urinate. It's 1.7% of the US population can't urinate.
That's because either they have spinal cord injury or a multiple sclerosis disease or or for some other reasons. They put in a catheter in their own bladder five times per day.
I can tell you, if you manage to put a catheter in your own bladder once, you have done a real achievement. They don't need this anymore.
They need a remote control and Implantica's device. Thereby, I will give the word to Andreas to talk about the finance update.
Andreas Öhrnberg
Many thanks, Peter. I will walk you through our financial performance for the fourth quarter of 2025.
Net sales for the fourth quarter amounted to €530,000, representing an increase of 20% compared to the same period last year. As discussed on earlier calls, Implantica is currently solely commercializing its lead product, RefluxStop, to selected European key opinion leaders.
As Peter has discussed, US market approval and European reimbursement coverage represent the key milestones to unlock the vast RefluxStop revenue opportunity. The business consistently achieves exceptional gross margins.
Adjusted gross margin for the fourth quarter amounted to 92%, up from 90% the same period last year. Operating loss for the fourth quarter amounted to €7.4 million, representing an increase of 3% compared to the same period last year.
R&D expenses increased by 12% year-on-year, driven by FDA inspections and data collection. During the fourth quarter, €1.3 million capitalized development costs were impaired.
This non-cash expense reflects a realignment of the product portfolio. For the full year, operating loss decreased to €20.5 million, representing an improvement of 19% compared to the prior year.
Let's turn to cash. Operating cash outflow amounted to €4.9 million for the quarter, 2% lower than the same period last year.
For the full year, operating cash outflow decreased by 27% to €16.6 million, underpinned by disciplined cost management. At the end of December 2025, we held €48.9 million cash and short-term investments.
The short-term investments are simple fixed deposits with a leading A+ rated Swiss bank. There is no interest-bearing debt in our capital structure.
Let me sum up this slide by saying we have a solid financial position. Moving to the next slide.
In addition to management, including our founder and principal shareholder, Dr. Peter Forsell, our shareholder base is primarily composed of high-quality Swedish and Swiss institutions.
We value the continued trust and long-term support we're receiving to ensure that GERD sufferers globally are getting access to the best available treatment at scale. Let me hand it back to you, Peter.
Peter Forsell
I have made a little summary slide here, which I thought could be on view meanwhile we see if we have any questions.
Nicole Pehrsson
I think we take the callers first if anyone's called in.
Operator
If you wish to ask a question, please dial pound key 5 on your telephone keypad to enter the queue. If you wish to withdraw your question, please dial pound key 6 on your telephone keypad.
The next question comes from Filip Wiberg from Pareto Securities. Please go ahead.
Filip Wiberg
Hi. I've lost my voice a little bit, please excuse me for that.
I've got some questions today. I'll try to take them one by one.
Perhaps I'll start with the FDA process here. I would like to just get a better sense of the current status here.
Where exactly you are at the moment? Have you done the testing yet and submitted it again, or is that still underway, to say?
Peter Forsell
The testing part were delayed due to third party, nothing we can do. The testing is now ongoing, and we expect it in the very near term to be finished.
Filip Wiberg
Okay. After that is done, you'll compile that data basically, and send it back to the FDA, and that's where the clock starts.
Is that accurate, or?
Peter Forsell
That's accurate. FDA has their own timeline.
We cannot affect that, to say. On the other hand, we know that FDA has already reviewed three all our three modules, and they have presented feedback and got answered then on all the feedback.
Of course, they have a more slim-lined process than they would have had if they had the whole PMA in hand.
Filip Wiberg
Yeah. Good.
Then it sounds like a delay of just a few months, compared to prior communication. Would you say that's accurate as well, or?
Peter Forsell
That's accurate, yes. Okay.
Filip Wiberg
Good. You talked about it during the presentation, and also wrote in the report, that you had 20 US surgeons that had completed hands-on training, some observational procedures at European centers, and cadaver-based surgical training in the US.
Does this refer to the cadaver training you did some time ago, or was this now also done in Q4?
Peter Forsell
No, this is referred to earlier training.
Filip Wiberg
Earlier training, okay. You're not allowed to do any such activities now before the approval in the US, for instance?
No,
Peter Forsell
we can only do basically activities related to the scientific world. By presenting our data of all the different congresses and meetings in US, and European surgeons flying over and talking and presenting, and also US surgeons, that is increased the awareness.
We have more than 100 surgeons who has lined up, to say, and want to start here. We are well prepared in a sales process, but it's not called sales.
It's called scientific awareness.
Filip Wiberg
Okay. Thanks for that.
Then just a question on the production of the 10,000 units. You've talked about it in a couple of reports now, I'm just curious how far you've come.
I've looked at the inventories in the balance sheet and seen it increase somewhat during the year, I was wondering if that's an effect of this increased production?
Peter Forsell
The tool, of course, is not something cheap. That's something so you can produce very quickly large amount of quantities of products.
This has been produced, finished, validated in Europe, finished everything is controlled that the production is correct with this tool. Then it's moved to US, and then you need to do another line of, to say, validation in the machine they will use in US.
Then we are ready to produce in US. We are already now producing these units in Europe, to say.
We will send them over to US.
Filip Wiberg
These 10,000 units, those will be produced in Europe now prior to the launch?
Peter Forsell
They will be produced prior to the launch, yes.
Filip Wiberg
Okay. How many have you done so far?
Peter Forsell
Oh, that was a difficult question. I can't say you exactly, but it's, maybe it can take six weeks to produce these units, something like that.
I can't say exactly.
Filip Wiberg
Okay. Then maybe just a few questions on Europe here also.
You had the tenders that you won in Italy now. I was just curious if you could share any more details around that.
How many years it is for, and if you've gotten the price that you want and the one that you've always talked about per RefluxStop device?
Peter Forsell
We only sell RefluxStop to full price. We do not give any kind of discount.
It does happen in some exceptional situation that we have given products for free for studies, and that's why you see the gross margin is 92%. Actually, the gross margin is 98%.
Altså, our device is cheaper to produce than a drug basically. In Italy now, it was two centers, and I think it is a two-year program for these two centers.
It's a step. It's opened the door, to say.
It will follow more and more of these. That's how it works in the budget system.
You need sort of to get accepted and take the first steps. This we have done now both in Italy and Spain.
We have won quite a bit of tenders, and this is a process that will take a couple of years. You get every year more centers, more products per center.
It's, as you heard during the presentation, it's extremely different in different countries. I selected Italy, Spain as one who's the budget system.
I selected Germany, which is completely based on this InEK reporting hospitals who reports all the cost of a procedure, and in UK, where they have this evaluation by NICE. Completely different system for every country basically.
Filip Wiberg
Okay. Have I understood it correctly then, you're expecting revenue from Italy here quite soon with this tender, and it goes on for basically two years out in time?
Peter Forsell
Yes. We have today quite many centers in Italy and Spain, many centers.
They have done not so many because they are not allowed to, but maybe 10 procedures or something like that, but quite many centers. I don't know exactly how many centers we have in Italy and Spain, but it's many.
Filip Wiberg
Okay. That's a very good answer.
Thanks. Then just perhaps in the UK as well.
I was wondering after this NICE recommendation, if you've been able to onboard any new hospitals since then, and if you're expecting any sales ramp here in '26, or if you have to wait for that full reimbursement that you talked about during the presentation?
Peter Forsell
There is more and more centers coming on board in terms of NHS hospitals, but all this process is a bit slow. It's lots of administration, people involved, and you make agreements that takes many months, and it's not like it's popping up like this and suddenly you have another 20 hospitals operating.
It's a process, to say. You need to take it step by step.
It's clear that having recommendation that we should be used in NHS hospitals, that's of course very, very powerful, and that will create a change, of course.
Filip Wiberg
Yeah. Then my last question is just on LINX here.
There have now been a few months since they announced that they will withdraw from the European market. I guess they're still on the market and will withdraw in the spring as I understand it.
Have you seen any changes so far in terms of the market dynamics, or if you've gotten even higher interest for RefluxStop from surgeons that have used LINX in the past, for instance?
Peter Forsell
Absolutely, from many different areas. For example, LINX was targeted to do a study that G-BA, the big healthcare organization governmental in Germany, they have got €4 million to do a study, and now they can't do this study, for example.
There's many centers who do LINX who contacts us, and because they realize that after end of March it will be no more products. That's of course very positive for us.
Still, most of our surgeries has done in a study format so far in Europe, and it's starting to take off step by step. It will be a process, I would say, over a couple of years more before we really can get going in a good way in Europe.
Then, of course, it's much different in United States, where you saw we had the two codes already, to produce this 10,000 products cost us $1 million, which is not so much. We are in a much, much better situation in US, and you can see that I showed you one example from another product in US that the US market is very different.
They sort of give priority to new technology, and they take care of new technology in a completely different way. To start in Europe or to start in United States is like night and day, and that's why it's so fantastic to get going in United States as we hope in the near term.
Then, of course, Europe will also come, and I think they could add on in a fantastic way, but that's because we have done all this groundwork for all these years. It's more complicated in Europe, and you basically expect a company to run a business for five years without getting paid before you come into the normal healthcare system, which is only Johnson & Johnson and Medtronic can afford.
It's sort of a non-functional system basically. It kills off all new technology, all new treatment.
It's different.
Filip Wiberg
Okay. Thank you very much.
That was all the questions that I had.
Operator
As a reminder, if you wish to ask a question, please dial pound key 5 on your telephone keypad. There are no more phone questions at this time, I hand the conference back to the speakers for any written questions and closing comments.
Nicole Pehrsson
Okay. Thank you very much.
I will address the questions. We have many repeat questions, I'll try to condense them.
One question is, do you expect to maintain such a high gross margin percentage in the US, or do you foresee price pressure there?
Peter Forsell
In US, we target a little price premium compared to the European market, because you have a little bit more legal cost, but we will follow the same principle, we hope, to try to keep the gross margin up. We have no intention to start to sell with lots of discount if it's not during any special circumstance, and that is not affecting the price at the end, because at the end we need to keep our price.
Yeah?
Nicole Pehrsson
You've mentioned a price of approximately $8,000 for RefluxStop in the US. Is that still the target?
Peter Forsell
I think our target price is $8,800, but that's completely undefined. It's need to be adapted depending on the situation.
Nicole Pehrsson
Can you describe the status and plans regarding information activities towards insurance companies in the US in order to build knowledge about RefluxStop?
Peter Forsell
Yes, what we have done is to prepare the dossier to present this for the insurance companies. Of course, we have quite fantastic presentation with all this clinical evidence we have built, with all this more than 30 articles, and yeah, we are in a good shape.
We have cost-benefit analysis that show it's more cost benefit, they save money basically, to operating with RefluxStop. We have a good situation, but we are not allowed to start the actual process until we have FDA approval.
Nicole Pehrsson
Do you plan to set up a production facility in the US or via a CMO? Is this in process?
Peter Forsell
We are producing in US, yes.
Nicole Pehrsson
Are you looking also at the Middle East and North Africa region and Latin America, I assume then via partners, outsourcing or licensing?
Peter Forsell
Of course, for example, Middle East is a very good market that is not so dependent on reimbursement. That, of course, will be a good market for us.
For the moment, we are focusing on the FDA approval and we are not doing anything else until we have that.
Nicole Pehrsson
What is the commercial structure or organization planned for the US, via partners or your own set-up?
Peter Forsell
Our own set-up.
Nicole Pehrsson
How much will LINX withdrawal in Europe boost revenue and uptake in Europe?
Peter Forsell
I guess it will be very valuable for us, but please remember that because it's not reimbursed fully yet, it will not take off in a fantastic way in Europe. It will be a process over a couple of years.
Nicole Pehrsson
You shared in your presentation that the other procedures had around 30 to 50% of complication rates. Could you share this figure for RefluxStop as well?
Peter Forsell
If I compare 40% rate for not able to belch and vomit after five years, in the RefluxStop group it was 0% to couldn't belch and vomit. If you take swallowing difficulties, it was 28.9% in the fundoplication group, and in the Nissen group we had 2.5%, 2.3%, one patient.
What else should we take? We have gas bloating, I think is 52% who has gas bloating in the fundoplication group, and I think we had the magnitude of 4.3% or something in the RefluxStop group.
That was I remember spontaneously, but there is of course many more data.
Nicole Pehrsson
How can robotic surgeries help you scale the business?
Peter Forsell
In United States, nearly 60% of all surgeries today is done with robotic surgery. It's of course very, very important that RefluxStop fit so well for robotic surgery.
We are developing parallel operating instructions for this type of surgery. This is a new development and we are joining.
Nicole Pehrsson
Some questions on InEK. How are you going to reach the 200 surgeries necessary to report of the InEK cost-reporting surgeries, and what will happen once you reach the number of 200?
Peter Forsell
As I said, we have seven InEK-reporting hospitals, and we have been negotiating with them that they together try to do these surgeries, everybody has agreed to focus really a lot on this, and we also performing a little registry study for this group. We are really trying, and people have actually committed to this, we hope we really should reach our goal, of course without any guarantees, but that's our target.
Nicole Pehrsson
When do you plan to relaunch the RCT with Dr. Schoppmann?
Peter Forsell
Our idea is to launch when we have the FDA approval, because our advisors has told us if we should not fool around with any study before we have FDA approval. That's the advice we are following.
Nicole Pehrsson
We just have I would say a final kind of question a couple of people have touched on is how do you intend to monetize RefluxStop in Europe, which you've addressed through the reimbursement, but maybe you can
Peter Forsell
Europe will be nearly as good as US if we just become into the healthcare systems, and we get paid for the device. Then so surgeons can operate.
That's what it's all about. It's not about the technology.
We are clearly a superior treatment, and it's just sad for the patients that they need to wait. In some countries like Sweden, it's only administrative people today who decides which treatment should be given, which is very sad.
It's all about costs. It doesn't matter if treatment are good or bad, cost is the first priority.
That's really, really sad if you compare to 1980s when I was a young surgeon, and Sweden was the best healthcare in Europe. It was fantastic.
For me as a surgeon, I think this influence from only administrative people, that's not good for the patients.
Nicole Pehrsson
A final question came in. Any comment on Japan and Canada?
Peter Forsell
I think I answered that, but I can repeat it. Canada has committed to approve us when we come with the US approval.
In Japan, it's high likelihood that they will approve us when we come with the US approval, but it's not as clear and it's no commitment made. All the FDA data need to be prepared in a format that is every of these organization they have a specific requirement for the format when you file.
That's what we are doing right now. We are preparing and organizing all the information we have in our FDA submission to also be able to file in Japan, which is actually 11% of the world market for devices like us.
I think that was all the questions. We try to answer them all in the best possible way.
We thank you very much for listening. Sorry it took some time, but we appreciate the time you spend.
Good luck. Have a nice evening.
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