Role Of High-resolution Manometry Research Articles

The Role of High-Resolution Manometry Prior to and Following Antireflux Surgery: The Padova Consensus.

In the last two decades the development of high-resolution manometry (HRM) has changed and revolutionized the diagnostic assessment of patients complain foregut symptoms. The role of HRM before and after antireflux procedure remains unclear, especially in surgical practice, where a clear understanding of esophageal physiology and hiatus anatomy is essential for optimal outcome of antireflux surgery (ARS). Surgeons and gastroenterologists (GIs) agree that assessing patients following antireflux procedures can be challenging. Although endoscopy and barium-swallow can reveal anatomic abnormalities, physiologic information on HRM allowing insight into the cause of eventually recurrent symptoms could be key to clinical decision making. A multi-disciplinary international working group (14 surgeons and 15 GIs) collaborated to develop consensus on the role of HRM pre- and post- ARS, and to develop a postoperative classification to interpret HRM findings. The method utilized was detailed literature review to develop statements, and the RAND/University of California, Los Angeles Appropriateness Methodology (RAM) to assess agreement with the statements. Only statements with an approval rate >80% or a final ranking with a median score of 7 were accepted in the consensus. The working groups evaluated the role of HRM prior to ARS and the role of HRM following ARS. This international initiative developed by surgeons and GIs together, summarizes the state of our knowledge of the use of HRM pre- and post-ARS. The Padova Classification was developed to facilitate the interpretation of HRM studies of patients underwent ARS.

Long-term results of treatment of achalasia cardia by combined balloon dilation. The role of high-resolution manometry in the diagnosis of achalasia. Endoscopic and manometric parallels

The aim. To analyze the results of treatment of achalasia cardia by balloon dilatation with an accent on hydrodilatation, to compare the types of achalasia cardia according to high-resolution manometry with endoscopic semiotics and to evaluate the effectiveness of endoscopic balloon dilatation depending on the type of achalasia. Materials and methods. The article details an additional method of endoscopic balloon dilatation of the cardia - hydrodilatation (42 patients). The results of endoscopic balloon dilatation were analyzed according to high-resolution manometry data (37 patients). High-resolution manometry data were also evaluated in correlation with endoscopic efficacy criteria (11 patients). Results. Hydrodilatation is used as an additional method after pneumodilatation to increase efficiency of treatment (39 patients) or as an independent method (3 patients) with a combination of achalasia cardia and cicatricial changes of the esophageal-gastric junction, as well as after surgery on the cardia. The combined balloon dilatation technique gives good immediate results in 89.7% (35/39), as an independent method - 100%. Of the total number of patients, 90.5% (38/42) completed the course of endoscopic dilatation with good results, despite the fact that this is a more complex group of patients resistant to standard intervention - balloon pneumodilatation. It is not known which high-resolution manometry data should be used to assess the effectiveness of balloon dilatation: the dilatation efficiency is 75% according to the resting pressure of the lower esophageal sphincter, 83.3% according to the total relaxation pressure, 66.7% according to the cumulative analysis, strictly adhering to the reference values, and 100% according to the tendency to lower pressure. Conclusion. Endoscopic balloon dilatation is a highly effective minimally invasive method of treating achalasia cardia. Hydrodilatation is used to improve the results of endoscopic treatment. For an objective assessment of the effectiveness of balloon dilatation, high-resolution manometry should be performed before and after treatment.

The Role of High Resolution Manometry in Non-Cardiac Chest Pain

The most common cause of noncardiogenic chest pain is gastroesophageal reflux disease, and other esophageal motility disorders are also frequent. Esophageal manometry is important for diagnosing esophageal motility disease. Recently, high resolution manometry (HRM) has emerged and is reported to be more useful than conventional esophageal manometry in evaluating primary esophageal motility disease. In this study, the role and usefulness of HRM in noncardiac chest pain were investigated. From August 2018 to April 2021, 136 patients with chest pain were enrolled. Classification was carried out according to Chicago classification version 3.0, and 95 out of 136 patients showed normal findings, and 23 patients showed ineffective esophageal motility. When gastroesophageal reflux disease was classified according to Los Angeles (LA) classification, LA-M was 20% (6/30), LA-A was 63.3% (19/30), LA-B was 16.6% (5/30), and LA-C was, there were no patients with LA-D. Through this study, it was confirmed that about 22% of patients with noncardiogenic chest pain had reflux esophagitis, and about 30% of patients had esophageal motility disease. High-resolution esophageal manometry appears to be useful for the differentiation of noncardiogenic chest pain caused by esophageal motility disorders other than reflux esophagitis. After diagnosis of esophageal motor disease, follow-up studies on whether non-cardiac chest pain improves after drug treatment is required. Keywords: Chest pain, Esophageal motility disorder, Esophagitis, Gastroesophageal reflux, High resolution manometry

The role of high-resolution manometry in the assessment of upper gastrointestinal involvement in systemic sclerosis: a systematic review.

Systemic sclerosis (SSc) affects the upper gastrointestinal (GI) system in 90% of patients. High-resolution manometry (HRM) assesses esophageal dysmotility, but its role in diagnosis and follow-up remains unclear. The objectives of this systematic review were to investigate the role of HRM in the assessment of SSc-associated upper GI involvement and to evaluate the correlation between HRM abnormalities and clinical characteristics and the effects of therapeutic interventions on HRM findings. Fifteen articles were included. Most (11/15) studies were of very good or good quality. Most studies assessed correlations between esophageal symptoms and esophageal dysmotility. Two studies assessed the effectiveness of buspirone and reported HRM findings. Studies assessing upper GI symptoms using validated questionnaires, such as the University of California Scleroderma Clinical Trial Consortium Gastrointestinal Tract 2.0 or Gastrointestinal Symptoms Severity Index score, found an association between absent contractility on HRM and upper GI symptoms, but even asymptomatic patients often have esophageal body dysmotility on HRM. Esophageal dysmotility positively correlates with the presence of interstitial lung disease on high-resolution computed tomography and reduced diffusion capacity (< 0.8 of predicted value). Trials investigating the effect of buspirone demonstrate both increased lower esophageal sphincter resting pressure and reduced upper GI symptoms. Most studies report on limited patient numbers and retrospective data. Potential bias was minimized using quality appraisal. HRM findings correlate to upper GI symptoms when assessed by validated questionnaires and can detect response to therapy in buspirone trials. Esophageal body dysmotility on HRM positively correlates with the presence of interstitial lung disease. KEY POINTS: • Esophageal body dysmotility on HRM correlates with presence of ILD. • HRM findings seem to correspond to clinical symptom alleviation in interventional trials, but data are still limited. • At present HRM, a procedure with a high negative burden to the patient, offers little to no role in the therapeutic strategy.

Role of high resolution manometry in the diagnostic and therapeutic approach of post fundoplication dysphagia

Role of high resolution manometry in the diagnostic and therapeutic approach of post fundoplication dysphagia

Three-dimensional high-resolution anorectal manometry can predict response to biofeedback therapy in defecation disorders.

Biofeedback therapy (BT) is a simple and effective technique for managing outlet constipation and fecal incontinence. Several clinical factors are known to predict BT response, but a 50% failure rate persists. Better selection of BT responsive patients is required. We aimed to determine whether the defecation disorder type per high-resolution manometry (HRM) was predictive of BT response. We analyzed clinical, manometric, and ultrasound endoscopic data from patients who underwent BT in our department between January 2015 and January 2016. Patients were classified into four groups per the following defecation disorder classification criteria: rectal pressure > 40mmHg and anal paradoxical contraction (type I); rectal pressure < 40mmHg and anal paradoxical contraction (type II); rectal pressure > 40mmHg and incomplete anal relaxation (type III); and rectal pressure < 40mmHg and incomplete anal relaxation (type IV). An experienced single operator conducted ten weekly 20-min sessions. Efficacy was evaluated with the visual analog scale. Of 92 patients, 47 (50.5%) responded to BT. Type IV and type II defecation disorders were predictive of success (p = 0.03) (OR = 5.03 [1.02; 24.92]) and failure (p = 0.05) (OR = 0.41 [0.17; 0.99]), respectively. The KESS score severity before BT (p = 0.03) (OR = 0.9 [0.81; 0.99]) was also predictive of failure. The manometry types identified according to the defecation disorder classification criteria were predictive of BT response. Our data confirm the role of three-dimensional HRM in the therapeutic management of anorectal functional disorders.

Role of Esophageal Motility, Acid Reflux, and of Acid Suppression in Nonobstructive Dysphagia.

The present study was aimed at evaluating, in dysphagic patients, the role of high-resolution manometry (HRM) findings, presence of gastroesophageal reflux disease (GERD), and proton-pump inhibitor (PPI) therapy on dysphagia perception. A relevant proportion of patients with nonobstructive dysphagia present normal esophageal HRM findings. Patients with GERD often complain of dysphagia and factors, such as hypersensitivity, might be involved in its occurrence. In total, 37 nonerosive reflux disease (NERD) patients with only dysphagia (group 1) and 52 patients with both dysphagia and typical GERD symptoms (group 2) were evaluated with symptom scores, HRM combined with impedance and 24 hours impedance-pH monitoring. In total, 44 NERD patients, not presenting dysphagia, underwent the same protocol. A total of 22/37 group 1 patients [11 with pathologic acid exposure time (AET)] were treated with esomeprazole 40 mg oid for 4 weeks and were reassessed during the last week of therapy. A total of 15/37 group 1 patients (40%), 27/52 group 2 patients (52%), and 19/44 (43%) NERD patients presented pathologic AET [P=not significant (NS)]. Group 1 patients with a pathologic AET showed a significantly lower mean distal contractile integral (DCI) and a significant correlation (ρ=-0.71) between individual DCI and total bolus transit time values. During PPI therapy, in group 1 patients with pathologic AET, the mean dysphagia score value decreased significantly [7.5 (range, 3 to 9) before, 4 (range, 2 to 6) during PPI; P<0.01)] and mean DCI value increased significantly. In total, 40% of dysphagic patients show a pathologic AET and reduced peristaltic vigor. In these patients, an adequate PPI therapy significantly decreases dysphagia frequency and severity and improves the esophageal peristaltic force.

Nonspecific motility disorders, irritable esophagus, and chest pain

This paper presents commentaries on whether Starling's law applies to the esophagus; whether erythromycin affects esophageal motility; the relationship between hypertensive lower esophageal sphincter and vigorous achalasia; whether ethnic- and gender-based norms affect diagnosis and treatment of esophageal motor disorders; health care and epidemiology of chest pain; whether normal pH excludes esophageal pain; the role of high-resolution manometry in noncardiac chest pain; whether pH-impedance should be included in the evaluation of noncardiac chest pain; whether there are there alternative therapeutic options to PPI for treating noncardiac chest pain; and the usefulness of psychological treatment and alternative medicine in noncardiac chest pain.

Clinical research to patients with achalasia after peroral endoscopic myotomy therapy by high resolution manometry

Objective To investigate the effects of peroral endoscopic myotomy （POEM） on esoph- ageal dynamics in patients with achalasia （AC） and appraise the role of high resolution manometry （HRM） in assessment of POEM therapy. Methods From July 2011 to September 2012, 20 patients with aehalasia underwent POEM in the department of gastroenterology, Tianjiu Medical University General Hospital. Preoperation esophageal dynamics of all the patients were evaluated by high resolution manometry （ HRM ） system and one month after POEM operation the test was repeated. Data of lower esophageal sphincter （LES） and esophageal body were analyzed, with 15 healthy volunteers as a contrast study. Results After POEM, the LES pressure （LESP） and 4-second integrated relaxation pressure （4slRP） significantly decreased： LESP [ pre-operation （24. 5 ± 13. 1 ） mm Hg vs. post-operation （ 8.5 ± 3.1 ）mm Hg, P 〈 0. 05 ] ; 4slRP [ pre-operation （20. 7 ± 6. 8 ） mm Hg vs. post-operation （ 5.0 ±3.4） mm Hg, P 〈 0. 05 ]. The LES relax rate （LESRR） significantly elevated [ pre-operation （ 12. 7± 9. 8 ） % vs. post-operation （ 39. 6 ± 18.1 ） % , P 〈0. 05]. However, the esophageal aperistalsis remained after POEM. The total of 20 patients were all type I aehalasia and responded well to POEM therapy. Post-operation data on the symptom scores markedly decreased and a significant correlation was found between the decreasing level of symptom scores and LESP, as well as the scores 4slRP in the 20 patients （ LESP ： r = 0. 751,P 〈 0. 05 ; 4slRP ： r = 0. 500, P 〈 0. 05 ）. Conclusion POEM can significantly improve esophageal dynamics in patients with aehalasia and the treatment outcome is definite. HRM plays an important role in evaluation of POEM therapy on achalasia, Key words: Achalasia; Peroral endoscopic myotomy; High resolution manometry

Oesophageal pain: A tough nut to crack the role of high resolution manometry guided segmental oesophageal myotomy

Introduction: Oesophageal motility disorders (OMDs) are a recognized cause of pain in 25-33% of patients with non-cardiac chest pain. The understanding of these disorders based on standard multichannel oesophageal manometry has improved with high resolution oesophageal manometry (HROM). This could facilitate selection of treatment modality including identifying those suitable for surgical myotomy while preserving oesophageal function. Material and methods: This discussion is based on a 65 year old lady with a 17 year history of oesophageal pain due to Nutcracker oesophagus. Persistence of symptoms despite medical management using proton pump inhibitors, calcium channel blockers, nitrates, endoscopic pneumatic dilatation & Botulinum toxin injection prompted re-referral to our specialist unit and analysis of residual oesophageal function using HROM. This revealed a segment of nutcracker oesophagus in the mid oesophagus with significant supine reflux. Result: Surgical treatment with trans-hiatal open focused oesophageal myotomy with preservation of lower oesophageal sphincter and floppy Nissen fundoplication led to satisfactory and complete resolution of symptoms. Discussion: HROM provides a clearer classification of the functional abnormalities and their co-relation to symptoms. This allows application of the best available treatment modality including surgery to achieve symptomatic relief with preservation of residual oesophageal function. Conclusion: Limited evidence is currently available on the comparative benefits of available treatment modalities for OMDs. HROM provides greater insight into OMDs and the benefits of available treatment modalities allowing selection of optimal treatment modality and preserving oesophageal function while achieving relief of the patients distressing symptoms.

Clinical Applications of Esophageal Impedance Monitoring and High-Resolution Manometry

Esophageal impedance monitoring and high-resolution manometry (HRM) are useful tools in the diagnostic work-up of patients with upper gastrointestinal complaints. Impedance monitoring increases the diagnostic yield for gastroesophageal reflux disease in adults and children and has become the gold standard in the diagnostic work-up of reflux symptoms. Its role in the work-up for belching disorders and rumination seems promising. HRM is superior to other diagnostic tools for the evaluation of achalasia and contributes to a more specific classification of esophageal disorders in patients with non-obstructive dysphagia. The role of HRM in patients with dysphagia after laparoscopic placement of an adjustable gastric band seems promising. Future studies will further determine the clinical implications of the new insights which have been acquired with these techniques. This review aims to describe the clinical applications of impedance monitoring and HRM.