Use Of High-resolution Manometry Research Articles

Modern Achalasia: Diagnosis, Classification, and Treatment.

Achalasia is a major esophageal motor disorder featured by the altered relaxation of the esophagogastric junction in the absence of effective peristaltic activity. As a consequence of the esophageal outflow obstruction, achalasia patients present with clinical symptoms of dysphagia, chest pain, weight loss, and regurgitation of indigested food. Other less specific symptoms can also present including heartburn, chronic cough, and aspiration pneumonia. The delay in diagnosis, particularly when the presenting symptoms mimic those of gastroesophageal reflux disease, may be as long as several years. The widespread use of high-resolution manometry has permitted earlier detection and uncovered achalasia phenotypes which can have prognostic and therapeutic implications. Other tools have also emerged to help define achalasia severity and which can be used as objective measures of response to therapy including the timed barium esophagogram and the functional lumen imaging probe. Such diagnostic innovations, along with the increased awareness by clinicians and patients due to the availability of alternative therapeutic approaches (laparoscopic and robotic Heller myotomy, and peroral endoscopic myotomy) have radically changed the natural history of the disorder. Herein, we report the most recent advances in the diagnosis, classification, and management of esophageal achalasia and underline the still-grey areas that needs to be addressed by future research to reach the goal of personalizing treatment.

Recommendations of the Russian Gastroenterological Association on Clinical Use of High-Resolution Manometry in Diagnosis of Esophageal Disorders

Aim. Current recommendations of the Russian Gastroenterological Association on clinical use of high-resolution manometry in diagnosis of esophageal disorders are intended to assist in clinical decision making, terminology standardisation and interpretation of clinical data.Key points. In 2018, a joint meeting of the Russian Gastroenterological Association and Russian Neurogastroenterology and Motility Group approved unified terminology and classification of esophageal motor function disorders for high-resolution manometry diagnosis.Gastrointestinal patient complaints typically concern esophageal disorders such as dysphagia, regurgitation, heart-burn, chest pain or belching. To exclude erosive and ulcerative lesions, eosinophilic esophagitis and organic changes, esophagogastroduodenoscopy and biopsy are recommended in pre-treatment. Upon excluding mucosal lesions and esophageal lumen obstruction as causal for symptoms, use of high-resolution manometry is recommended. This method of esophageal examination has become the “gold standard” in diagnosis of motor disorders.High-resolution manometry enables detailed investigation of integral quantitative and qualitative characteristics of esophagus motor function and specific related disorders, analysis of esophageal contractile propagation and strictly coordinated synchronous peristalsis of upper esophageal sphincter, esophagus and lower esophageal sphincter, which malfunction may provoke development of achalasia, esophagospasm, hiatal hernia, ineffective eso pha geal motility and other motor disorders.Conclusion. High-resolution manometry is a relatively new method for study of esophagus motor function gaining increasingly wide application in clinical practice. It enables a medical professional to obtain evidence that may critically affect the choice of optimal patient care strategy and effective treatment. Current recommendations are based on an extensive review of up-to-date information and will be updated with new corpus of clinical data and assessment emerging in evidential medicine to provide gastroenterologists country-wide with latest scientific and practical guidelines.

Use of High-resolution Manometry to Detect Upper Airway Obstruction During Sleep

Use of High-resolution Manometry to Detect Upper Airway Obstruction During Sleep

PS01.005: HIGH-RESOLUTION MANOMETRY GUIDING SURGICAL PROCEDURE FOR TREATMENT OF ACHALASIA OF THE ESOPHAGUS. LONG-TERM RESULTS OF A PROSPECTIVE STUDY

Abstract Background Laparoscopic myotomy and fundoplication for the treatment of achalasia presents with 90% success rate. The intraoperative use of manometry during surgery has been previously introduced to improve the outcome. Recently, we presented our pilot study proposing the use of the HRM during surgery. The aim of this study is to evaluate the long-term outcome of the intraoperative use of High-Resolution Manometry (HRM) in achalasia patients. Methods In this prospective study, consecutive achalasia patients underwent laparoscopic myotomy and fundoplication along with real-time use of HRM. Eckardt scores (ES) and HRM results were collected before and after surgery. Results Twenty-three achalasia patients (22% Type I, 57% Type II, 22% Type III, according to Chicago Classification v3.0) with a mean age 48 years underwent calibrated and uneventful myotomy and fundoplication. Eleven myotomies were further extended, while sixteen fundoplications were intraoperatively modified, according to manometric findings. During postoperative follow-up, mean resting and residual pressures of the LES were significantly decreased after surgery (16,1 vs. 41,9, P = 0 and 9 vs. 28,7, P = 0, respectively). The ES was also diminished (1 vs. 7, P = 0). Conclusion The intraoperative use of HRM during laparoscopic myotomy and fundoplication for the treatment of achalasia of the esophagus is a safe, promising and efficient approach aiming to individualize both myotomy and fundoplication for each achalasia patient. Disclosure All authors have declared no conflicts of interest.

Management and Treatment of Patients with Dysphagia

Dysphagia occurs when food or liquid is prevented from moving from the mouth to the stomach. The normal aging process and age-related disease contribute to the prevalence of dysphagia as do acquired acute and chronic progressive diseases. This paper will define compensatory techniques and discuss research that has led to evidence-based rehabilitative approaches in the treatment of deglutitive disorders. The multidisciplinary science of deglutology has advanced in evaluation including the use of high-resolution manometry and computed tomography to compliment radiographic techniques in evaluation and to better understand the changes that occur with management and treatment. We now understand the physiologic change that can occur with swallowing exercise and how both compensatory and rehabilitative techniques are not a one size fits all scenario. Evidence-based research allows clinicians to confidently provide better care and outcomes for patients with dysphagia.

Long-term outcome of myotomy and fundoplication based on intraoperative real-time high-resolution manometry in achalasia patients.

BackgroundCurrent treatment options for achalasia of the esophagus predominantly consist of endoscopic myotomy or laparoscopic myotomy combined with a partial fundoplication. The intraoperative use of conventional manometry has previously been proposed with various results. The aim of the present study was to introduce the use of high-resolution manometry (HRM) during surgical treatment for achalasia and to assess the long-term outcome of this technique.MethodsWe enrolled achalasia patients within the time period November 2013 to July 2016 who underwent HRM and evaluation of Eckardt scores (ES) before and after tailored laparoscopic myotomy and fundoplication with intraoperative recording using HRM.ResultsTwenty patients were classified as having achalasia type I (20%), type II (55%), or type III (25%). During surgery, 9 myotomies were extended and 13 fundoplications were modified according to HRM findings. Mean resting (16.1 vs. 41.9 mmHg) and residual (9 vs. 28.7 mmHg) pressures of the lower esophageal sphincter and ES (0.7 vs. 6.9) were significantly eliminated postoperatively over a mean follow-up time of 17.7 months.ConclusionsThe use of intraoperative HRM gives us the advantage of simultaneous real-time estimation of intraluminal pressures of the esophagus and the ability to identify the exact points that produce pressure during laparoscopy. Consequently, it may be the key to the tailoring of the Heller-Dor technique and improving the outcomes for achalasia patients.

Can the upper esophageal sphincter contractile integral help classify achalasia?

Background:The use of high-resolution manometry (HRM) in achalasia patients has revealed abnormal findings concerning upper esophageal sphincter (UES) function. The introduction of the UES contractile integral (UES-CI), as with the distal contractile integral (DCI), may complement the interpretation of the manometric study of achalasia subtypes, defined by the Chicago Classification v3.0.Methods:Patients were classified into achalasia subtypes based on HRM. UES length (cm), UES resting pressure (mmHg), and UES residual pressure (mmHg) were recorded. UES-CI (mmHg·sec·cm) was calculated in a manner similar to that used for the DCI measurement at rest (landmark CI), corrected for respiration, and its relation to achalasia subtypes was evaluated.Results:Twenty-four achalasia patients with mean age 55.29 years were included. Of these, 16.6% (n=4) were diagnosed with achalasia type I, 58.3% (n=14) with type II, and 25% (n=6) with type III. The landmark UES-CI, mean UES-CI, UES-CI corrected for respiration, and UES resting pressure were found to be significantly higher among patients with achalasia type II compared to the other types (1768.9 vs. 677.1, P=0.03; 1827.1 vs. 3555.1, P=0.036; 174.2 vs. 72.8, P=0.027; and 108.1 vs. 55.8, P=0.009, respectively).Conclusions:We introduce the CI index as a tool for the manometric evaluation of the UES in achalasia. UES resting pressure, landmark UES-CI and mean UES-CI were significantly higher in achalasia patients with panesophageal pressurization compared to types I and III. This finding may reflect a protective reaction against the risk of aspiration in this group, but further studying and clinical correlation is required.

Diagnostic yield of high-resolution manometry with a solid test meal for clinically relevant, symptomatic oesophageal motility disorders: serial diagnostic study

The use of high-resolution manometry (HRM) to diagnose oesophageal motility disorders is based on ten single water swallows (SWS); however, this approach might not be representative of oesophageal function during the ingestion of normal food. We tested whether inclusion of a standardised solid test meal (STM) to HRM studies increases test sensitivity for major motility disorders. Additionally, we assessed the frequency and cause of patient symptoms during STM. Consecutive patients who were referred for investigation of oesophageal symptoms were recruited at Nottingham University Hospitals (Nottingham, UK) in the development study and at University Hospital Zürich (Zürich, Switzerland) in the validation study. HRM was done in the upright, seated position with a solid-state assembly. During HRM, patients ingested ten SWS, followed by a standardised 200 g STM. Diagnosis of oesophageal motility disorders was based on the Chicago Classification validated for SWS (CCv3) and with STM (CC-S), respectively. These studies are registered with ClinicalTrials.gov, numbers NCT02407938 and NCT02397616. The development cohort included 750 patients of whom 360 (48%) had dysphagia and 390 (52%) had reflux or other symptoms. The validation cohort consisted of 221 patients, including 98 (44%) with dysphagia and 123 (56%) with reflux symptoms. More patients were diagnosed with a major motility disorder by use of an STM than with SWS in the development set (321 [43%] patients diagnosed via STM vs 163 [22%] via SWS; p<0·0001) and validation set (73 [33%] vs 49 [22%]; p=0·014). The increase was most evident in patients with dysphagia (241 [67%] of 360 patients on STM vs 125 [35%] patients on SWS in the development set, p<0·0001), but was also present in those referred with reflux symptoms (64 [19%] of 329 patients vs 32 [10%] patients in the development set, p=0·00060). Reproduction of symptoms was reported by nine (1%) of 750 patients during SWS and 461 (61%) during STM (p<0·0001). 265 (83%) of 321 patients with major motility disorders and 107 (70%) of 152 patients with minor motility disorders reported symptoms during the STM (p=0·0038), compared with 89 (32%) of 277 patients with normal motility as defined with CC-S (p<0·0001). The diagnostic sensitivity of HRM for major motility disorders is increased with use of the STM compared with SWS, especially in patients with dysphagia. Observations made during STM can establish motility disorders as the cause of oesophageal symptoms. None.

Chicago Classification of Esophageal Motility Disorders: Applications and Limits in Adults and Pediatric Patients with Esophageal Symptoms.

The Chicago classification (CC) is most valued for its systematic approach to esophageal disorders and great impact in unifying practice for esophageal manometric studies. In view of the ever-growing wealth of knowledge and experience gained by the expanding use of high-resolution manometry (HRM) in various clinical scenarios, the CC is regularly updated. Its clinical impact and ability to predict clinical outcome, both in adults and pediatrics, will be further promoted by recognizing its current limitations, incorporating new metrics in its diagnostic algorithms and adjusting theHRM protocols based on the clinical question posed. Herein, we discuss the current limitations of the CC and highlight some areas of improvement for the future.

Incidence and Prevalence of Achalasia in Central Chicago, 2004-2014, Since the Widespread Use of High-Resolution Manometry.

Reported global incidence and prevalence values for achalasia vary widely, from 0.03 to 1.63 per 100,000 persons per year and from 1.8 to 12.6 per 100,000 persons per year, respectively. This study aimed to reconcile these low values with findings from a major referral center, in central Chicago (which began using high-resolution manometry in 2004 and used it in all clinical studies since 2005), and has determined the incidence and prevalence of achalasia to be much greater. We collected data from the Northwestern Medicine Enterprise Data Warehouse database (tertiary care setting) of adults residing in Chicago with an encounter diagnosis of achalasia from 2004 through 2014. Patient files were reviewed to confirm diagnosis and residential address. US Census Bureau population data were used as the population denominator. We assumed that we encountered every incident case in the city to calculate incidence and prevalence estimates. Data were analyzed for the city at large and for the 13 zip codes surrounding the Northwestern Memorial Hospital (NMH), the NMH neighborhood. We identified 379 cases (50.9% female) that met the full inclusion criteria; of these, 246 were incident cases. Among these, 132 patients resided in the NMH neighborhood, 89 of which were incident cases. Estimated yearly incidences were stable over the study period, ranging from 0.77 to 1.35 per 100,000 citywide (average, 1.07 per 100,000) and from 1.41 to 4.60 per 100,000 in the NMH neighborhood (average, 2.92 per 100,000). The corresponding prevalence values increased progressively, from 4.68 to 14.42 per 100,000 citywide and from 15.64 to 32.58 per 100,000 in the NMH neighborhood. The incidence and prevalence of achalasia in central Chicago diagnosed using state-of-the-art technology and diagnostic criteria are at least 2- to 3-fold greater than previous estimates. Additional studies are needed to determine the generalizability of these data to other regions.

High Resolution Esophageal Manometry in Patients with Chagas Disease: A Cross-Sectional Evaluation.

IntroductionGastrointestinal involvement affects 30–40% of the patients with chronic Chagas disease. Esophageal symptoms appear once the structural damage is established. Little is known about the usefulness of high resolution manometry to early identification of esophageal involvement.MethodWe performed a cross-sectional study at the Vall d’Hebron University Hospital (Barcelona, Spain) between May 2011 and April 2012. Consecutive patients diagnosed with Chagas disease in the chronic phase were offered to participate. All patients underwent a structured questionnaire about digestive symptoms, a barium esophagogram (Rezende classification) and an esophageal high resolution manometry (HRM). A control group of patients with heartburn who underwent an esophageal HRM in our hospital was selected.Results62 out of 73 patients that were included in the study fulfilled the study protocol. The median age of the Chagas disease group (CG) was 37 (IQR 32–45) years, and 42 (67.7%) patients were female. Twenty-seven (43.5%) patients had esophageal symptoms, heartburn being the most frequent. Esophagogram was abnormal in 5 (8.77%). The esophageal HRM in the CG showed a pathological motility pattern in 14 patients (22.6%). All of them had minor disorders of the peristalsis (13 with ineffective esophageal motility and 1 with fragmented peristalsis). Hypotonic lower esophageal sphincter was found more frequently in the CG than in the control group (21% vs 3.3%; p<0.01). Upper esophageal sphincter was hypertonic in 22 (35.5%) and hypotonic in 1 patient. When comparing specific manometric parameters or patterns in the CG according to the presence of symptoms or esophagogram no statistically significant association were seen, except for distal latency.ConclusionThe esophageal involvement measured by HRM in patients with chronic Chagas disease in our cohort is 22.6%. All the patients with esophageal alterations had minor disorders of the peristalsis. Symptoms and esophagogram results did not correlate with the HRM results.

Characterization and follow-up of esophagogastric junction outflow obstruction detected by high resolution manometry.

Esophagogastric junction outflow obstruction (EGJOO) is a newly described diagnostic entity growing in importance due to the use of high resolution manometry (HRM). There is little knowledge regarding its incidence, etiopathogeny, long-term evolution, and most suitable treatment. Our objective was to increase the awareness of EGJOO to optimize the management of these patients. We conducted a historical (retrospective and prospective) study of patients diagnosed with EGJOO using HRM combined with multichannel intraluminal impedance, comparing their manometric and impedance characteristics with those of a control group. Symptoms, etiology of obstruction, acid exposure, clinical course (and its associated factors), and response to treatment were also evaluated in the EGJOO group. Forty-four subjects were included (28 patients and 16 controls). Esophagogastric junction outflow obstruction patients presented incomplete esophageal transit more frequently than controls. Patients with structural obstruction had dysphagia more frequently than patients with functional obstruction, and different manometric, impedance, and pH-metric patterns. Over one-third of the EGJOO patients presented a spontaneous resolution of symptoms without EGJOO treatment. In the multivariate analysis, the variables associated with this spontaneous symptomatic resolution included typical symptoms of gastro-esophageal reflux disease or epigastralgia as the main symptom and resting or basal pressure of the upper esophageal sphincter <50 mmHg. The majority of EGJOO patients presented intact peristalsis which may compensate for the lack of EGJ relaxation. In the EGJOO patients presenting favorable factors associated with a spontaneous resolution of symptoms, invasive treatments should be considered with special caution. Structural etiologies are more amenable to management, while the remainder may improve without intervention.

Achalasia in Pediatric Population: Use of High-Resolution Manometry in Children, Achalasia in Pediatric Population

Achalasia is a rare esophageal motor disorder in the pediatric population, it is characterized by symptoms that mimic common diseases in children as gastroesophageal reflux disease (GERD), behavioral and eating disorders (ED). The clinical spectrum in children can range from typical symptoms such as progressive dysphagia, chest pain and weight loss, until nocturnal cough, recurrent pneumonia, asthma, stridor, aspiration, vomiting and feeding difficulties. Children may have delayed development and eating disorders. It is a disease that affects the physical, behavioral and psychosocial sphere. We report three cases of children with complex clinical presentation, an 11-year old boy with feeding difficulties initially diagnosed as eating disorder and behavioral disorder, a 14-year old girl with non-cardiac chest pain and a girl with Allgrove syndrome who presented dysphagia at 7 years old. In all three cases, the final diagnosis was established with esophageal manometry, with typical findings described in adults. The aim of the study is to describe the diagnosis and management of achalasia in pediatric populations.

Tu1973 Esophageal Dysmotility Is Highly Prevalent in Persons With SCI Compared to Able-Bodied Controls As Identified With High-Resolution Manometry and the Use of the Chicago Classification

BACKGROUND: A paucity of information exists with regard to the effects of spinal cord injury (SCI) on esophageal motility. Due to the complete or partial loss of sensory innervation to the esophagus, a symptom-based diagnosis of esophageal dysmotility is often delayed, if even appreciated, although some degree of occult impaired motility is likely to be present. AIM: To compare the incidence and to determine the differences in esophageal motility parameters between persons with chronic SCI and able-bodied controls by the use of high resolution manometry (HRM) and the Chicago Classification (CC). METHODS: HRM was performed in 39 asymptomatic individuals: 14 able-bodied controls (AB) and 25 SCI subjects (level of injury between C5-T10). A catheter that contained multiple pressure sensors which were arranged at 360 degrees was introduced into the esophagi of subjects at a distance that permitted both the upper (UES) and lower (LES) esophageal sphincters to be captured. After a baseline period to assess basal pressures, each subject was asked to perform 10 wet swallows of 5 ml boluses of isotonic saline while esophageal pressure and impedance were recorded. Esophageal topography parameters (EPT) were calculated using analysis software and two independent reviewers classified the manometric findings according to the CC. RESULTS: There were no significant differences in gender, age or BMI between AB and SCI groups. Eighty-four % (21 out of 25) of the SCI subjects studied were diagnosed with at least one motility abnormality: 12% with Type II achalasia, 4% with Type III achalasia, 20% with EGJ outflow obstruction, 4%with a hypercontractile esophagus, and 48%with peristaltic abnormalities (i.e., weak peristalsis with small or large defects or frequent failed peristalsis). In contrast, only 7% (1 out of 14) of the AB subjects was diagnosed with any type of motility disorder (hypercontractile esophagus). CONCLUSION: Despite the lack of subjective complaints or clinical awareness, esophageal dysmotility appears to be relatively prevalent in the SCI population. The use of new and improved esophageal manometry techniques and a more stringent classification system permitted the presence of wide array of motility disorders in almost all subjects with SCI to be identified, including achalasia that went previously undiagnosed in 4 subjects. Future work will be required to clarify the clinical

Defining esophageal landmarks, gastroesophageal reflux disease, and Barrett's esophagus

The following paper on gastroesophageal reflux disease (GERD) and Barrett's esophagus (BE) includes commentaries on defining esophageal landmarks; new techniques for evaluating upper esophageal sphincter (UES) tone; differential diagnosis of GERD, BE, and hiatal hernia (HH); the use of high-resolution manometry for evaluation of reflux; the role of fundic relaxation in reflux; the use of 24-h esophageal pH-impedance testing in differentiating acid from nonacid reflux and its potential inclusion in future Rome criteria; classification of endoscopic findings in GERD; the search for the cell origin that generates BE; and the relationship between BE, Barrett's carcinoma, and obesity.

Evaluation of esophageal high-resolution manometry in awake and sedated dogs

To evaluate the use of high-resolution manometry (HRM) in awake and sedated dogs and to assess potential effects of a standard sedation protocol. 22 Beagles. An HRM catheter with 36 pressure sensors was inserted intranasally in each dog. After an adaption period of 5 minutes, each set of measurements included 5 swallows of a liquid and 5 swallows of a solid bolus. Measurements were repeated 30 minutes after IM administration of buprenorphine and acepromazine. HRM was successfully performed in 14 dogs. Data sets of 8 dogs were adequate for analysis. For the upper esophageal sphincter, median values of baseline pressure, residual pressure, relaxation time to nadir, and relaxation duration were determined for awake and sedated dogs for liquid and solid swallows. For the tubular portion of the esophagus, median values of peristaltic contractile integral, bolus transit time, and contractile front velocity were determined for awake and sedated dogs for liquid and solid swallows. For the lower esophageal sphincter, median values of baseline pressure and residual pressure were determined for awake and sedated dogs for liquid and solid swallows. Significant differences (awake vs sedated) were found for the upper esophageal sphincter residual pressure (liquid swallows), relaxation time to nadir (liquid swallows), bolus transit time (solid swallows), and contractile front velocity (solid swallows). HRM was feasible for evaluation of esophageal function in most awake dogs. Although sedation in uncooperative patients may minimally influence results of some variables, an overall assessment of swallowing should be possible.

Transition zone defect associated with the response to proton pump inhibitor treatment in patients with globus sensation

Few data describing short-term proton pump inhibitor (PPI) treatment in patients with globus sensation exist. The aim of this study was to evaluate the use of high-resolution manometry (HRM) for predicting the response to PPI treatment in patients with globus sensation. A total of 41 patients with globus sensation were treated with PPIs for 4 weeks and were classified as positive and negative responders. HRM topographical plots were analyzed for relevant manometric parameters. In addition, clinical and HRM data of 20 patients with typical gastroesophageal reflux disease (GERD) not presenting globus symptom were analyzed. Of the 41 patients, 19 (46%) were clinically diagnosed with GERD. The proportion of patients with favorable symptomatic improvement was higher in patients with GERD than in those without reflux (P=0.046). Positive and negative responders to PPI treatment did not differ in upper esophageal sphincter and proximal esophageal contraction. In globus patients with GERD, the temporal and spatial dimension of the transitional zone were greater among negative responders than among PPI-positive responders (P=0.010 and P=0.011). Regarding GERD patients without globus, there was no significant difference in transition zone defect according to PPI responsiveness. By receiver operating characteristic curve analysis, 2.1 cm and 1.1 s were found to be the spatial and temporal transitional zone dimensions that best differentiated positive and negative responders. In patients with GERD-related globus, there were larger transition zone defect in the negative responders compared with the PPI-positive responders.

Current status in the treatment options for esophageal achalasia

Recent advances in the treatment of achalasia include the use of high-resolution manometry to predict the outcome of patients and the introduction of peroral endoscopic myotomy (POEM). The first multicenter randomized, controlled, 2-year follow-up study conducted by the European Achalasia Trial group indicated that laparoscopic Heller myotomy (LHM) was not superior to pneumatic dilations (PD). Publications on the long-term success of laparoscopic surgery continue to emerge. In addition, laparoscopic single-site surgery is applicable to advanced laparoscopic operations such as LHM and anterior fundoplication. The optimal treatment option is an ongoing matter of debate. In this review, we provide an update of the current progress in the treatment of esophageal achalasia. Unless new conclusive data prove otherwise, LHM is considered the most durable treatment for achalasia at the expense of increased reflux-associated complications. However, PD is the first choice for non-surgical treatment and is more cost-effective. Repeated PD according to an "on-demand" strategy based on symptom recurrence can achieve long-term remission. Decision making should be based on clinical evidence that identifies a subcategory of patients who would benefit from specific treatment options. POEM has shown promise but its long-term efficacy and safety need to be assessed further.

Persistent dysphagia after removal of an adjustable gastric band for morbid obesity: a rare complication

Esophageal and gastric pouch dilatations are not uncommon after laparoscopic adjustable gastric banding for morbid obesity. Most of the cases are treated by gastric band deflation or removal. We report here the case of a 44-year-old woman with vomiting and severe dysphagia persisting despite gastric band removal, in relation with a scar stenosis and a gastric pouch trapped in the thorax, treated by laparoscopic surgery. This case underlines the usefulness of high-resolution manometry in the diagnostic work-up of these often difficult cases.

The clinical usefulness of high-resolution manometry for the management of achalasia

Introduction: For many years, the assessment of esophageal motility relied on conventional manometry, typically performed through catheters with limited spatial resolution (pressure transducers spaced 5 cm apart). High-resolution manometry (HRM) uses a large number of closely spaced pressure sensors. This arrangement enables continuous monitoring of the entire pressure profi le from the pharynx to the stomach. Advances in computer processing have allowed this increased amount of data to be displayed as spatiotemporal plots rather than simple line graphs; these HRM pressure topography plots are considered more intuitive and may decrease interpretation time, and they provide a simpler and faster way to perform manometry because the “pull through” required to identify the lower esophageal sphincter and position the conventional manometry catheter is obviated [1]. Moreover, HRM provides accurate measurement of the esophageal sphincters in the presence of esophageal shortening or catheter displacement because the closely spaced sensors provide continuous monitoring of all pressure zones. Finally, HRM pressure topography can distinguish between luminal pressurization due to muscular contractions and that caused by retained bolus material [2]. Studies in healthy volunteers recently have defi ned normal fi ndings for esophageal peristalsis [3] and esophagogastric junction dynamics [4], and a classifi cation of esophageal motility disorders based on pressure topography has begun to take shape [5]. This classifi cation includes three achalasia subtypes based on HRM topography fi ndings in the esophageal body: negligible pressurization, pan-esophageal pressurization, and spastic contractions. Understandably, HRM has generated much enthusiasm. However, studies clearly documenting the advantages of this technique over conventional manometry in the clinical setting have been lacking. The study discussed here by Pandolfi no et al. addresses the usefulness of HRM in the management of achalasia.