Imperfect high-resolution manometry studies: Prevalence and predictive factors

Nasopharyngeal airway assistance improves esophageal intubation rates of high-resolution esophageal manometry catheters

BACKGROUND

High-resolution esophageal manometry (HREM) is the gold standard test for esophageal motility disorders. Nasopharyngeal airway-assisted insertion of the HREM catheter is a suggested salvage technique for failure from the inability to pass the catheter through the upper esophageal sphincter (UES). It has not been demonstrated that the nasopharyngeal airway improves procedural success rate.

METHODS

Patients undergoing HREM between March 2019 and March 2023 were evaluated. Chart review was conducted for patient factors and procedural success rates before and after use of nasopharyngeal airway. Patients from March 2019 to May 2021 did not have nasopharyngeal airway available and were compared to patients from May 2021 to March 2023 who had the nasopharyngeal airway available.

KEY RESULTS

In total, 523 HREM studies were conducted; 234 occurred prior to nasopharyngeal airway availability, and 289 occurred with nasopharyngeal airway availability. There was no difference in HREM catheter UES intubation rates between periods when a nasopharyngeal airway attempt was considered procedural failure (85% vs. 85%, p = 0.9). Nasopharyngeal airway use after UES intubation failure lead to improved UES intubation rates (94% vs. 85%, p < 0.01). Thirty-six patients that failed HREM catheter UES intubation had the procedure reattempted with a nasopharyngeal airway, 30 (83%) of which were successful. The nasopharyngeal airway assisted catheter UES intubation for failures attributed to nasal pain and hypersensitivity, gagging, coughing, and pharyngeal coiling.

CONCLUSIONS & INFERENCES

Utilization of the nasopharyngeal airway increased rates of UES intubation. When HREM catheter placement through the UES fails, placement of a nasopharyngeal airway can be trialed to overcome patient procedural intolerance.

Technical Success in Performing Esophageal High-Resolution Manometry in Patients with an Epiphrenic Diverticulum

High-resolution manometry (HRM) is the gold standard for diagnosing esophageal motility disorders, yet it can be poorly tolerated and technically challenging. Epiphrenic diverticula (ED) are located in the distal esophagus and are associated with underlying motility disorders. ED patients (2008-2022) were retrospectively compared to achalasia patients (2008-2022) and all other patients (2021-2022) who underwent HRM at a single center. Complete success was defined as at least 7 interpretable swallows including measurements throughout the esophagus into the stomach. HRM studies involving children, previously treated achalasia, and sedation or endoscopic-assistance were excluded. 20 ED patients (mean age 66; 60% female) were compared to 76 achalasia patients and 199 controls. HRM was completely successful in 70.0% of ED patients, 85.5% of achalasia (p = 0.106 vs ED), and 91.0% of controls (p = 0.004 vs ED). Most failures in the ED and achalasia groups were due to inability to traverse the esophagogastric junction (EGJ), while patient intolerance was the main reason in controls. Half of the ED group had motility disorders (25% achalasia, 15% hypercontractile esophagus, 10% absent contractility). Large diverticulum size was inversely associated with technical success compared to small diverticulum size (40% vs 100%, p = 0.013), while the presence of a motility disorder did not significantly affect success (60% vs 88.9%, p = 0.303). In conclusion, ED is a predictor of unsuccessful HRM. This appears to be mainly related to an inability to traverse the EGJ due to the size of the diverticulum. Consideration should be given to alternative means of evaluating motility, such as endoscopy-assisted HRM, given the high likelihood of failure with traditional HRM.

Risk Factors Associated with Unsuccessful High-Resolution Manometry

High-resolution manometry (HRM) is used to evaluate the esophageal motor function. Unfortunately, there are times when testing cannot be performed accurately. Our study aimed to quantify the occurrence of failed HRM and identify the associated risk factors. HRM tests were retrospectively collected between September 2021 and August 2022. HRM reports that could not be interpreted based on standard HRM protocol as per Chicago guidelines were classified as failed tests. Information reviewed included testing indications, patient demographics, previous medical/symptom history, and follow-up testing for failed HRM. We then compared patients with successful vs. unsuccessful HRM based on our pre-specified factors. 152 HRM tests were performed, of which 28 tests (18%) were unsuccessful. Factors associated with failed manometry included a history of nausea/vomiting, dyspepsia, and achalasia. Patients who were unable to tolerate the probe during testing were more likely to have a history of dyspepsia (OR 20.3, p = < 0.001) and/or nausea/vomiting (OR 13.8, p = < 0.001). A history of achalasia was found to have an odds ratio of 13.2 when examining failure because of curling of the manometry catheter (p = 0.012). All seven patients who had repeat HRM with endoscopic placement were successful in obtaining diagnostic information. There are two groups that have risk factors for unsuccessful HRM testing. A history of nausea/vomiting and dyspepsia symptoms were associated with being unable to tolerate the manometry probe. The second group comprises patients with a history of achalasia in whom probe curling is more common. Future research targeting these risk factors may minimize diagnostic and treatment delays.

Esophageal Dilation in Patients with Achalasia Is a Predictive Factor for the Inability to Traverse the Esophagogastric Junction with a Manometric Catheter

INTRODUCTION

The insertion of a high-resolution manometry (HRM) catheter into the stomach is essential for accurate manometric diagnoses; however, it is impossible in some cases due to the inability to traverse the esophagogastric junction (EGJ). Predictive factors for these patients have not been investigated in detail, necessitating time-consuming and burdensome procedures for investigators and patients. Therefore, the present study investigated the percentage of and risk factors for failed intubation at the EGJ.

METHODS

We initially reviewed the medical charts of consecutive HRM procedures performed at our hospital between September 2018 and January 2023. Patient characteristics and the findings of endoscopy and esophagography (where available) were compared between successful and failed procedures. A multivariate logistic regression analysis was conducted to identify predictive factors for the inability to traverse the EGJ. We then validated the predictive factors identified by reviewing consecutive procedures performed between February 2023 and August 2023.

RESULTS

Among the 781 procedures performed, 55 (7.0%) failed due to the inability to traverse the EGJ. Achalasia was the most common disorder in these procedures. An older age and dilated esophagus of >34 mm were independent predictive factors for the inability to traverse the EGJ in patients with treatment-naïve achalasia. In the validation study, 7 out of 68 procedures (10.3%) failed due to the inability to traverse the EGJ. A flowchart using the findings of endoscopy and an esophageal diameter of >34 mm predicted the inability to traverse the EGJ with a sensitivity of 71.4% and specificity of 86.9%.

CONCLUSION

Based on an esophageal diameter >34 mm and endoscopic findings, we predicted the inability to traverse the EGJ in more than 70% of patients. A multi-center prospective study is warranted in the future.

Guidewire-assisted placement of water-perfused esophageal high-resolution manometry probe when gastric insertion fails: A single-center experience

BACKGROUND

Blind positioning of a high-resolution manometry (HRM) probe across the esophagogastric junction (EGJ) is not always possible. We report our experience using guidewire-assisted water-perfused HRM probe insertion when the EGJ could not be traversed.

METHODS

Retrospective study analyzing the failure rate of EGJ insertion during HRM, and reporting a series of guidewire-assisted procedures.

KEY RESULTS

Among 2727 HRM procedures, the failure rate for traversing the EGJ was 2.7% (73 patients). The technique of guidewire-assisted placement of the HRM probe was used in 25 patients; it was well-tolerated and successful in all patients. No motility disorder was found in 6 patients. In four patients with previously diagnosed achalasia, achalasia subtype changed to type III in one patient. While a suspected motility disorder at barium esophagram and/or initial imperfect HRM tracing was confirmed in 10 patients, a new motility disorder was diagnosed in five patients using guidewire-assisted placement of the HRM probe.

CONCLUSIONS AND INFERENCES

In cases of inability to traverse the EGJ, insertion of a water-perfused HRM probe using an endoscopically-placed nasogastric guidewire allows successful EGJ and esophageal peristalsis assessment. Although motility disorders are often suspected using alternative diagnostic modalities, guidewire-assisted placement of HRM may be helpful for revealing them in patients where alternative diagnostic modalities are either unavailable or inconclusive.