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Esophageal Diseases Center University of Padova

La manometria esofagea ad alta risoluzione

Dott. Renato Salvador University of Padova

Department of Surgical, Oncological and Gastroenterological Sciences Clinica Chirurgica 3

Policlinico Universitario di Padova School of Medicine, Padova, Italy


Conventional Manometry

High Resoution Manometry

HRM

CM

10 min 30 min

p < 0.0001

procedure time

High Resolution Manometry: mean procedure time 8 min 13 sec (range 6’49 – 11’01)

Conventional Manometry: mean procedure time 33 min 45 sec (range 20’19 – 55’10)

Salvador R, Peters JH et al, Journal of American College of Surgeon. Jun 2009


High Resolution Manometry: mean procedure time 31 min (range 22 – 39)

Conventional Water perfusion: mean procedure time 42 min (range 36 – 48) p<0.05

Sadowski DC, Broenink L, Can J Gastroenterology 2008


IRP: Mean EGJ pressure measured with an

electronic equivalent of a sleeve sensor for 4

contiguous or non-contiguous seconds of

relaxation in the ten second window following

deglutitive UES relaxation.

Normal value: < 15mmHg


DCI: Amplitude x duration x length (mmHg‐s-

cm) of the distal esophageal contraction greater

than 20 mmHg from proximal (P) to distal (D)

pressure troughs.

Normal value: < 5000 mmHg-s-cm


CDP: The inflection point along the 30 mmHg isobaric contour where propagation velocity slows demarcating the tubular esophagus from the phrenic ampulla


DL (sec): Interval between UES relaxation and the CDP

Normal value: > 4.5 sec


CFV (cm/s): Slope of the tangent approximating the 30 mmHg isobaric contour between P and the CDP

Normal value: < 9 cm/s


J. Pandolfino et al. American Journal of Gastroenterology 2007

Lower Esopagheal Sphincter

EGJ: Esophageal Gastric Junction

Is a complex sphincter with both intrinsic (LES) and extrinsic (Crura Diaphragm)

contractile element


Malposizionamento del catetere Catetere arrotolato – Mirror effect Deglutizioni multiple

Mancanza della termocompensazione Effetto del copricatetere


Chicago Classification (v3.0)

International High Resolution Manometry Working Group. The Chicago Classification of esophageal motility disorders, v3.0. Neurogastroenterol Motil. 2015


139 consecutive achalasia patients underwent pre-operative HRM and Laparoscopic Heller-Dor


• All patients had absence of normal peristalsis, but 11/139 (10.9%)

had an IRP <15 mmHg

• All 11 patients had a barium swallow showing a grade I-II disease and a

endoscopy negative for other diseases

• All patients had a positive final outcome after LHM

Salvador R, Savarino E, Costantini M, et al (Journal Gastrointestinal Surgery ; Jan 2016)


Salvador R, Savarino E, Costantini M, et al (Journal Gastrointestinal Surgery ; Jan 2016)

p = 0.01

IRP: 25.1 mmHg (IQR 17.3- 31.1)

IRP: 29 mmHg (IQR 22.8- 37.9)


Type I no distal esophageal pressurization >

30 mmHg in > 8/10 swallows

Type II at least 2 test swallows were

associated with panesophageal pressurization > 30 mm Hg

Type III 2 or more spastic

contractions (Pressurization Front Velocity > 8 cm/sec)


Trattamento Autore Pattern 1 Pattern 2 Pattern 3 p-value

Heller-Dor laparoscopica Salvador R, JOGS 2010 85.4% 93.5% 69.6% p<0.001

Dilatazione pneumatica Pratap N, NGM 2011 63% 90% 33.3% p=0.042

POEM Nabi Z, EIO 2017 87.5% 93.5% 75% p=0.05

Heller-Dor vs

Dilatazione pneumatica

Randomized Trial, Rohof, Salvador

Gastroenterology 2013

LHD 81% versus

PD 85%

LHD 93% versus

PD 100%

LHD 86% versus

PD 40% p<0.01


Achalasia Type I: No contractility Type II: ≥20% PEP Type III: >20% spasm (DL<4.5s)

IRP ≥ ULN and 100% failed peristalsis or spasm

Yes Disorders with EGJ

outflow obstruction

1

EGJ Outflow Obstruction Incomplete achalasia Mechanical obstruction

IRP ≥ ULN and not Type I-III achalasia

Yes 2

No


4.4 s

6 cm/s

Premature Contraction

2 s

Time (s)

0

5

10

15

20

25

30

35

3.0 cm

Bolus Escape

30 cm/s

Premature Contraction

3.0 s

45 cm/s

2 s

Time (s)

0

5

10

15

20

25

30

35

7.5 cm

150

mmHg

0

100

50


Jackhammer Esophagus

DCI = >8,000

150

mmHg

0

100

50

DCI = 2,371 mmHg-s-cm

DCI = 15,191 mmHg-s-

cm

5 s

0

5

10

15

20

25

30

35

0

5

10

15

20

25

30

35

Jackhammer Esophagus

Time (s) Time (s)

5 s





outflow obstruction

Major disorders of peristalsis

Entities not seen in normal subjects

Minor disorders of peristalsis

Impaired clearance

1

DES ≥ 20% premature (DL<4.5s) Jackhammer esophagus ≥ 20% DCI >8,000 mmHgscm Absent Contractility No scorable contraction Consider achalasia

IRP normal and Low DL or high DCI or 100% failed peristalsis

Yes 3

No



Yes 2

No

Ineffective Motility (IEM) >50% ineffective swallows Fragmented peristalsis >50% fragmented swallows

and not ineffective

No

IRP normal and >50% ineffective swallows

4 Yes





outflow obstruction

Major disorders of peristalsis

Entities not seen in normal subjects

Minor disorders of peristalsis

Impaired clearance

1

IRP normal and > 40% effective swallows

5 No

DES ≥ 20% premature (DL<4.5s) Jackhammer esophagus ≥ 20% DCI >8,000 mmHgscm Absent Contractility No scorable contraction Consider achalasia

IRP normal and Low DL or high DCI or 100% failed peristalsis

Yes 3

No



Yes 2

No

Ineffective Motility (IEM) >50% ineffective swallows Fragmented peristalsis >50% fragmented swallows

and not ineffective

No

IRP normal and >50% ineffective swallows

4 Yes

Normal Yes


• Defective Lower Esoghageal Sphincter (Deficit meccanico del SEI)

• Low LES Basal Pressure - Ridotta pressione basale del SEI

• Short LES total length - Ridotta lunghezza totale del SEI

• Short LES abdominal length - Ridotta lunghezza addominale del SEI


Evidence of Hernia: 2 distal high pressure zones are identified in 33 pts

Confirmation of a hiatal hernia was present: • in 30/33 pts (91%) on upper endoscopy • in 17/21 (81%) on video barium swallow




Structurally defective LES: 53 pts Short total length: 39 pts (73.6%) Short abdominal length: 31 pts (58.5%) Low resting pressure: 15 pts (28.3%)



Structurally defective LES Proof of GERD (pH positive, Barrett or esophagitis): 93%


Manometria convenzionale High Resolution Manometry HRM 3D

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