BOSTON – Patients who can’t tolerate standard esophageal manometry may be able to undergo an alternative procedure known as endoscopically assisted water perfusion esophageal manometry, with results that are useful in guiding clinical management.
Between 2007 and 2009, 88 (2.7%) of 3,304 patients who were sent for assessment of a motility disorder using standard esophageal manometry failed the procedure. However, many of these patients were able to tolerate an alternative procedure – endoscopically assisted water perfusion esophageal manometry (EAM) – with minimal sedation, reported Dr. Rita Brun and Dr. Kyle Staller, who presented the study results at Neurogastroenterology and Motility 2010.
According to the researchers, patients may be unable to tolerate standard manometry for different reasons. In the group of 88 patients who were identified via retrospective analysis, 87.5% could not tolerate intranasal intubation and 12.5% had anatomical obstacles, such as large hiatal hernias, esophageal diverticula, or prior nasal surgery.
But EAM appears to offer an effective alternative. “To our knowledge, this technique has not been reported previously,” said Dr. Brun, a gastroenterologist associated with Massachusetts General Hospital in Boston. “EAM with minimal sedation is a safe, reliable, and feasible technique providing objective diagnostic information. EAM is geared toward an especially challenging patient population, in whom no other way to assess esophageal motility is feasible yet quantified manometric information for clinical management is required. EAM can provide a needed solution in cases of problematic catheter placement, where evaluation of esophageal motility is a necessity.”
For EAM, patients are minimally sedated, using 2 puffs of lidocaine spray followed by a standard intravenous minimally conscious sedation protocol using primarily midazolam and fentanyl. A standard upper endoscopy is performed. The guide wire is inserted via the working channel of the scope, and the scope is then pulled out, leaving the wire in the stomach. A water perfusion manometry catheter is introduced over the wire, and standard water perfusion manometry is carried out. The mean time from beginning of sedation until withdrawal of the manometry probe was 42 minutes, with the procedure itself lasting about 31 minutes.
To assess the clinical value of EAM, Dr. Staller of Massachusetts General Hospital performed a retrospective analysis of the medical records of all adult patients who had undergone EAM between 2007 and 2009. In all, 41 of the 88 patients who had failed transnasal standard manometry went on to EAM. An additional 10 patients – in whom standard manometry was not appropriate because they had Zenker diverticulum, severe achalasia, or neurologic disease – were sent directly to EAM. Of these 51 patients (37 females; mean age, 60 years; age range, 24-88 years), 5 were excluded because they could not complete EAM, which yielded 46 patient records for clinical analysis.
Of the 46 patients, 10 patients were lost to follow-up. Among the 36 remaining patients, EAM had a direct influence on clinical management for 88.9% (32 patients) and had no meaningful impact for 11.1% (4 patients), according to Dr. Staller.
For instance, 27.8% (10) underwent EAM as part of a preoperative work-up for antireflux surgery. Of those, three did not undergo surgery based on the study results, whereas the other seven proceeded to surgery.
Overall, 12 patients (33.3%) were diagnosed with achalasia as a result of EAM and were treated for that condition with Botox, dilatation, or myotomy (4, 3, and 5 patients, respectively). Achalasia was ruled out in one patient, which prevented an invasive intervention.
Another 12 patients had their medications changed because of the EAM findings. In some cases, a promotility agent was added or an acid-suppression regimen was modified. Some patients had more than one change in their management.
Disclosures: The research was supported in part by a grant from the International Foundation of Functional Gastrointestinal Disorders. No other disclosures were reported.