Recent advances.docx

Recent advances.docx

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Recentadvances

Gut2008;57:

405-423

Recentadvancesinclinicalpractice

Oesophagealhigh-resolutionmanometry:

movingfromresearchintoclinicalpractice

MRFox1,2,AJBredenoord3

1ClinicforGastroenterologyandHepatology,UniversityHospitalZürich,Zürich,Switzerland

2OesophagealLaboratory&DepartmentofGastroenterology,St.Thomas’Hospital,London,UK

3DepartmentofGastroenterology,SintAntoniusHospital,Nieuwegein,TheNetherlands

Correspondenceto:

DrMarkRFox,ClinicforGastroenterologyandHepatology,UniversityHospitalZürich,CH-4103Zürich,Switzerland;dr.mark.fox@

Revisedversionreceived17August2007

Accepted23August2007

ABSTRACT

Manometrymeasurespressurewithintheoesophageallumenandsphincters,andprovidesanassessmentoftheneuromuscularactivitythatdictatesfunctioninhealthanddisease.Itisperformedtoinvestigatethecauseoffunctionaldysphagia,unexplained"non-cardiac"chestpain,andinthepre-operativework-upofpatientsreferredforanti-refluxsurgery.Manometrictechniqueshaveimprovedinastep-wisefashionfromasinglepressurechanneltothedevelopmentofhigh-resolutionmanometry（HRM）withupto36pressuresensors.Atthesametime,advancesincomputerprocessingallowpressuredatatobepresentedinrealtimeasacompact,visuallyintuitive"spatiotemporalplot"ofoesophagealpressureactivity.HRMrecordingsrevealthecomplexfunctionalanatomyoftheoesophagusanditssphincters.Spatiotemporalplotsprovideobjectivemeasurementsoftheforcesthatmovefoodandfluidfromthepharynxtothestomachanddeterminetheriskofrefluxevents.TheintroductionofcommerciallyavailableHRMhasbeenfollowedbyrapiduptakeofthetechnique.ThisreviewexaminesthecurrentevidencethatsupportsthemoveofHRMfromtheresearchsettingintoclinicalpractice.Itisassessedwhetheradetaileddescriptionofpressureactivityidentifiesclinicallyrelevantoesophagealdysfunctionthatismissedbyconventionalinvestigation,increasingdiagnosticyieldandaccuracy.TheneedforanewclassificationsystemforoesophagealmotoractivitybasedonHRMrecordingsisdiscussed.Lookingaheadthepotentialofthistechnologytoguidemoreeffectivemedicalandsurgicaltreatmentofoesophagealdiseaseisconsideredbecause,ultimately,itisthisthatwilldefinethesuccessofHRMinclinicalpractice.

Summary:

High-resolutionmanometry

∙High-resolutionmanometry（HRM）isarecentdevelopmentmadepossiblebycatheterswithcloselyspaced（<2cm）pressuresensors

∙HRMrevealsthecomplexfunctionalanatomyofoesophagealperistalsisandtheoesophago-gastricjunction

∙"Spatiotemporalplots"derivedfromHRMdataprovideobjectivemeasurementsoftheforcesthatdrivefoodandfluidfromthepharynxtothestomach

∙HRMimprovestheabilitytopredictthesuccessorfailureofbolusmovementthroughtheoesophaguscomparedtoconventionalmanometry（andtheoccurrenceofrefluxevents）

∙Thecomponentsoftheanti-refluxbarrier（loweroesophagealsphincterandcruraldiaphragm）canbedistinguishedandtheirdynamicinteractioncanbestudied

∙OveralldiagnosticagreementbetweenHRMandconventionalmanometryishigh;however,HRMincreasesdiagnosticyieldespeciallyincasesoffunctionaldysphagia

∙Measurementoftheoesophago-gastricpressuregradientincreasesdiagnosticaccuracyforachalasiaanddifferentiatesoesophagealspasmfromrapidelevationoftheintra-boluspressureduetofocaldysmotilityorimpairedLOSfunction

DEVELOPMENTOFMANOMETRYTECHNOLOGY

Theidealmanometricsystemwouldacquirecontinuous,high-fidelitypressuredatafromthepharynxtothestomachwithcircumferentialsensitivity.Theequipmentshouldbecheap.Theprocedureshouldbequickandeasytoperformandanalyse.Presentationofpressuredatashoulddisplaynotonlyoesophagealcontractilitybutprovideanaccurateassessmentoftheforcesthatdrivebolusmovement,12andidentify（orexclude）abnormaloesophagealfunctionasthecauseofapatient’ssymptoms.

Technologicaladvancesinmanometryandimageprocessinghavemovedtowardsthis"ideal"sincethefirstdescriptionofintra-oesophagealpressuremeasurementinthelate19thcentury.Eachadvancehasbroughtnewinsights.Balloon-tippedcathetersprovidedthefirst,rudimentary,measurementsofoesophagealfunctioninanimalsandhumans.Inthefirsthalfofthe20thcenturybundlesofnon-perfused,open-tippedcatheterswereusedtoobservepropulsive,peristalticcontractions.Theintroductionoflow-compliance,pneumo-hydraulicperfusionsystemsandside-holecathetersincreasedmeasurementaccuracy.Convenient,solid-statecatheterswithintraluminaltransducerswerealsointroduced.Thesedevelopmentsledtotheadoptionofmanometryinclinicalpractice;however,stablemeasurementsofthepharyngo-oesophagealsegmentandloweroesophagealsphincter（LOS）,especiallyduringswallowingandLOSrelaxation,remaineddifficultduetomovementofthesphincterrelativetopointpressuresensors.In1956,Fykeandcolleaguesintroducedthestationpull-throughtechniquetoensurethatLOSpressurewassampledreliablyasthesensorpassedthroughthehigh-pressurezone.3Thismethodisstillinwideuse;however,thepull-throughistime-consuming,notwelltolerated,haseffectsonLOSpressure,andcannotbeusedtoassessLOSmovementorrelaxation.4Thisproblemwassolvedfirstin1976byDentwiththeintroductionofaperfusedsleevesensorthatsignalsthegreatestpressurealongitslength,sothatmaximumLOSpressureismeasuredcontinuously.5ExtensiveliteraturesupportsthismethodformonitoringofLOSpressureandrecognitionofspontaneous,transientLOSrelaxations（TLOSRs）asthemostcommonmechanismofgastro-oesophagealreflux.67

Foradulthumans,a6cmsleeveisusuallyadequate,thoughoesophagealshorteningduringspasmandrefluxeventsoccasionallycausesexcursionoftheLOSwhichexceedsthelengthofthesleeve.89Currentguidelinesrecommendpressuremonitoringwithfourtoeightsensorsincludingasleevesensorasthecurrent"goldstandard"foroesophagealstudies（definedas"conventionalmanometry"inthisreview）.1011Nevertheless,duetotheinconvenienceofwater-perfusedtechniques,manyclinicalmotilitylaboratoriescontinuetousesolidstatecatheterswithwidelyspaced"point"pressuresensorsthatfailtocompensateforsphinctermovementanddonotprovidereliablemeasurementsofswalloworspontaneousLOSrelaxations.4

"CONVENTIONALMANOMETRY"

Despitethetechnicaladvancesdescribedabove,"conventionalmanometry"isnottheidealinvestigationofoesophagealfunction（table1）.Moreover,considerabletimeandexpertisearerequiredtoobtainatechnicallyadequateandmaximallyinformativestudyofoesophagealfunctionbythesetechniques.

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Table1Comparisonofmanometricmethods

Atpresent,abnormalmotoractivityisdefinedintermsofafewbasicpatternsseeninoesophagealmanometry:

incompletesphincterrelaxation,oesophagealspasm,hypertensivecontractions,andlossoftoneandmotility.1213Thisclassificationissimple;however,evenforexperiencedphysiologistsinspecialistcentres,inter-observeragreementintheinterpretationofmanometricmeasurementsispoor.14Onlyachalasiaandseverediffuseoesophagealspasmarespecificdisorderswithmanometricabnormalitiesthatareabsentinhealthysubjects.Otheroesophagealmotilitydisordersarepoorlydefined,ofteninclude"abnormalities"thatcanbefoundinsymptom-freeindividualsaswell,1516andareinconsistentovertime.17Moreover,theassociationbetweenconventionalmanometricfindings,symptomseverityandcourseofdiseaseispoor.18–20Thustheclinicalsignificanceofoesophagealdysmotilityisoftenuncertainandmanydiagnosesbasedonconventionalmanometryaresubjective,basedasmuchontheclinicalpresentationastheobjectivepressurerecordings.

HIGH-RESOLUTIONMANOMETRY

ThefoundationsofHRMwerelaidintheearly1990sbyClouseandStaiano.Inaseriesofstudiespressureactivitywasassessedforseveralswallowsatcloselyspacedpositionsthroughtheoesophagus.Time,catheterpositionandaveragepressurewerethenreconstructedintopseudo-3D"topographicplots"thatdemonstratedthefunctionalanatomyoftheoesophagus（fig1）.21–23Similarstudiesexaminedthegastro-oesophagealjunction.24However,incommonwithallpull-throughtechniques,onlyasnap-shotviewofoesophagealmotilitywasprovidedandintermittenteventscouldnotbestudied.

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Figure1Exampleoftopographicdisplayofnormaloesophagealpressuredatareconstructedfromseparatemeasurementsatmultiplelevelsduringastationpull-through.Thepseudo-3Dsurfaceplotdisplaysthecharacteristicpeaksandtroughsoftheperistalticpressurewaveproceedingfromtheproximaloesophagus（background）,untilitmergeswiththeLESafter-contraction（foreground）.Thecontourplotofthesameswallowsuperimposedatthetopofthefiguredemonstrateshow3Ddataarerepresentedusingconcentricringsat10mmHgintervalstoindicateincreasingamplitudes.（ReproducedfromClouseandStaiano,22withpermission.）

AnadequatedescriptionofoesophagealandLOSpressureactivityrequirescontinuousrecordingsfromalargenumberofcloselyspacedpressuresensors.Theadventof"true"high-resolutionmanometrycamewiththedevelopmentofmicro-manometricwater-perfusedassemblieswith21–32channelsand,2526morerecently,novelsolid-statetechnologythatallowedconstructionofcatheterswithupto36pressuresensors.27–