Recent advances.docx
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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–
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