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Oesophageal manometry is the investigation of choice for assessment of motor function of the oesophagus.1 It can be performed to identify patients with a major disorder of motility, if this is suspected, or to help decide whether a patient is appropriate for anti-reflux surgery. The Chicago classification has been developed to aid analysis and interpretation of high-resolution manometry.2 Prior to high resolution manometry and the Chicago classification, despite there being no universally accepted classification of motility disorders, certain conditions were well described (Table 1).3

Table 1: Criteria for disorders of motility with conventional water perfusion manometry (major disorders of motility above red line).3

OGJ: Oesophagogastric junction; LOS: Lower oesophageal sphincter.

Limited access to oesophageal manometry can result in delays to diagnosis and treatment for major motility disorders of the oesophagus as well as anti-reflux surgery. Because high resolution manometry is not readily available globally and is more expensive to set up and maintain,4 conventional water perfusion manometry retains a role in assessing oesophageal motility. A comparative study of water perfusion and solid-state systems for oesophageal manometry concluded that most pressure measurements were consistent between the two systems. Patient tolerance was better for water perfusion manometry.5

Authors have advocated manometry both routinely and selectively prior to anti-reflux surgery.6–9 However, criteria for selective use of manometry are not clearly defined. A thorough history is mandatory and may increase clinical suspicion of gastro-oesophageal reflux or a primary motility disorder.

In patients being assessed for dysphagia, a symptom questionnaire along with contrast radiography and gastroscopy can help predict the diagnosis of achalasia.10

This study aimed to determine whether symptoms can reliably predict a major disorder of oesophageal motility as assessed by conventional water perfusion manometry.

Methods

The need for formal ethics approval was waived by the Health and Disability Ethics Committee (HDEC), Ministry of Health, New Zealand.

De-identified data from all patients who underwent conventional water perfusion oesophageal manometry and a pre-manometry questionnaire between October 1998 and August 2018 were extracted from a database. Data included demographic data (age, sex), oesophageal manometry results and responses to a pre-manometry questionnaire.

Oesophageal manometry was performed using a standardised protocol. Patients fasted for six hours prior to manometry. Acid suppression medications were not withheld. A water perfused system with an eight-lumen catheter assembly was used (Mui Scientific, Mississauga, Canada). The proximal side hole is 6cm from the second side hole. The next four side holes are spaced at 5cm increments. A 6cm sleeve sensor and a distal side hole then follow. The catheter assembly was connected to a pressure transducer/perfusion pump unit (Dentsleeve Mark II, Mui Scientific, Mississauga, Canada). This unit was connected to a polygraph (PC Polygraph HR, Synectics Medical, Enfield, UK), which emits a trace for subsequent computer software analysis (POLYGRAM for Windows, Version 2.04, Synectics Medical, Enfield, UK).

With patients sitting upright, the catheter was passed trans-nasally into the stomach, and deep inspiration was performed to determine the location of the diaphragm. In a left lateral position, the high-pressure zone of the lower oesophageal sphincter (LOS) was identified by performing a station pull-through. With the distal side hole in the stomach and the sleeve sensor over the LOS, the catheter was fixed.

Patients took ten syringe-administered 5mL water swallows, 30 seconds apart. This was followed by two consecutive dry bread swallows, recording symptoms of dysphagia or chest pain.

Oesophageal manometry results were reviewed by the senior author (RR) and each patient given one of ten diagnoses based on the criteria in Table 1.3 The diagnoses were categorised into two groups: (1) major disorders of motility and (2) minor disorders of motility/normal. The diagnostic criteria apply to conventional water perfusion manometry and pre-date the Chicago classification. For consistency, these diagnoses were unchanged for the study period. The conventional water perfusion manometry diagnoses have been correlated to the most alike high-resolution manometry diagnoses in the Chicago classification v3 (Table 2).

Table 2: Correlation of manometric diagnostic criteria between conventional water perfusion manometry and high-resolution manometry.

A questionnaire with 16 symptoms was completed immediately before manometry. Patients assigned a result of ‘never’, ‘occasionally’ or ‘frequently’ to each symptom by checking a box.

Achalasia was selected as a model of a well described major motility disorder of the oesophagus that has negative clinical outcomes if left untreated. A literature review was performed to identify the most common symptoms in achalasia as dysphagia (92–100%), regurgitation (59–87%) and chest pain (42–74%).11–13

Thus the patient questionnaire responses to the three symptoms, dysphagia, regurgitation, and chest pain, were analysed. The exact words printed on the questionnaire were ‘difficulty in swallowing’, ‘regurgitation’ and ‘chest pain’.

Data also included whether patients were dysphagic to a bread challenge (observed at time of manometry). These data were collected for analysis if available. Questionnaire responses of ‘occasionally’ or ‘frequently’ to each of the three symptoms resulted in that symptom being considered present. A fourth clinical category, ‘any dysphagia’, described patients with either dysphagia symptoms (occasional or frequent) or dysphagia to a bread challenge.

The presence of each of the four clinical features was compared between the two diagnostic categories (major disorders of motility and minor disorders of motility/normal).

Permutations of clinical features using ‘or’ as a function were analysed (eg, ‘any dysphagia’ or ‘chest pain’), generating seven possible clinical feature combinations (Table 3). The presence of clinical feature combinations was compared between the two diagnostic categories.

Comparisons were performed using Fisher’s exact test and Pearson’s Chi-Squared test. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 25 (IBM Corp, Armonk, NY, USA). A p-value <0.05 was considered statistically significant.

Table 3: Major disorders of motility; clinical features in isolation and in combination using ‘or’ function.

Results

Data were available for 555 patients. Eight patients had a history of anti-reflux surgery, and one patient had incomplete manometry results. These patients were excluded, leaving 546 patients eligible for analysis. An audit of indications for manometry for the study period showed that 78% of manometry studies were performed as routine assessment prior to fundoplication, and 22% were undertaken to investigate patient symptoms.

Thirty-three (6%) patients had a major disorder of motility, and 513 (94%) had normal manometry or a minor disorder of peristalsis (Tables 1 and 2).

There was no statistically significant difference between patients with a major disorder of motility when compared to those with a minor disorder of motility/normal, when assessed for age or sex. The median age of patients with a major disorder of motility was 56 years compared to 50 years in patients with a minor disorder of motility/normal (p=0.384). Thirteen of 33 (39.4%) patients with a major disorder of motility were male compared to 266 of 513 (51.9%) patients with a minor disorder of motility/normal (p=0.209).

In all patients having oesophageal manometry, on the questionnaire 286 of 546 (52%) reported dysphagia as either occasional or frequent.

All 16 patients with achalasia diagnosed on manometry reported dysphagia as a symptom, and of these, 15 had frequent dysphagia (Figure 1). Of 530 patients without achalasia, 270 (51%) had symptoms of dysphagia. The presence of dysphagia as a symptom in patients with achalasia was statistically significant when compared to dysphagia in patients without achalasia (p<0.001).

Dysphagia was not universal in patients with aperistalsis, with three of four patients with aperistalsis reporting dysphagia.

Rates of dysphagia as a symptom and ‘any dysphagia’ (as a symptom or provoked with bread) were higher in patients with a major disorder of motility (dysphagia in 27/33 (82%) patients, ‘any dysphagia’ in 31/33 (94%) patients), in comparison to patients with a minor disorder of motility/normal (dysphagia in 259/513 (50%) patients, ‘any dysphagia’ in 301/513 (59%) patients). This was statistically significant (dysphagia p<0.001; ‘any dysphagia’ p<0.001). Dysphagia as a symptom was 82% sensitive, and ‘any dysphagia’ was 94% sensitive in identifying a major disorder of oesophageal motility. Specificity was 50% for dysphagia as a symptom and 41% for ‘any dysphagia’ (Table 3).

Chest pain was reported by 338 of 513 (66%) patients with a minor disorder of motility/normal and 26 of 33 (79%) patients with a major disorder of motility (p=0.181).

Regurgitation was present in 435 of 513 (85%) patients with a minor disorder of motility/normal and 25 of 33 (76%) of patients with a major disorder of motility (p=0.213).

The presence of any dysphagia or chest pain was 100% sensitive in identifying patients with a major disorder of motility. Specificity was 15% with 435 of 513 patients with a minor disorder of motility/normal also having dysphagia as a symptom, dysphagia to a bread challenge or chest pain. This was statistically significant (p=0.009) (Table 3).

Figure 1: Symptom frequency in oesophageal motility disorders.

Discussion

In our study, dysphagia was the most reliable clinical feature in identifying a major disorder of oesophageal motility, with a sensitivity of 94% (dysphagia as a symptom or in response to a bread challenge). Adding chest pain with an ‘or’ function increased sensitivity to 100% but with a sacrifice in specificity.

We have also shown that dysphagia is reported by all patients with achalasia. This is consistent with international series of achalasia patients where rates of dysphagia are 92–100%11–13

Dysphagia was also reported by more than half of all patients undergoing conventional water perfusion oesophageal manometry. Chest pain (67%) and regurgitation (84%) were common in all patients undergoing oesophageal manometry for all indications. In isolation, these latter two symptoms were poor at discriminating between a major disorder of motility and normal motility.

Our data regarding dysphagia, chest pain and regurgitation are in keeping with international literature. A population-based study from Cologne using a questionnaire showed that 65% of those with moderate to severe reflux symptoms reported additional dysphagia symptoms.14 In a further population based study, 53% and 58% of patients with non-cardiac chest pain also had heartburn and regurgitation respectively.15

If manometry is performed as part of the work up for anti-reflux surgery, excluding achalasia is important. Rather than fundoplication in isolation, achalasia patients are better served by cardiomyotomy as well. There has also been increasing use of POEM (PerOral Endoscopic Myotomy) for achalasia as an alternative to laparoscopic myotomy and partial fundoplication. The implications of other major disorders of motility are less clear.

In a study of 15 patients with high amplitude peristaltic contractions (≥150mmHg) who underwent Nissen fundoplication, 27% developed new dysphagia or new chest pain. The authors concluded that new chest pain, which occurred in three patients (20%), should be discussed with patients preoperatively, but that high amplitude peristaltic contractions were not a contraindication to Nissen fundoplication.16

A manometry database of patients with gastro-oesophageal reflux who underwent 270-degree posterior fundoplication identified nine patients with aperistalsis. Five (56%) of these patients had dysphagia pre-operatively, and two of six (33%) had long-term dysphagia.17

A retrospective study of patients undergoing Nissen fundoplication for gastro-oesophageal reflux identified 15 patients with functional oesophagogastric junction (OGJ) outflow obstruction diagnosed with manometry and 196 control patients. At one year after surgery, there was no difference in rates of dysphagia or proportion of patients requiring dilatation for dysphagia (13.3% vs 13.8%).18

Some surgeons may not consider these rates of post-operative chest pain or dysphagia acceptable. Thus identification of high amplitude peristaltic contractions, aperistalsis or functional OGJ outflow obstruction may still be deemed necessary by some surgeons if anti-reflux surgery is being considered.

Unexpectedly in our series, dysphagia was more common in patients with hypertensive LOS with complete relaxation (minor disorder of motility) when compared to hypertensive LOS with incomplete relaxation (major disorder of motility). This latter group of patients has preserved peristalsis, and in the Chicago classification v3, it may be considered as OGJ outflow obstruction/incompletely expressed achalasia. It is important to detect these patients although the clinical significance and sequelae of non-mechanical OGJ outflow obstruction are unclear. In our cohort, six patients had hypertensive LOS with incomplete relaxation. Two of these had no follow up as their referral for manometry was external. One patient with no pre-manometry dysphagia had a hiatus hernia repair without fundoplication. He presented two years later with dysphagia and required endoscopic dilatation. Of the remaining three patients, one reported dysphagia on questionnaire. All three were treated with laparoscopic cardiomyotomy and partial fundoplication. None of these three patients had post-operative dysphagia and are all clinically improved (from chest pain and regurgitation in the two who never had dysphagia). Follow-up time was three months to eight years.

In a series of 16 patients with non-mechanical OGJ outflow obstruction diagnosed by high-resolution manometry, nine underwent intervention. Three patients had cardiomyotomy, three had pneumatic dilatation, two had Botox and one had standard dilatation.19 At 12 months, cardiomyotomy was effective in relieving symptoms in all three patients, and non-surgical intervention was ineffective in all six patients who had endoscopic treatment. Of all 16 patients, 15 (94%) had dysphagia prior to intervention.

A series from the Netherlands describes 34 patients with idiopathic OGJ outflow obstruction diagnosed by manometry. Of these patients, eight had typical achalasia symptoms (dysphagia was the dominant symptom in all).20 These eight patients were treated with Botox (five patients) and pneumatic dilatation (three patients). Follow-up time was 6 to 18 months. Patients treated with Botox all had a short-lived effect (symptom free for 6 to 10 months), while pneumatic dilatation was effective in one patient but not in two. Three of the eight patients in the treatment group developed achalasia between 11 and 18 months, and these three patients had intact peristalsis on index manometry.

Idiopathic OGJ outflow obstruction includes a spectrum of symptoms and has an unpredictable progression to achalasia. In our series, although cardiomyotomy was effective in symptom relief, only one of four patients had dysphagia initially. The patient who had a hiatus hernia repair (and no pre-operative dysphagia) took two years to develop dysphagia; this time period suggests a loss of peristalsis and possible progression to achalasia, although manometry was not repeated.

In our series, each diagnosis had a distinctive pattern of symptom frequency except for normal/minor disorders of motility (hypertensive LOS with complete relaxation, non-specific dysmotility) (Figure 1).

Other approaches to identify patients with major disorders of peristalsis have been employed. A study of 431 patients aimed to establish whether contrast swallow could identify patients with disorders of peristalsis that would change the operative plan of a surgeon.21 These authors reported that, if a major motility disorder was present, the contrast swallow was abnormal in 27 of 28 patients (sensitivity of 96.4%). Although their manometric criteria for diagnoses were consistent with the Chicago classification v3, these authors considered achalasia, absent contractility and ineffective oesophageal motility to be the only disorders that could alter surgical decision making. This conflicts with our consensus that OGJ outflow obstruction, hypercontractile (Jackhammer) oesophagus and diffuse oesophageal spasm are also potential contraindications to primary anti-reflux surgery (the Chicago classification v3 classifies these as major disorders of peristalsis). Thus, in this study by Alicuben and colleagues, if OGJ outflow obstruction, hypercontractile oesophagus and diffuse oesophageal spasm were considered major motility disorders, 49 of 60 patients with a major disorder of peristalsis had an abnormal contrast swallow, giving a sensitivity of 81.7% rather than the reported 96.4%.21

Strengths of our study include a standardised manometry protocol over the whole study period, analysis of a large number of patients, with 33 having a major disorder of motility, and constant diagnostic criteria for the whole study period. Manometry interpretation was performed by the same clinician for the whole study period.

There are limitations of our study. Oesophageal manometry was conventional water perfusion manometry and not high-resolution manometry. Despite this, we are not aware of any mis-diagnoses in this patient cohort. The retrospective nature of our study could potentially introduce bias, although in all cases the questionnaire was performed prior to manometric diagnosis. The study is also limited by the inherent weakness of any symptom-based questionnaire. It is possible that a different type of questionnaire may be of higher yield. However, this is not yet established. The majority of patients in our study had oesophageal manometry performed as routine work up prior to consideration of anti-reflux surgery. The low number of major motility disorders likely reflects the referral pattern for the service.

In our study, dysphagia as a symptom or in response to a bread challenge had a sensitivity of 94% in identifying a major disorder of oesophageal motility. Thus, if there is a need to exclude such a condition prior to anti-reflux surgery when access to oesophageal manometry is limited (eg, Christchurch is the only centre on the South Island of New Zealand where manometry is available), a symptom questionnaire, bread challenge and contrast swallow may be acceptable.

Summary

Abstract

AIM: This study aimed to determine whether symptoms can reliably predict a major disorder of oesophageal motility as assessed by conventional water perfusion manometry. METHODS: Data from patients who underwent conventional water perfusion oesophageal manometry and a pre-manometry questionnaire between October 1998 and August 2018 were extracted from a database. Clinical features (dysphagia, chest pain, regurgitation, dysphagia to a bread challenge) and combinations of these clinical features were compared to manometric diagnoses. RESULTS: Data from 546 patients were analysed. Thirty-three (6%) patients had a major disorder of motility, and 513 (94%) had normal manometry or a minor disorder of motility. ‘Any dysphagia’ (dysphagia as a symptom or dysphagia to a bread challenge) or ‘chest pain’ was experienced by all patients with a major disorder of motility and 435 of 513 patients with normal manometry or a minor disorder of motility (p=0.009). Sensitivity was 100%, and specificity was 15%, in identifying patients with a major disorder of motility using symptom combinations and a bread challenge. CONCLUSION: Symptoms and provoked dysphagia to bread were able to predict patients with a major disorder of oesophageal motility with a sensitivity of 100%. However, as specificity was 15%, confirmation with manometry is indicated if possible.

Aim

Method

Results

Conclusion

Author Information

Conrad Stranz: Oesophagogastric Surgical Unit, Royal Adelaide Hospital, Australia. Thomas Watkinson: Department of Upper GI Surgery, Queen Elizabeth Hospital, United Kingdom. Andrea Cross: Department of General Surgery, Canterbury District Health Board, New Zealand. Peter Hamer: Department of General Surgery, Central Coast Local Health District, Australia. Ross Roberts: Department of General Surgery, Canterbury District Health Board, New Zealand.

Acknowledgements

We thank Ms Debbie Osborn and Dr Bruce Dobbs for technical assistance.

Correspondence

Conrad Stranz, Oesophagogastric Surgical Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia 5000, Australia, +61 8 7074 0000 (phone), +61 8 7074 6193 (fax)

Correspondence Email

conrad.stranz@gmail.com

Competing Interests

Nil.

1. Patti MG, Gorodner MV, Galvani C, et al. Spectrum of esophageal motility disorders: implications for diagnosis and treatment. Arch Surg 2005; 140 (5): 442-448.

2. Rohof WOA, Bredenoord AJ. Chicago classification of esophageal motility disorders: lessons learned. Curr Gastroenterol Rep 2017; 19: 37.

3. Richter JE. Oesophageal motility disorders. Lancet. 2001; 358: 823-828.

4. ASGE Technology Committee, Wang A, Pleskow DK, et al. Esophageal function testing. Gastrointest Endosc 2012; 76 (2): 231-243.

5. Wang K, Duan L, Ge Y, et al. A comparative study of 22-channel water-perfusion system and solid-state system with 36-sensors in esophageal manometry. BMC Gastroenterology 2012 12:157.

6. Fibbe C, Layer P, Keller J, et al. Esophageal motility in reflux disease before and after fundoplication: A prospective, randomized, clinical and manometric study. Gastroenterology 2001; 121 (1): 5-14.

7. Akyüz F, Arici S, Ermis F, Mungan Z. Utility of esophageal manometry and pH-metry in gastroesophageal reflux disease before surgery. Turk J Gastroenterol 2009; 20 (4): 261-265.

8. Frantzides CT, Carlson MA, Madan AK, et al. Selective use of esophageal manometry and 24-hour pH monitoring before laparoscopic fundoplication. J Am Coll Surg 2003; 197 (3): 358-363.

9. Riedl O, Gadenstätter M, Lechner W, et al. Preoperative lower esophageal sphincter manometry data neither impact manifestations of GERD nor outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg 2009; 13 (7): 1189-1197.

10. Ferri LE, Cools-Lartigue J, Cao J, et al. Clinical predictors of achalasia. Dis Esophagus 2010; 23 (1): 76-81.

11. Howard PJ, Maher L, Pryde A, et al. Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. Gut 1992; 33 (8): 1011-1015.

12. d’Alteroche L, Oung C, Fourquet F, et al. Evolution of clinical and radiological features at diagnosis of achalasia during a 19-year period in central France. Eur J Gastroenterol Hepatol 2001; 13 (2): 121-126.

13. Eckardt VF. Clinical presentation and complications of achalasia. Gastrointest Endosc Clin N Am 2001; 11 (2): 281-292.

14. Bollschweiler E, Knoppe K, Wolfgarten E, Hölscher AH. Prevalence of dysphagia in patients with gastroesophageal reflux in Germany. Dysphagia 2008; 23 (2): 172-176.

15. Eslick GE. Non-cardiac chest pain: epidemiology and natural history, health care seeking and quality of life. Gastroenterol Clin North Am 2004; 33: 1-23.

16. Barreca M, Oelschlager BK, Pellegrini CA. Outcomes of laparoscopic Nissen fundoplication in patients with the “hypercontractile esophagus”. Arch Surg 2002; 137: 724-729.

17. Armijo PR, Hennings D, Leon M, et al. Surgical management of gastroesophageal reflux disease in patients with severe esophageal dysmotility. J Gastrointest Surg 2019; 23: 36-42.

18. Switzer NJ, Holcomb C, Jalviland AD, et al. Laparoscopic Nissen fundoplication improves disease‐specific quality of life in patients with gastroesophageal reflux disease and functional gastroesophageal outflow obstruction. Surg Endosc 2020; 34 (6): 2608-2612.

19. Scherer JR, Kwiatek MA, Soper NJ, et al. Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia. J Gastrointest Surg 2009; 13 (12): 2219-2225.

20. Van Hoeij FB, Smout AJ, Bredenoord AJ. Characterization of idiopathic esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2015; 27 (9): 1310-1316.

21. Alicuben ET, Bildzukewicz N, Samakar K, et al. Routine esophageal manometry is not useful in patients with normal videoesophagram. Surg Endosc 2019; 33 (5): 1650-1653.

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Oesophageal manometry is the investigation of choice for assessment of motor function of the oesophagus.1 It can be performed to identify patients with a major disorder of motility, if this is suspected, or to help decide whether a patient is appropriate for anti-reflux surgery. The Chicago classification has been developed to aid analysis and interpretation of high-resolution manometry.2 Prior to high resolution manometry and the Chicago classification, despite there being no universally accepted classification of motility disorders, certain conditions were well described (Table 1).3

Table 1: Criteria for disorders of motility with conventional water perfusion manometry (major disorders of motility above red line).3

OGJ: Oesophagogastric junction; LOS: Lower oesophageal sphincter.

Limited access to oesophageal manometry can result in delays to diagnosis and treatment for major motility disorders of the oesophagus as well as anti-reflux surgery. Because high resolution manometry is not readily available globally and is more expensive to set up and maintain,4 conventional water perfusion manometry retains a role in assessing oesophageal motility. A comparative study of water perfusion and solid-state systems for oesophageal manometry concluded that most pressure measurements were consistent between the two systems. Patient tolerance was better for water perfusion manometry.5

Authors have advocated manometry both routinely and selectively prior to anti-reflux surgery.6–9 However, criteria for selective use of manometry are not clearly defined. A thorough history is mandatory and may increase clinical suspicion of gastro-oesophageal reflux or a primary motility disorder.

In patients being assessed for dysphagia, a symptom questionnaire along with contrast radiography and gastroscopy can help predict the diagnosis of achalasia.10

This study aimed to determine whether symptoms can reliably predict a major disorder of oesophageal motility as assessed by conventional water perfusion manometry.

Methods

The need for formal ethics approval was waived by the Health and Disability Ethics Committee (HDEC), Ministry of Health, New Zealand.

De-identified data from all patients who underwent conventional water perfusion oesophageal manometry and a pre-manometry questionnaire between October 1998 and August 2018 were extracted from a database. Data included demographic data (age, sex), oesophageal manometry results and responses to a pre-manometry questionnaire.

Oesophageal manometry was performed using a standardised protocol. Patients fasted for six hours prior to manometry. Acid suppression medications were not withheld. A water perfused system with an eight-lumen catheter assembly was used (Mui Scientific, Mississauga, Canada). The proximal side hole is 6cm from the second side hole. The next four side holes are spaced at 5cm increments. A 6cm sleeve sensor and a distal side hole then follow. The catheter assembly was connected to a pressure transducer/perfusion pump unit (Dentsleeve Mark II, Mui Scientific, Mississauga, Canada). This unit was connected to a polygraph (PC Polygraph HR, Synectics Medical, Enfield, UK), which emits a trace for subsequent computer software analysis (POLYGRAM for Windows, Version 2.04, Synectics Medical, Enfield, UK).

With patients sitting upright, the catheter was passed trans-nasally into the stomach, and deep inspiration was performed to determine the location of the diaphragm. In a left lateral position, the high-pressure zone of the lower oesophageal sphincter (LOS) was identified by performing a station pull-through. With the distal side hole in the stomach and the sleeve sensor over the LOS, the catheter was fixed.

Patients took ten syringe-administered 5mL water swallows, 30 seconds apart. This was followed by two consecutive dry bread swallows, recording symptoms of dysphagia or chest pain.

Oesophageal manometry results were reviewed by the senior author (RR) and each patient given one of ten diagnoses based on the criteria in Table 1.3 The diagnoses were categorised into two groups: (1) major disorders of motility and (2) minor disorders of motility/normal. The diagnostic criteria apply to conventional water perfusion manometry and pre-date the Chicago classification. For consistency, these diagnoses were unchanged for the study period. The conventional water perfusion manometry diagnoses have been correlated to the most alike high-resolution manometry diagnoses in the Chicago classification v3 (Table 2).

Table 2: Correlation of manometric diagnostic criteria between conventional water perfusion manometry and high-resolution manometry.

A questionnaire with 16 symptoms was completed immediately before manometry. Patients assigned a result of ‘never’, ‘occasionally’ or ‘frequently’ to each symptom by checking a box.

Achalasia was selected as a model of a well described major motility disorder of the oesophagus that has negative clinical outcomes if left untreated. A literature review was performed to identify the most common symptoms in achalasia as dysphagia (92–100%), regurgitation (59–87%) and chest pain (42–74%).11–13

Thus the patient questionnaire responses to the three symptoms, dysphagia, regurgitation, and chest pain, were analysed. The exact words printed on the questionnaire were ‘difficulty in swallowing’, ‘regurgitation’ and ‘chest pain’.

Data also included whether patients were dysphagic to a bread challenge (observed at time of manometry). These data were collected for analysis if available. Questionnaire responses of ‘occasionally’ or ‘frequently’ to each of the three symptoms resulted in that symptom being considered present. A fourth clinical category, ‘any dysphagia’, described patients with either dysphagia symptoms (occasional or frequent) or dysphagia to a bread challenge.

The presence of each of the four clinical features was compared between the two diagnostic categories (major disorders of motility and minor disorders of motility/normal).

Permutations of clinical features using ‘or’ as a function were analysed (eg, ‘any dysphagia’ or ‘chest pain’), generating seven possible clinical feature combinations (Table 3). The presence of clinical feature combinations was compared between the two diagnostic categories.

Comparisons were performed using Fisher’s exact test and Pearson’s Chi-Squared test. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 25 (IBM Corp, Armonk, NY, USA). A p-value <0.05 was considered statistically significant.

Table 3: Major disorders of motility; clinical features in isolation and in combination using ‘or’ function.

Results

Data were available for 555 patients. Eight patients had a history of anti-reflux surgery, and one patient had incomplete manometry results. These patients were excluded, leaving 546 patients eligible for analysis. An audit of indications for manometry for the study period showed that 78% of manometry studies were performed as routine assessment prior to fundoplication, and 22% were undertaken to investigate patient symptoms.

Thirty-three (6%) patients had a major disorder of motility, and 513 (94%) had normal manometry or a minor disorder of peristalsis (Tables 1 and 2).

There was no statistically significant difference between patients with a major disorder of motility when compared to those with a minor disorder of motility/normal, when assessed for age or sex. The median age of patients with a major disorder of motility was 56 years compared to 50 years in patients with a minor disorder of motility/normal (p=0.384). Thirteen of 33 (39.4%) patients with a major disorder of motility were male compared to 266 of 513 (51.9%) patients with a minor disorder of motility/normal (p=0.209).

In all patients having oesophageal manometry, on the questionnaire 286 of 546 (52%) reported dysphagia as either occasional or frequent.

All 16 patients with achalasia diagnosed on manometry reported dysphagia as a symptom, and of these, 15 had frequent dysphagia (Figure 1). Of 530 patients without achalasia, 270 (51%) had symptoms of dysphagia. The presence of dysphagia as a symptom in patients with achalasia was statistically significant when compared to dysphagia in patients without achalasia (p<0.001).

Dysphagia was not universal in patients with aperistalsis, with three of four patients with aperistalsis reporting dysphagia.

Rates of dysphagia as a symptom and ‘any dysphagia’ (as a symptom or provoked with bread) were higher in patients with a major disorder of motility (dysphagia in 27/33 (82%) patients, ‘any dysphagia’ in 31/33 (94%) patients), in comparison to patients with a minor disorder of motility/normal (dysphagia in 259/513 (50%) patients, ‘any dysphagia’ in 301/513 (59%) patients). This was statistically significant (dysphagia p<0.001; ‘any dysphagia’ p<0.001). Dysphagia as a symptom was 82% sensitive, and ‘any dysphagia’ was 94% sensitive in identifying a major disorder of oesophageal motility. Specificity was 50% for dysphagia as a symptom and 41% for ‘any dysphagia’ (Table 3).

Chest pain was reported by 338 of 513 (66%) patients with a minor disorder of motility/normal and 26 of 33 (79%) patients with a major disorder of motility (p=0.181).

Regurgitation was present in 435 of 513 (85%) patients with a minor disorder of motility/normal and 25 of 33 (76%) of patients with a major disorder of motility (p=0.213).

The presence of any dysphagia or chest pain was 100% sensitive in identifying patients with a major disorder of motility. Specificity was 15% with 435 of 513 patients with a minor disorder of motility/normal also having dysphagia as a symptom, dysphagia to a bread challenge or chest pain. This was statistically significant (p=0.009) (Table 3).

Figure 1: Symptom frequency in oesophageal motility disorders.

Discussion

In our study, dysphagia was the most reliable clinical feature in identifying a major disorder of oesophageal motility, with a sensitivity of 94% (dysphagia as a symptom or in response to a bread challenge). Adding chest pain with an ‘or’ function increased sensitivity to 100% but with a sacrifice in specificity.

We have also shown that dysphagia is reported by all patients with achalasia. This is consistent with international series of achalasia patients where rates of dysphagia are 92–100%11–13

Dysphagia was also reported by more than half of all patients undergoing conventional water perfusion oesophageal manometry. Chest pain (67%) and regurgitation (84%) were common in all patients undergoing oesophageal manometry for all indications. In isolation, these latter two symptoms were poor at discriminating between a major disorder of motility and normal motility.

Our data regarding dysphagia, chest pain and regurgitation are in keeping with international literature. A population-based study from Cologne using a questionnaire showed that 65% of those with moderate to severe reflux symptoms reported additional dysphagia symptoms.14 In a further population based study, 53% and 58% of patients with non-cardiac chest pain also had heartburn and regurgitation respectively.15

If manometry is performed as part of the work up for anti-reflux surgery, excluding achalasia is important. Rather than fundoplication in isolation, achalasia patients are better served by cardiomyotomy as well. There has also been increasing use of POEM (PerOral Endoscopic Myotomy) for achalasia as an alternative to laparoscopic myotomy and partial fundoplication. The implications of other major disorders of motility are less clear.

In a study of 15 patients with high amplitude peristaltic contractions (≥150mmHg) who underwent Nissen fundoplication, 27% developed new dysphagia or new chest pain. The authors concluded that new chest pain, which occurred in three patients (20%), should be discussed with patients preoperatively, but that high amplitude peristaltic contractions were not a contraindication to Nissen fundoplication.16

A manometry database of patients with gastro-oesophageal reflux who underwent 270-degree posterior fundoplication identified nine patients with aperistalsis. Five (56%) of these patients had dysphagia pre-operatively, and two of six (33%) had long-term dysphagia.17

A retrospective study of patients undergoing Nissen fundoplication for gastro-oesophageal reflux identified 15 patients with functional oesophagogastric junction (OGJ) outflow obstruction diagnosed with manometry and 196 control patients. At one year after surgery, there was no difference in rates of dysphagia or proportion of patients requiring dilatation for dysphagia (13.3% vs 13.8%).18

Some surgeons may not consider these rates of post-operative chest pain or dysphagia acceptable. Thus identification of high amplitude peristaltic contractions, aperistalsis or functional OGJ outflow obstruction may still be deemed necessary by some surgeons if anti-reflux surgery is being considered.

Unexpectedly in our series, dysphagia was more common in patients with hypertensive LOS with complete relaxation (minor disorder of motility) when compared to hypertensive LOS with incomplete relaxation (major disorder of motility). This latter group of patients has preserved peristalsis, and in the Chicago classification v3, it may be considered as OGJ outflow obstruction/incompletely expressed achalasia. It is important to detect these patients although the clinical significance and sequelae of non-mechanical OGJ outflow obstruction are unclear. In our cohort, six patients had hypertensive LOS with incomplete relaxation. Two of these had no follow up as their referral for manometry was external. One patient with no pre-manometry dysphagia had a hiatus hernia repair without fundoplication. He presented two years later with dysphagia and required endoscopic dilatation. Of the remaining three patients, one reported dysphagia on questionnaire. All three were treated with laparoscopic cardiomyotomy and partial fundoplication. None of these three patients had post-operative dysphagia and are all clinically improved (from chest pain and regurgitation in the two who never had dysphagia). Follow-up time was three months to eight years.

In a series of 16 patients with non-mechanical OGJ outflow obstruction diagnosed by high-resolution manometry, nine underwent intervention. Three patients had cardiomyotomy, three had pneumatic dilatation, two had Botox and one had standard dilatation.19 At 12 months, cardiomyotomy was effective in relieving symptoms in all three patients, and non-surgical intervention was ineffective in all six patients who had endoscopic treatment. Of all 16 patients, 15 (94%) had dysphagia prior to intervention.

A series from the Netherlands describes 34 patients with idiopathic OGJ outflow obstruction diagnosed by manometry. Of these patients, eight had typical achalasia symptoms (dysphagia was the dominant symptom in all).20 These eight patients were treated with Botox (five patients) and pneumatic dilatation (three patients). Follow-up time was 6 to 18 months. Patients treated with Botox all had a short-lived effect (symptom free for 6 to 10 months), while pneumatic dilatation was effective in one patient but not in two. Three of the eight patients in the treatment group developed achalasia between 11 and 18 months, and these three patients had intact peristalsis on index manometry.

Idiopathic OGJ outflow obstruction includes a spectrum of symptoms and has an unpredictable progression to achalasia. In our series, although cardiomyotomy was effective in symptom relief, only one of four patients had dysphagia initially. The patient who had a hiatus hernia repair (and no pre-operative dysphagia) took two years to develop dysphagia; this time period suggests a loss of peristalsis and possible progression to achalasia, although manometry was not repeated.

In our series, each diagnosis had a distinctive pattern of symptom frequency except for normal/minor disorders of motility (hypertensive LOS with complete relaxation, non-specific dysmotility) (Figure 1).

Other approaches to identify patients with major disorders of peristalsis have been employed. A study of 431 patients aimed to establish whether contrast swallow could identify patients with disorders of peristalsis that would change the operative plan of a surgeon.21 These authors reported that, if a major motility disorder was present, the contrast swallow was abnormal in 27 of 28 patients (sensitivity of 96.4%). Although their manometric criteria for diagnoses were consistent with the Chicago classification v3, these authors considered achalasia, absent contractility and ineffective oesophageal motility to be the only disorders that could alter surgical decision making. This conflicts with our consensus that OGJ outflow obstruction, hypercontractile (Jackhammer) oesophagus and diffuse oesophageal spasm are also potential contraindications to primary anti-reflux surgery (the Chicago classification v3 classifies these as major disorders of peristalsis). Thus, in this study by Alicuben and colleagues, if OGJ outflow obstruction, hypercontractile oesophagus and diffuse oesophageal spasm were considered major motility disorders, 49 of 60 patients with a major disorder of peristalsis had an abnormal contrast swallow, giving a sensitivity of 81.7% rather than the reported 96.4%.21

Strengths of our study include a standardised manometry protocol over the whole study period, analysis of a large number of patients, with 33 having a major disorder of motility, and constant diagnostic criteria for the whole study period. Manometry interpretation was performed by the same clinician for the whole study period.

There are limitations of our study. Oesophageal manometry was conventional water perfusion manometry and not high-resolution manometry. Despite this, we are not aware of any mis-diagnoses in this patient cohort. The retrospective nature of our study could potentially introduce bias, although in all cases the questionnaire was performed prior to manometric diagnosis. The study is also limited by the inherent weakness of any symptom-based questionnaire. It is possible that a different type of questionnaire may be of higher yield. However, this is not yet established. The majority of patients in our study had oesophageal manometry performed as routine work up prior to consideration of anti-reflux surgery. The low number of major motility disorders likely reflects the referral pattern for the service.

In our study, dysphagia as a symptom or in response to a bread challenge had a sensitivity of 94% in identifying a major disorder of oesophageal motility. Thus, if there is a need to exclude such a condition prior to anti-reflux surgery when access to oesophageal manometry is limited (eg, Christchurch is the only centre on the South Island of New Zealand where manometry is available), a symptom questionnaire, bread challenge and contrast swallow may be acceptable.

Summary

Abstract

AIM: This study aimed to determine whether symptoms can reliably predict a major disorder of oesophageal motility as assessed by conventional water perfusion manometry. METHODS: Data from patients who underwent conventional water perfusion oesophageal manometry and a pre-manometry questionnaire between October 1998 and August 2018 were extracted from a database. Clinical features (dysphagia, chest pain, regurgitation, dysphagia to a bread challenge) and combinations of these clinical features were compared to manometric diagnoses. RESULTS: Data from 546 patients were analysed. Thirty-three (6%) patients had a major disorder of motility, and 513 (94%) had normal manometry or a minor disorder of motility. ‘Any dysphagia’ (dysphagia as a symptom or dysphagia to a bread challenge) or ‘chest pain’ was experienced by all patients with a major disorder of motility and 435 of 513 patients with normal manometry or a minor disorder of motility (p=0.009). Sensitivity was 100%, and specificity was 15%, in identifying patients with a major disorder of motility using symptom combinations and a bread challenge. CONCLUSION: Symptoms and provoked dysphagia to bread were able to predict patients with a major disorder of oesophageal motility with a sensitivity of 100%. However, as specificity was 15%, confirmation with manometry is indicated if possible.

Aim

Method

Results

Conclusion

Author Information

Conrad Stranz: Oesophagogastric Surgical Unit, Royal Adelaide Hospital, Australia. Thomas Watkinson: Department of Upper GI Surgery, Queen Elizabeth Hospital, United Kingdom. Andrea Cross: Department of General Surgery, Canterbury District Health Board, New Zealand. Peter Hamer: Department of General Surgery, Central Coast Local Health District, Australia. Ross Roberts: Department of General Surgery, Canterbury District Health Board, New Zealand.

Acknowledgements

We thank Ms Debbie Osborn and Dr Bruce Dobbs for technical assistance.

Correspondence

Conrad Stranz, Oesophagogastric Surgical Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia 5000, Australia, +61 8 7074 0000 (phone), +61 8 7074 6193 (fax)

Correspondence Email

conrad.stranz@gmail.com

Competing Interests

Nil.

1. Patti MG, Gorodner MV, Galvani C, et al. Spectrum of esophageal motility disorders: implications for diagnosis and treatment. Arch Surg 2005; 140 (5): 442-448.

2. Rohof WOA, Bredenoord AJ. Chicago classification of esophageal motility disorders: lessons learned. Curr Gastroenterol Rep 2017; 19: 37.

3. Richter JE. Oesophageal motility disorders. Lancet. 2001; 358: 823-828.

4. ASGE Technology Committee, Wang A, Pleskow DK, et al. Esophageal function testing. Gastrointest Endosc 2012; 76 (2): 231-243.

5. Wang K, Duan L, Ge Y, et al. A comparative study of 22-channel water-perfusion system and solid-state system with 36-sensors in esophageal manometry. BMC Gastroenterology 2012 12:157.

6. Fibbe C, Layer P, Keller J, et al. Esophageal motility in reflux disease before and after fundoplication: A prospective, randomized, clinical and manometric study. Gastroenterology 2001; 121 (1): 5-14.

7. Akyüz F, Arici S, Ermis F, Mungan Z. Utility of esophageal manometry and pH-metry in gastroesophageal reflux disease before surgery. Turk J Gastroenterol 2009; 20 (4): 261-265.

8. Frantzides CT, Carlson MA, Madan AK, et al. Selective use of esophageal manometry and 24-hour pH monitoring before laparoscopic fundoplication. J Am Coll Surg 2003; 197 (3): 358-363.

9. Riedl O, Gadenstätter M, Lechner W, et al. Preoperative lower esophageal sphincter manometry data neither impact manifestations of GERD nor outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg 2009; 13 (7): 1189-1197.

10. Ferri LE, Cools-Lartigue J, Cao J, et al. Clinical predictors of achalasia. Dis Esophagus 2010; 23 (1): 76-81.

11. Howard PJ, Maher L, Pryde A, et al. Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. Gut 1992; 33 (8): 1011-1015.

12. d’Alteroche L, Oung C, Fourquet F, et al. Evolution of clinical and radiological features at diagnosis of achalasia during a 19-year period in central France. Eur J Gastroenterol Hepatol 2001; 13 (2): 121-126.

13. Eckardt VF. Clinical presentation and complications of achalasia. Gastrointest Endosc Clin N Am 2001; 11 (2): 281-292.

14. Bollschweiler E, Knoppe K, Wolfgarten E, Hölscher AH. Prevalence of dysphagia in patients with gastroesophageal reflux in Germany. Dysphagia 2008; 23 (2): 172-176.

15. Eslick GE. Non-cardiac chest pain: epidemiology and natural history, health care seeking and quality of life. Gastroenterol Clin North Am 2004; 33: 1-23.

16. Barreca M, Oelschlager BK, Pellegrini CA. Outcomes of laparoscopic Nissen fundoplication in patients with the “hypercontractile esophagus”. Arch Surg 2002; 137: 724-729.

17. Armijo PR, Hennings D, Leon M, et al. Surgical management of gastroesophageal reflux disease in patients with severe esophageal dysmotility. J Gastrointest Surg 2019; 23: 36-42.

18. Switzer NJ, Holcomb C, Jalviland AD, et al. Laparoscopic Nissen fundoplication improves disease‐specific quality of life in patients with gastroesophageal reflux disease and functional gastroesophageal outflow obstruction. Surg Endosc 2020; 34 (6): 2608-2612.

19. Scherer JR, Kwiatek MA, Soper NJ, et al. Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia. J Gastrointest Surg 2009; 13 (12): 2219-2225.

20. Van Hoeij FB, Smout AJ, Bredenoord AJ. Characterization of idiopathic esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2015; 27 (9): 1310-1316.

21. Alicuben ET, Bildzukewicz N, Samakar K, et al. Routine esophageal manometry is not useful in patients with normal videoesophagram. Surg Endosc 2019; 33 (5): 1650-1653.

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Oesophageal manometry is the investigation of choice for assessment of motor function of the oesophagus.1 It can be performed to identify patients with a major disorder of motility, if this is suspected, or to help decide whether a patient is appropriate for anti-reflux surgery. The Chicago classification has been developed to aid analysis and interpretation of high-resolution manometry.2 Prior to high resolution manometry and the Chicago classification, despite there being no universally accepted classification of motility disorders, certain conditions were well described (Table 1).3

Table 1: Criteria for disorders of motility with conventional water perfusion manometry (major disorders of motility above red line).3

OGJ: Oesophagogastric junction; LOS: Lower oesophageal sphincter.

Limited access to oesophageal manometry can result in delays to diagnosis and treatment for major motility disorders of the oesophagus as well as anti-reflux surgery. Because high resolution manometry is not readily available globally and is more expensive to set up and maintain,4 conventional water perfusion manometry retains a role in assessing oesophageal motility. A comparative study of water perfusion and solid-state systems for oesophageal manometry concluded that most pressure measurements were consistent between the two systems. Patient tolerance was better for water perfusion manometry.5

Authors have advocated manometry both routinely and selectively prior to anti-reflux surgery.6–9 However, criteria for selective use of manometry are not clearly defined. A thorough history is mandatory and may increase clinical suspicion of gastro-oesophageal reflux or a primary motility disorder.

In patients being assessed for dysphagia, a symptom questionnaire along with contrast radiography and gastroscopy can help predict the diagnosis of achalasia.10

This study aimed to determine whether symptoms can reliably predict a major disorder of oesophageal motility as assessed by conventional water perfusion manometry.

Methods

The need for formal ethics approval was waived by the Health and Disability Ethics Committee (HDEC), Ministry of Health, New Zealand.

De-identified data from all patients who underwent conventional water perfusion oesophageal manometry and a pre-manometry questionnaire between October 1998 and August 2018 were extracted from a database. Data included demographic data (age, sex), oesophageal manometry results and responses to a pre-manometry questionnaire.

Oesophageal manometry was performed using a standardised protocol. Patients fasted for six hours prior to manometry. Acid suppression medications were not withheld. A water perfused system with an eight-lumen catheter assembly was used (Mui Scientific, Mississauga, Canada). The proximal side hole is 6cm from the second side hole. The next four side holes are spaced at 5cm increments. A 6cm sleeve sensor and a distal side hole then follow. The catheter assembly was connected to a pressure transducer/perfusion pump unit (Dentsleeve Mark II, Mui Scientific, Mississauga, Canada). This unit was connected to a polygraph (PC Polygraph HR, Synectics Medical, Enfield, UK), which emits a trace for subsequent computer software analysis (POLYGRAM for Windows, Version 2.04, Synectics Medical, Enfield, UK).

With patients sitting upright, the catheter was passed trans-nasally into the stomach, and deep inspiration was performed to determine the location of the diaphragm. In a left lateral position, the high-pressure zone of the lower oesophageal sphincter (LOS) was identified by performing a station pull-through. With the distal side hole in the stomach and the sleeve sensor over the LOS, the catheter was fixed.

Patients took ten syringe-administered 5mL water swallows, 30 seconds apart. This was followed by two consecutive dry bread swallows, recording symptoms of dysphagia or chest pain.

Oesophageal manometry results were reviewed by the senior author (RR) and each patient given one of ten diagnoses based on the criteria in Table 1.3 The diagnoses were categorised into two groups: (1) major disorders of motility and (2) minor disorders of motility/normal. The diagnostic criteria apply to conventional water perfusion manometry and pre-date the Chicago classification. For consistency, these diagnoses were unchanged for the study period. The conventional water perfusion manometry diagnoses have been correlated to the most alike high-resolution manometry diagnoses in the Chicago classification v3 (Table 2).

Table 2: Correlation of manometric diagnostic criteria between conventional water perfusion manometry and high-resolution manometry.

A questionnaire with 16 symptoms was completed immediately before manometry. Patients assigned a result of ‘never’, ‘occasionally’ or ‘frequently’ to each symptom by checking a box.

Achalasia was selected as a model of a well described major motility disorder of the oesophagus that has negative clinical outcomes if left untreated. A literature review was performed to identify the most common symptoms in achalasia as dysphagia (92–100%), regurgitation (59–87%) and chest pain (42–74%).11–13

Thus the patient questionnaire responses to the three symptoms, dysphagia, regurgitation, and chest pain, were analysed. The exact words printed on the questionnaire were ‘difficulty in swallowing’, ‘regurgitation’ and ‘chest pain’.

Data also included whether patients were dysphagic to a bread challenge (observed at time of manometry). These data were collected for analysis if available. Questionnaire responses of ‘occasionally’ or ‘frequently’ to each of the three symptoms resulted in that symptom being considered present. A fourth clinical category, ‘any dysphagia’, described patients with either dysphagia symptoms (occasional or frequent) or dysphagia to a bread challenge.

The presence of each of the four clinical features was compared between the two diagnostic categories (major disorders of motility and minor disorders of motility/normal).

Permutations of clinical features using ‘or’ as a function were analysed (eg, ‘any dysphagia’ or ‘chest pain’), generating seven possible clinical feature combinations (Table 3). The presence of clinical feature combinations was compared between the two diagnostic categories.

Comparisons were performed using Fisher’s exact test and Pearson’s Chi-Squared test. Statistical analysis was performed using IBM SPSS Statistics for Windows, version 25 (IBM Corp, Armonk, NY, USA). A p-value <0.05 was considered statistically significant.

Table 3: Major disorders of motility; clinical features in isolation and in combination using ‘or’ function.

Results

Data were available for 555 patients. Eight patients had a history of anti-reflux surgery, and one patient had incomplete manometry results. These patients were excluded, leaving 546 patients eligible for analysis. An audit of indications for manometry for the study period showed that 78% of manometry studies were performed as routine assessment prior to fundoplication, and 22% were undertaken to investigate patient symptoms.

Thirty-three (6%) patients had a major disorder of motility, and 513 (94%) had normal manometry or a minor disorder of peristalsis (Tables 1 and 2).

There was no statistically significant difference between patients with a major disorder of motility when compared to those with a minor disorder of motility/normal, when assessed for age or sex. The median age of patients with a major disorder of motility was 56 years compared to 50 years in patients with a minor disorder of motility/normal (p=0.384). Thirteen of 33 (39.4%) patients with a major disorder of motility were male compared to 266 of 513 (51.9%) patients with a minor disorder of motility/normal (p=0.209).

In all patients having oesophageal manometry, on the questionnaire 286 of 546 (52%) reported dysphagia as either occasional or frequent.

All 16 patients with achalasia diagnosed on manometry reported dysphagia as a symptom, and of these, 15 had frequent dysphagia (Figure 1). Of 530 patients without achalasia, 270 (51%) had symptoms of dysphagia. The presence of dysphagia as a symptom in patients with achalasia was statistically significant when compared to dysphagia in patients without achalasia (p<0.001).

Dysphagia was not universal in patients with aperistalsis, with three of four patients with aperistalsis reporting dysphagia.

Rates of dysphagia as a symptom and ‘any dysphagia’ (as a symptom or provoked with bread) were higher in patients with a major disorder of motility (dysphagia in 27/33 (82%) patients, ‘any dysphagia’ in 31/33 (94%) patients), in comparison to patients with a minor disorder of motility/normal (dysphagia in 259/513 (50%) patients, ‘any dysphagia’ in 301/513 (59%) patients). This was statistically significant (dysphagia p<0.001; ‘any dysphagia’ p<0.001). Dysphagia as a symptom was 82% sensitive, and ‘any dysphagia’ was 94% sensitive in identifying a major disorder of oesophageal motility. Specificity was 50% for dysphagia as a symptom and 41% for ‘any dysphagia’ (Table 3).

Chest pain was reported by 338 of 513 (66%) patients with a minor disorder of motility/normal and 26 of 33 (79%) patients with a major disorder of motility (p=0.181).

Regurgitation was present in 435 of 513 (85%) patients with a minor disorder of motility/normal and 25 of 33 (76%) of patients with a major disorder of motility (p=0.213).

The presence of any dysphagia or chest pain was 100% sensitive in identifying patients with a major disorder of motility. Specificity was 15% with 435 of 513 patients with a minor disorder of motility/normal also having dysphagia as a symptom, dysphagia to a bread challenge or chest pain. This was statistically significant (p=0.009) (Table 3).

Figure 1: Symptom frequency in oesophageal motility disorders.

Discussion

In our study, dysphagia was the most reliable clinical feature in identifying a major disorder of oesophageal motility, with a sensitivity of 94% (dysphagia as a symptom or in response to a bread challenge). Adding chest pain with an ‘or’ function increased sensitivity to 100% but with a sacrifice in specificity.

We have also shown that dysphagia is reported by all patients with achalasia. This is consistent with international series of achalasia patients where rates of dysphagia are 92–100%11–13

Dysphagia was also reported by more than half of all patients undergoing conventional water perfusion oesophageal manometry. Chest pain (67%) and regurgitation (84%) were common in all patients undergoing oesophageal manometry for all indications. In isolation, these latter two symptoms were poor at discriminating between a major disorder of motility and normal motility.

Our data regarding dysphagia, chest pain and regurgitation are in keeping with international literature. A population-based study from Cologne using a questionnaire showed that 65% of those with moderate to severe reflux symptoms reported additional dysphagia symptoms.14 In a further population based study, 53% and 58% of patients with non-cardiac chest pain also had heartburn and regurgitation respectively.15

If manometry is performed as part of the work up for anti-reflux surgery, excluding achalasia is important. Rather than fundoplication in isolation, achalasia patients are better served by cardiomyotomy as well. There has also been increasing use of POEM (PerOral Endoscopic Myotomy) for achalasia as an alternative to laparoscopic myotomy and partial fundoplication. The implications of other major disorders of motility are less clear.

In a study of 15 patients with high amplitude peristaltic contractions (≥150mmHg) who underwent Nissen fundoplication, 27% developed new dysphagia or new chest pain. The authors concluded that new chest pain, which occurred in three patients (20%), should be discussed with patients preoperatively, but that high amplitude peristaltic contractions were not a contraindication to Nissen fundoplication.16

A manometry database of patients with gastro-oesophageal reflux who underwent 270-degree posterior fundoplication identified nine patients with aperistalsis. Five (56%) of these patients had dysphagia pre-operatively, and two of six (33%) had long-term dysphagia.17

A retrospective study of patients undergoing Nissen fundoplication for gastro-oesophageal reflux identified 15 patients with functional oesophagogastric junction (OGJ) outflow obstruction diagnosed with manometry and 196 control patients. At one year after surgery, there was no difference in rates of dysphagia or proportion of patients requiring dilatation for dysphagia (13.3% vs 13.8%).18

Some surgeons may not consider these rates of post-operative chest pain or dysphagia acceptable. Thus identification of high amplitude peristaltic contractions, aperistalsis or functional OGJ outflow obstruction may still be deemed necessary by some surgeons if anti-reflux surgery is being considered.

Unexpectedly in our series, dysphagia was more common in patients with hypertensive LOS with complete relaxation (minor disorder of motility) when compared to hypertensive LOS with incomplete relaxation (major disorder of motility). This latter group of patients has preserved peristalsis, and in the Chicago classification v3, it may be considered as OGJ outflow obstruction/incompletely expressed achalasia. It is important to detect these patients although the clinical significance and sequelae of non-mechanical OGJ outflow obstruction are unclear. In our cohort, six patients had hypertensive LOS with incomplete relaxation. Two of these had no follow up as their referral for manometry was external. One patient with no pre-manometry dysphagia had a hiatus hernia repair without fundoplication. He presented two years later with dysphagia and required endoscopic dilatation. Of the remaining three patients, one reported dysphagia on questionnaire. All three were treated with laparoscopic cardiomyotomy and partial fundoplication. None of these three patients had post-operative dysphagia and are all clinically improved (from chest pain and regurgitation in the two who never had dysphagia). Follow-up time was three months to eight years.

In a series of 16 patients with non-mechanical OGJ outflow obstruction diagnosed by high-resolution manometry, nine underwent intervention. Three patients had cardiomyotomy, three had pneumatic dilatation, two had Botox and one had standard dilatation.19 At 12 months, cardiomyotomy was effective in relieving symptoms in all three patients, and non-surgical intervention was ineffective in all six patients who had endoscopic treatment. Of all 16 patients, 15 (94%) had dysphagia prior to intervention.

A series from the Netherlands describes 34 patients with idiopathic OGJ outflow obstruction diagnosed by manometry. Of these patients, eight had typical achalasia symptoms (dysphagia was the dominant symptom in all).20 These eight patients were treated with Botox (five patients) and pneumatic dilatation (three patients). Follow-up time was 6 to 18 months. Patients treated with Botox all had a short-lived effect (symptom free for 6 to 10 months), while pneumatic dilatation was effective in one patient but not in two. Three of the eight patients in the treatment group developed achalasia between 11 and 18 months, and these three patients had intact peristalsis on index manometry.

Idiopathic OGJ outflow obstruction includes a spectrum of symptoms and has an unpredictable progression to achalasia. In our series, although cardiomyotomy was effective in symptom relief, only one of four patients had dysphagia initially. The patient who had a hiatus hernia repair (and no pre-operative dysphagia) took two years to develop dysphagia; this time period suggests a loss of peristalsis and possible progression to achalasia, although manometry was not repeated.

In our series, each diagnosis had a distinctive pattern of symptom frequency except for normal/minor disorders of motility (hypertensive LOS with complete relaxation, non-specific dysmotility) (Figure 1).

Other approaches to identify patients with major disorders of peristalsis have been employed. A study of 431 patients aimed to establish whether contrast swallow could identify patients with disorders of peristalsis that would change the operative plan of a surgeon.21 These authors reported that, if a major motility disorder was present, the contrast swallow was abnormal in 27 of 28 patients (sensitivity of 96.4%). Although their manometric criteria for diagnoses were consistent with the Chicago classification v3, these authors considered achalasia, absent contractility and ineffective oesophageal motility to be the only disorders that could alter surgical decision making. This conflicts with our consensus that OGJ outflow obstruction, hypercontractile (Jackhammer) oesophagus and diffuse oesophageal spasm are also potential contraindications to primary anti-reflux surgery (the Chicago classification v3 classifies these as major disorders of peristalsis). Thus, in this study by Alicuben and colleagues, if OGJ outflow obstruction, hypercontractile oesophagus and diffuse oesophageal spasm were considered major motility disorders, 49 of 60 patients with a major disorder of peristalsis had an abnormal contrast swallow, giving a sensitivity of 81.7% rather than the reported 96.4%.21

Strengths of our study include a standardised manometry protocol over the whole study period, analysis of a large number of patients, with 33 having a major disorder of motility, and constant diagnostic criteria for the whole study period. Manometry interpretation was performed by the same clinician for the whole study period.

There are limitations of our study. Oesophageal manometry was conventional water perfusion manometry and not high-resolution manometry. Despite this, we are not aware of any mis-diagnoses in this patient cohort. The retrospective nature of our study could potentially introduce bias, although in all cases the questionnaire was performed prior to manometric diagnosis. The study is also limited by the inherent weakness of any symptom-based questionnaire. It is possible that a different type of questionnaire may be of higher yield. However, this is not yet established. The majority of patients in our study had oesophageal manometry performed as routine work up prior to consideration of anti-reflux surgery. The low number of major motility disorders likely reflects the referral pattern for the service.

In our study, dysphagia as a symptom or in response to a bread challenge had a sensitivity of 94% in identifying a major disorder of oesophageal motility. Thus, if there is a need to exclude such a condition prior to anti-reflux surgery when access to oesophageal manometry is limited (eg, Christchurch is the only centre on the South Island of New Zealand where manometry is available), a symptom questionnaire, bread challenge and contrast swallow may be acceptable.

Summary

Abstract

AIM: This study aimed to determine whether symptoms can reliably predict a major disorder of oesophageal motility as assessed by conventional water perfusion manometry. METHODS: Data from patients who underwent conventional water perfusion oesophageal manometry and a pre-manometry questionnaire between October 1998 and August 2018 were extracted from a database. Clinical features (dysphagia, chest pain, regurgitation, dysphagia to a bread challenge) and combinations of these clinical features were compared to manometric diagnoses. RESULTS: Data from 546 patients were analysed. Thirty-three (6%) patients had a major disorder of motility, and 513 (94%) had normal manometry or a minor disorder of motility. ‘Any dysphagia’ (dysphagia as a symptom or dysphagia to a bread challenge) or ‘chest pain’ was experienced by all patients with a major disorder of motility and 435 of 513 patients with normal manometry or a minor disorder of motility (p=0.009). Sensitivity was 100%, and specificity was 15%, in identifying patients with a major disorder of motility using symptom combinations and a bread challenge. CONCLUSION: Symptoms and provoked dysphagia to bread were able to predict patients with a major disorder of oesophageal motility with a sensitivity of 100%. However, as specificity was 15%, confirmation with manometry is indicated if possible.

Aim

Method

Results

Conclusion

Author Information

Conrad Stranz: Oesophagogastric Surgical Unit, Royal Adelaide Hospital, Australia. Thomas Watkinson: Department of Upper GI Surgery, Queen Elizabeth Hospital, United Kingdom. Andrea Cross: Department of General Surgery, Canterbury District Health Board, New Zealand. Peter Hamer: Department of General Surgery, Central Coast Local Health District, Australia. Ross Roberts: Department of General Surgery, Canterbury District Health Board, New Zealand.

Acknowledgements

We thank Ms Debbie Osborn and Dr Bruce Dobbs for technical assistance.

Correspondence

Conrad Stranz, Oesophagogastric Surgical Unit, Royal Adelaide Hospital, Port Road, Adelaide, South Australia 5000, Australia, +61 8 7074 0000 (phone), +61 8 7074 6193 (fax)

Correspondence Email

conrad.stranz@gmail.com

Competing Interests

Nil.

1. Patti MG, Gorodner MV, Galvani C, et al. Spectrum of esophageal motility disorders: implications for diagnosis and treatment. Arch Surg 2005; 140 (5): 442-448.

2. Rohof WOA, Bredenoord AJ. Chicago classification of esophageal motility disorders: lessons learned. Curr Gastroenterol Rep 2017; 19: 37.

3. Richter JE. Oesophageal motility disorders. Lancet. 2001; 358: 823-828.

4. ASGE Technology Committee, Wang A, Pleskow DK, et al. Esophageal function testing. Gastrointest Endosc 2012; 76 (2): 231-243.

5. Wang K, Duan L, Ge Y, et al. A comparative study of 22-channel water-perfusion system and solid-state system with 36-sensors in esophageal manometry. BMC Gastroenterology 2012 12:157.

6. Fibbe C, Layer P, Keller J, et al. Esophageal motility in reflux disease before and after fundoplication: A prospective, randomized, clinical and manometric study. Gastroenterology 2001; 121 (1): 5-14.

7. Akyüz F, Arici S, Ermis F, Mungan Z. Utility of esophageal manometry and pH-metry in gastroesophageal reflux disease before surgery. Turk J Gastroenterol 2009; 20 (4): 261-265.

8. Frantzides CT, Carlson MA, Madan AK, et al. Selective use of esophageal manometry and 24-hour pH monitoring before laparoscopic fundoplication. J Am Coll Surg 2003; 197 (3): 358-363.

9. Riedl O, Gadenstätter M, Lechner W, et al. Preoperative lower esophageal sphincter manometry data neither impact manifestations of GERD nor outcome after laparoscopic Nissen fundoplication. J Gastrointest Surg 2009; 13 (7): 1189-1197.

10. Ferri LE, Cools-Lartigue J, Cao J, et al. Clinical predictors of achalasia. Dis Esophagus 2010; 23 (1): 76-81.

11. Howard PJ, Maher L, Pryde A, et al. Five year prospective study of the incidence, clinical features, and diagnosis of achalasia in Edinburgh. Gut 1992; 33 (8): 1011-1015.

12. d’Alteroche L, Oung C, Fourquet F, et al. Evolution of clinical and radiological features at diagnosis of achalasia during a 19-year period in central France. Eur J Gastroenterol Hepatol 2001; 13 (2): 121-126.

13. Eckardt VF. Clinical presentation and complications of achalasia. Gastrointest Endosc Clin N Am 2001; 11 (2): 281-292.

14. Bollschweiler E, Knoppe K, Wolfgarten E, Hölscher AH. Prevalence of dysphagia in patients with gastroesophageal reflux in Germany. Dysphagia 2008; 23 (2): 172-176.

15. Eslick GE. Non-cardiac chest pain: epidemiology and natural history, health care seeking and quality of life. Gastroenterol Clin North Am 2004; 33: 1-23.

16. Barreca M, Oelschlager BK, Pellegrini CA. Outcomes of laparoscopic Nissen fundoplication in patients with the “hypercontractile esophagus”. Arch Surg 2002; 137: 724-729.

17. Armijo PR, Hennings D, Leon M, et al. Surgical management of gastroesophageal reflux disease in patients with severe esophageal dysmotility. J Gastrointest Surg 2019; 23: 36-42.

18. Switzer NJ, Holcomb C, Jalviland AD, et al. Laparoscopic Nissen fundoplication improves disease‐specific quality of life in patients with gastroesophageal reflux disease and functional gastroesophageal outflow obstruction. Surg Endosc 2020; 34 (6): 2608-2612.

19. Scherer JR, Kwiatek MA, Soper NJ, et al. Functional esophagogastric junction obstruction with intact peristalsis: a heterogeneous syndrome sometimes akin to achalasia. J Gastrointest Surg 2009; 13 (12): 2219-2225.

20. Van Hoeij FB, Smout AJ, Bredenoord AJ. Characterization of idiopathic esophagogastric junction outflow obstruction. Neurogastroenterol Motil 2015; 27 (9): 1310-1316.

21. Alicuben ET, Bildzukewicz N, Samakar K, et al. Routine esophageal manometry is not useful in patients with normal videoesophagram. Surg Endosc 2019; 33 (5): 1650-1653.

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