How to Effectively Use High-Resolution Esophageal Manometry.

Esophageal manometry is the definitive test to evaluate esophageal motility and is indicated in the diagnostic evaluation of patients with nonobstructive dysphagia. Esophageal manometry is also indicated in the preoperative evaluation of patients obtaining a high-quality HRM study. Decisions toward or away from foregut surgery (Heller myotomy, Nissen fundoplication), which can be associated with significant morbidity, are often based on HRM studies. These are high-impact, often difficult, decisions and high-quality studies optimize patient outcomes. Additionally, manometry requires transnasal intubation, which is uncomfortable and can make patients very averse to repeat procedures, so it is incumbent on those making the first attempt to do it properly. When done properly, an HRM study is like a radiograph that can be put on a memory stick or CD and sent to an expert for a second opinion if necessary. However, faxed (black and white) copies of computer84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110 111 112 before antireflux surgery to gauge the adequacy of peristalsis. Additionally, manometry is used in other clinical scenarios such as in the evaluation of noncardiac chest pain, in the evaluation of regurgitation, and in symptomatic evaluation after antireflux or achalasia surgery. Over the past decade, there have been significant advances in manometric device technology, manometric data display, and manometric data analysis. Consequently, high-resolution manometry (HRM) with 36 closely spaced pressure sensors, data display in the format of Clouse plots (color isobaric contours), and the Chicago Classification have become widely adopted into clinical practice representing an update from ‘conventional’ line tracing manometry. This evolution offers great promise in standardizing the performance and interpretation of esophageal manometric studies. However, it also challenges trainees and practitioners to become sufficiently familiar with HRM to effectively use it in their practice environment. That does not mean that every practice must learn to perform HRM studies; only that they develop sufficient expertise to optimally manage patients with primary or secondary motility disorders. In many cases, this may involve referral to a regional center of excellence. Just as with transplant hepatology, endoscopic mucosal resection, complicated inflammatory bowel disease, biliary tract disease, or gastrointestinal cancers, sometimes recognizing the complexity of the problem and making the appropriate referral best serve the patient.