Greater use of high-resolution manometry systems should make esophageal motility evaluations more comfortable and acceptable to patients while also providing a better understanding of a range of motility problems, according to new research.

Esophageal function testing with high-resolution manometry (HRM) systems takes less than 10 minutes and is “already beginning to show us things that were not readily recognizable with traditional manometry,” according to Dr. Jeffrey H. Peters, professor and chair of the surgery department at the University of Rochester (New York).

“We don’t know quite what to make of them yet, but all kinds of variations that weren’t as evident with traditional manometry are beginning to emerge, and time will tell exactly what they mean.”

HRM testing is reserved for use in patients with suspected esophageal motility disorders, such as achalasia, esophageal spasm, and gastroesophageal reflux disease (GERD), which have available surgical treatments. Patients with chest pain or difficulty swallowing also may undergo HRM testing.

The visual display of pressure activity, which is accomplished using HRM software, makes interpretation more intuitive – a boon for surgeons who may find it difficult to interpret line tracings using the “fairly straightforward, simple technology” of traditional manometric systems with water-perfused catheters, Dr. Peters noted.

Using HRM to determine the normal and pathologic functioning of the esophagus, Dr. Peters and his associates studied 50 healthy asymptomatic volunteers (mean age 27 years) and 106 patients (mean age 53 years) who were referred to and evaluated at the university during 2005-2007. None of the referred patients had malignant disease or earlier foregut surgical procedures (J. Am. Coll. Surg. 2009;208:1035-44).

The manometric catheter used in the study (ManoScan 360, Sierra Scientific Instruments Inc.) sends data in real time from its array of 36 pressure transduction sensors to Sierra Scientific Instruments’ ManoView software for analysis. The clinician can view topographic color contour plots of esophageal pressure activity in different regions of the esophagus before, during, and after swallowing in conjunction with various interpretation tools. The tools help the physician assess sphincter relaxation and esophageal body contraction.

For a randomly selected group of 40 patients, the mean procedure time was significantly shorter for HRM (8.2 minutes) than for 10 swallows with conventional impedance manometry, excluding 10 viscous swallows (24.4 minutes), which “should improve acceptance and compliance of patients for the procedure,” Dr. Peters said, because “it’s more rapid and comfortable for the patients.”

The investigators observed abnormal manometric values in 91 of the 106 patients, who had experienced heartburn (95 patients), regurgitation (92), cough (60), chest pain (41), hoarseness (40), dysphagia (22), wheezing (17), and epigastric pain (15).

Assessments of the lower esophageal sphincter (LES) in 103 patients detected abnormalities in 71 patients. The sphincter was structurally defective in 53 patients, most often because of a short total length (39), short abdominal length (31), and low resting pressure (15). Other abnormal sphincters were hypertensive (6) or had impaired relaxation (17), defined as residual pressure greater than 14.7 mm Hg.

Among GERD patients, HRM testing showed that most of those with a defective LES had endoscopic or radiographic evidence of a hiatal hernia. Esophageal pH was abnormal in more than three-fourths of the patients who underwent testing, while endoscopy confirmed that a similar proportion had erosive esophagitis or Barrett’s esophagus.

In patients with HRM evidence of a hiatal hernia, endoscopy confirmed the condition in 30 of 33 patients, and video barium swallow confirmed it in 17 of 21 patients.

Achalasia was found in 4 of 6 patients with a hypertensive LES. Of 17 patients who had incomplete LES relaxation, 13 had a final diagnosis of achalasia.

During a swallow frame analysis with the system, 58 (55%) of the 106 patients had abnormal motility of the esophageal body, including abnormalities in wave progression (34) and contraction amplitude (42). Abnormal segmental amplitudes were seen in 42 patients.

HRM systems are widely available and appear to be gradually replacing traditional manometry. The cost of HRM is comparable to that of traditional manometric systems, but the high-resolution catheter costs about $9,000-$10,000 and can be used for about 200 esophageal function tests, Dr. Peters said in an interview.

Sierra Scientific Instruments provides HRM training at four U.S. locations (and one in London) each year, in addition to Webinars. “Most people who have been doing traditional motility [studies] find it fairly straightforward to switch,” Dr. Peters said.

In their paper, however, he and his colleagues noted that “although HRM clearly simplifies the performance of a motility study, there is a considerable learning curve for accurate interpretation. In fact, there are aspects of the image that remain poorly defined, such as identification and measurement of a ‘bolus pressure.’”

Another HRM system on the market is called the Insight Manometry System, made by Sandhill Scientific Inc.

None of investigators had any relevant disclosures.

Copyright (c) 2009 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

一项研究表明，更多地应用高分辨率测压（HRM）系统可使得食管动力评价对病人来说变得更为舒适也更可接受，也可帮助人们更好地了解一系列的食管动力问题。

 

应用HRM系统进行食管功能检测仅需不到10min的时间，“并已帮助我们发现一些传统测压方法无法发现的情况”，Jeffrey H. Peters博士说，他是纽约罗彻斯特大学的外科主任和教授。

 

 “我们还不太清楚如何解释这些发现，但所有这些在传统测压方法下无法清晰显示的变化在不断被发现，时间会告诉大家它们到底意味着什么。”

 

HRM应用于疑有食管动力障碍的患者，如食管失弛缓症、食管痉挛、胃食管反流病（GERD），这些疾病均有外科治疗方法。有胸痛或吞咽困难的患者亦可行HRM检测。

 

Peters博士指出，通过HRM软件实现的压力活动的可视化显示，使其解读更为直观，借助注水导管的传统测压系统虽是“十分直接、简单的技术”，但对于那些发现应用传统测压方法可能很难解读压力线性轨迹的医生来说HRM是一种福荫。

 

Peters博士和其同事对50名健康无症状的志愿者（平均年龄27岁）和106例于2005～2007年在该大学就诊的患者（平均年龄53岁）进行了研究，他们应用HRM来确定功能正常和有病变的食管。所有受试患者均无恶性病变，之前亦均未接受过前肠外科治疗（J. Am. Coll. Surg. 2009;208:1035-44）。

 

该研究中应用的测压导管（ManoScan 360, Sierra 科学仪器公司）通过其36个压力传导传感器实时地将数据传送至Sierra科仪器公司的ManoView软件中以进行分析。联合其他不同解读工具，临床人员可观察受试者吞咽前、吞咽期间和吞咽后三个时段体现食管不同区域压力活动的彩色等高线地形图。借助这些工具，医生可评价食管括约肌松弛和食管体收缩。

 

在随机选取的40例患者中发现，HRM的平均检测时间（8.2 min）比传统阻抗测压方式（10次吞咽）显著缩短，这排除了10次黏性吞咽（24.4 min），“这将提高患者对此操作的接受程度和顺应性”，Peters博士说，因为“对于患者来说，它更快也更舒适”。

 

研究者在106例患者中的91例中发现测压值不正常，其中95例有烧心，92例有反流，60例有咳嗽，41例有胸痛，40例有嗓音嘶哑，22例有吞咽困难，17例有喘鸣，15例有上腹疼痛症状。

 

对103例患者的下食管括约肌（LES）的评价发现71例存在异常。其中53例存在括约肌结构上的缺陷，最常见的是总长度较短（39例），腹段较短（31例），静息压力较低（15例）。括约肌的其他异常包括压力过高（6例）或放松状态异常（17例），即静息压大于14.7 mmHg。

 

在GERD患者中，HRM检测发现LES异常的患者大多在内镜或放射检查下可见食管裂孔疝的证据。接受检测的患者中有超过3/4的患者其食管pH异常，而内镜检查证实相同数量的患者患有糜烂性食管炎或巴雷特食管。

 

对于HRM发现食管裂孔疝的患者，内镜检查证实33例中30例有这种病症，可视钡餐证实21例中17例有这种病症。

 

在6例LES高压的患者中，4例被发现有食管失弛缓症。而17例LES松弛障碍的患者中，13例最终被诊断为失弛缓症。

 

在此系统的吞咽形态分析中，58例（106例中的55%）食管体运动异常，包括波前进（34例）和收缩振幅异常（42例）。42例发现节段振幅异常。

 

HRM系统已被广泛应用，并有逐渐取代传统测压计的现象。HRM的费用与传统测压系统有可比性，但其高分辨率导管大约花费9,000~10, 000美元，可供200次食管功能检测，Peters博士在受访时说。

 

除了网络研讨会外，Sierra科技仪器公司每年在美国的4个地方提供HRM培训（一个在伦敦）。“大多之前进行过传统食管动力研究的人员发现转换至HRM非常简单，”Peter博士说。

 

在论文中，Peters博士及其同事提出“虽然HRM显著地简化了食管动力研究过程，但要准确地解读HRM需要经过一个较长的学习曲线。实际上，此图像的在某此方面仍不够精确，如‘食团压力’的确认和测定。”

 

市面上的另外一种HRM系统叫做Insight测压系统，由Sandhill科学公司生产。

 

研究者均无相关利益冲突声明。

 

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