BOSTON (EGMN) – Patients who can’t tolerate standard esophageal manometry may be able to undergo an alternative procedure known as endoscopically assisted water perfusion esophageal manometry, with results that are useful in guiding clinical management.

Between 2007 and 2009, 88 (2.7%) of 3,304 patients who were sent for assessment of a motility disorder using standard esophageal manometry failed the procedure. However, many of these patients were able to tolerate an alternative procedure – endoscopically assisted water perfusion esophageal manometry (EAM) – with minimal sedation, reported Dr. Rita Brun and Dr. Kyle Staller, who presented the study results at Neurogastroenterology and Motility 2010.

According to the researchers, patients may be unable to tolerate standard manometry for different reasons. In the group of 88 patients who were identified via retrospective analysis, 87.5% could not tolerate intranasal intubation and 12.5% had anatomical obstacles, such as large hiatal hernias, esophageal diverticula, or prior nasal surgery.

But EAM appears to offer an effective alternative. “To our knowledge, this technique has not been reported previously,” said Dr. Brun, a gastroenterologist associated with Massachusetts General Hospital in Boston. “EAM with minimal sedation is a safe, reliable, and feasible technique providing objective diagnostic information. EAM is geared toward an especially challenging patient population, in whom no other way to assess esophageal motility is feasible yet quantified manometric information for clinical management is required. EAM can provide a needed solution in cases of problematic catheter placement, where evaluation of esophageal motility is a necessity.”

For EAM, patients are minimally sedated, using 2 puffs of lidocaine spray followed by a standard intravenous minimally conscious sedation protocol using primarily midazolam and fentanyl. A standard upper endoscopy is performed. The guide wire is inserted via the working channel of the scope, and the scope is then pulled out, leaving the wire in the stomach. A water perfusion manometry catheter is introduced over the wire, and standard water perfusion manometry is carried out. The mean time from beginning of sedation until withdrawal of the manometry probe was 42 minutes, with the procedure itself lasting about 31 minutes.

To assess the clinical value of EAM, Dr. Staller of Massachusetts General Hospital performed a retrospective analysis of the medical records of all adult patients who had undergone EAM between 2007 and 2009. In all, 41 of the 88 patients who had failed transnasal standard manometry went on to EAM. An additional 10 patients – in whom standard manometry was not appropriate because they had Zenker diverticulum, severe achalasia, or neurologic disease – were sent directly to EAM. Of these 51 patients (37 females; mean age, 60 years; age range, 24-88 years), 5 were excluded because they could not complete EAM, which yielded 46 patient records for clinical analysis.

Of the 46 patients, 10 patients were lost to follow-up. Among the 36 remaining patients, EAM had a direct influence on clinical management for 88.9% (32 patients) and had no meaningful impact for 11.1% (4 patients), according to Dr. Staller.

For instance, 27.8% (10) underwent EAM as part of a preoperative work-up for antireflux surgery. Of those, three did not undergo surgery based on the study results, whereas the other seven proceeded to surgery.

Overall, 12 patients (33.3%) were diagnosed with achalasia as a result of EAM and were treated for that condition with Botox, dilatation, or myotomy (4, 3, and 5 patients, respectively). Achalasia was ruled out in one patient, which prevented an invasive intervention.

Another 12 patients had their medications changed because of the EAM findings. In some cases, a promotility agent was added or an acid-suppression regimen was modified. Some patients had more than one change in their management.

Disclosures: The research was supported in part by a grant from the International Foundation of Functional Gastrointestinal Disorders. No other disclosures were reported.

Copyright (c) 2010 Elsevier Global Medical News. All rights reserved. This material may not be published, broadcast, rewritten, or redistributed.

波士顿(EGMN)——一项临床试验结果表明，无法耐受标准食管测压法的患者可以采用一种称作内镜辅助水灌注食管测压法(EAM)的有效替代方法进行食管测压。

研究者称，2007～2009年间，3,304例患者入院采用标准食管测压法治疗后，88例治疗失败(2.7%)，失败原因为：87.5%患者无法忍受鼻腔插管，12.5％患者存在解剖学障碍，如大裂孔疝疝气、食管憩室，或曾进行过鼻部手术。然而，他们都能够忍受EAM。

为了评估EAM的临床价值，美国波士顿马萨诸塞州总医院的医生对2007～2009年间行EAM术的所有成年患者进行了回顾性分析。总体上，88例标准经鼻测压法失败的者中有41例进行了EAM，另有10例因咽食管憩室(Zenker diverticulum)、严重失弛缓症或神经系统疾病而不适宜进行标准测压法的患者行EAM。这51例患者(37名女性，平均年龄60岁，年龄范围24~88岁)中有5例因为未完成EAM而被排除。

在完成EAM的46例患者中，10例在随访中失去联系。余下36例中，EAM对临床处置起到直接作用的占88.9%(32例)，没有显著影响的占11.1%(4例)。12例(33.3％)因EAM的结果而被诊断为贲门失弛缓症，另有1例排除了贲门失弛缓症。有12例患者因EAM的结果而改变药物治疗策略。

行EAM时，患者仅需最低限度的麻醉，2次利多卡因喷雾后再通过静脉给予咪达唑仑和芬太尼麻醉，随后行上消化道内镜检查。通过导管进行水灌注，施行标准的水灌注测压法。从麻醉开始到测压探针抽回，平均需要42 min，而水灌注测压法本身的持续时间约为31 min。

 研究者称EAM测压目前还未被报道过，此法仅需要最低限度的麻醉需求，更加安全、可靠，也更具有可行性，能给患者提供客观的诊断信息；对于一些特别具有挑战性的患者群，EAM测压发可通过植入导管来评价食管蠕动能力，给患者提供解决方案。

 研究者披露本研究部分得到国际功能性胃肠紊乱基金会资助，并表示无其他需要披露的事项。

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