Gastroenterol Res

Gastroenterology Research, ISSN 1918-2805 print, 1918-2813 online, Open Access

Article copyright, the authors; Journal compilation copyright, Gastroenterol Res and Elmer Press Inc

Journal website http://www.gastrores.org

Original Article

Volume 12, Number 3, June 2019, pages 157-165

Revisiting the Reliability of the Endoscopy and Sedation-Assisted High-Resolution Esophageal Motility Assessment

Figure 2. Computed tomography (CT) scan showing a dilatated and tortuous esophagus, presence of food residue, smooth-tapered appearance (bird beak sign) of the esophagogastric junction (EGJ) and loss of gastric air bubble characteristic of achalasia.

**Table 1.** Demographic Information, Indications for HRM and Endoscopy Assistance Among the Patients Included in the Study Group
Case no.	Age	Gender	Indication for HRM	Indication for endoscopy assistance
HRM: high-resolution manometry; EGJ: esophagogastric junction.
1	81	Female	Dysphagia evaluation	Inability to traverse EGJ and coiling of catheter
2	63	Male	Dysphagia evaluation	Patient discomfort and coiling of the catheter
3	57	Female	Dysphagia evaluation	Inability to traverse EGJ and coiling of catheter
4	57	Male	Dysphagia evaluation	Patient discomfort and pharyngeal catheter coiling
5	63	Male	Dysphagia evaluation	Patient discomfort
6	54	Male	Pre-operative evaluation of type 3 para-esophageal hiatal hernia repair and fundoplication	Coiling of the catheter in the distal esophageal diverticulum and hernia sac
7	50	Male	Pre-operative evaluation of type 1 para-esophageal hiatal hernia repair and fundoplication	Large hiatal hernia and coiling of catheter in hernia
8	74	Male	Dysphagia evaluation	Inability to traverse EGJ and coiling of catheter
9	66	Female	Dysphagia evaluation	Inability to traverse EGJ and coiling of catheter
10	66	Female	Dysphagia evaluation	Inability to traverse EGJ and coiling of catheter
11	58	Female	Fundoplication revision pre-operative evaluation	Patient discomfort and inability to traverse EGJ
12	51	Male	Dysphagia evaluation	Inability to traverse EGJ and coiling of catheter
13	49	Female	Pre-operative evaluation of type 3 hiatal hernia repair and fundoplication	Large hiatal hernia and coiling of catheter in hernia
14	61	Female	Post-operative distal esophagectomy dysphagia evaluation	Inability to traverse the EGJ

Table 1. Demographic Information, Indications for HRM and Endoscopy Assistance Among the Patients Included in the Study Group

Case no.

Age

Gender

Indication for HRM

Indication for endoscopy assistance

HRM: high-resolution manometry; EGJ: esophagogastric junction.

Female

Dysphagia evaluation

Inability to traverse EGJ and coiling of catheter

Male

Dysphagia evaluation

Patient discomfort and coiling of the catheter

Female

Dysphagia evaluation

Inability to traverse EGJ and coiling of catheter

Male

Dysphagia evaluation

Patient discomfort and pharyngeal catheter coiling

Male

Dysphagia evaluation

Patient discomfort

Male

Pre-operative evaluation of type 3 para-esophageal hiatal hernia repair and fundoplication

Coiling of the catheter in the distal esophageal diverticulum and hernia sac

Male

Pre-operative evaluation of type 1 para-esophageal hiatal hernia repair and fundoplication

Large hiatal hernia and coiling of catheter in hernia

Male

Dysphagia evaluation

Inability to traverse EGJ and coiling of catheter

Female

Dysphagia evaluation

Inability to traverse EGJ and coiling of catheter

Female

Dysphagia evaluation

Inability to traverse EGJ and coiling of catheter

Female

Fundoplication revision pre-operative evaluation

Patient discomfort and inability to traverse EGJ

Male

Dysphagia evaluation

Inability to traverse EGJ and coiling of catheter

Female

Pre-operative evaluation of type 3 hiatal hernia repair and fundoplication

Large hiatal hernia and coiling of catheter in hernia

Female

Post-operative distal esophagectomy dysphagia evaluation

Inability to traverse the EGJ

**Table 2.** Findings on Manometry, Barium Esophagogram and Diagnosis of Patients in the Study Group
Case no.	Diagnosis on HRM	IRP	DL	Esophageal peristalsis	Correction for IRP inflation (10%)	Barium esophagogram
HRM: high-resolution manometry; EGJ: esophagogastric junction; IRP: integrated relaxation pressure; DL: distal latency.
1	Type I achalasia	22		Aperistalsis	20	Not performed
2	Type II achalasia	24	2.1	Isobaric pan-esophageal pressurization	22	Mildly diminished esophageal motility with dilatation
3	Type I achalasia	22		Aperistalsis	20	Achalasia pattern of the esophagus with narrowing above EGJ
4	Type II achalasia	36	2.4	Isobaric pan-esophageal pressurization	32	Diminished motility with dilatation of the lower esophagus
5	Type II achalasia	24	2.2	Isobaric pan-esophageal pressurization	22	Dilatation of the lower esophagus
6	Ineffective esophageal motility	14	5.2	Ineffective esophageal motility	13	Not performed
7	Normal esophageal motility	14	5.1	Normal esophageal motility	13	Large hiatal hernia with reflux
8	Ineffective esophageal motility	8	4.9	Ineffective esophageal motility	7	Gastroesophageal reflux
9	EGJ obstruction	20	5.1	Normal esophageal motility	18	Small hiatal hernia
10	EGJ obstruction	33	4.9	Normal esophageal motility	30	No dilatation with poor emptying of esophagus
11	Normal esophageal motility	14	5.1	Normal esophageal motility	13	Mild degree of gastroesophageal reflux seen through the fundoplication
12	Type III achalasia	30	2.1	Simultaneous esophageal contraction	27	Incomplete emptying of the lower esophagus
13	Ineffective esophageal motility	7		Ineffective esophageal motility	6	Large hiatal hernia with reflux
14	Normal esophageal motility	Not available due to surgical resection of the lower esophageal sphincter	Normal		Patent EGJ anastomosis

Table 2. Findings on Manometry, Barium Esophagogram and Diagnosis of Patients in the Study Group

Case no.

Diagnosis on HRM

IRP

Esophageal peristalsis

Correction for IRP inflation (10%)

Barium esophagogram

HRM: high-resolution manometry; EGJ: esophagogastric junction; IRP: integrated relaxation pressure; DL: distal latency.

Type I achalasia

Aperistalsis

Not performed

Type II achalasia

2.1

Isobaric pan-esophageal pressurization

Mildly diminished esophageal motility with dilatation

Type I achalasia

Aperistalsis

Achalasia pattern of the esophagus with narrowing above EGJ

Type II achalasia

2.4

Isobaric pan-esophageal pressurization

Diminished motility with dilatation of the lower esophagus

Type II achalasia

2.2

Isobaric pan-esophageal pressurization

Dilatation of the lower esophagus

Ineffective esophageal motility

5.2

Ineffective esophageal motility

Not performed

Normal esophageal motility

5.1

Normal esophageal motility

Large hiatal hernia with reflux

Ineffective esophageal motility

4.9

Ineffective esophageal motility

Gastroesophageal reflux

EGJ obstruction

5.1

Normal esophageal motility

Small hiatal hernia

EGJ obstruction

4.9

Normal esophageal motility

No dilatation with poor emptying of esophagus

Normal esophageal motility

5.1

Normal esophageal motility

Mild degree of gastroesophageal reflux seen through the fundoplication

Type III achalasia

2.1

Simultaneous esophageal contraction

Incomplete emptying of the lower esophagus

Ineffective esophageal motility

Large hiatal hernia with reflux

Normal esophageal motility

Not available due to surgical resection of the lower esophageal sphincter

Normal

Patent EGJ anastomosis

**Table 3.** Diagnosis of Patients Undergoing Endoscopy-Assisted HRM and Their Management/Treatment
Case no.	Diagnosis on manometry	Treatment
HRM: high-resolution manometry; EGJ: esophagogastric junction; GERD: gastroesophageal reflux disease.
1	Type I achalasia	Patient refused balloon dilatation and Heller’s myotomy - managed with calcium channel blocker
2	Type II achalasia	Heller’s myotomy
3	Type I achalasia	Balloon dilation, patient refused Heller’s myotomy
4	Type II achalasia	Patient refused balloon dilatation and Heller’s myotomy - managed with calcium channel blocker
5	Type II achalasia	Heller’s myotomy
6	Ineffective esophageal motility	Nissen’s fundoplication
7	Normal esophageal motility	Toupet’s 270° fundoplication
8	Ineffective esophageal motility	GERD management
9	EGJ obstruction	Observant management
10	EGJ obstruction	Observant management
11	Normal esophageal motility	Planned for the revision of the fundoplication
12	Type III achalasia	Heller’s myotomy
13	Ineffective esophageal motility	Undergoing evaluation for Nissen’s fundoplication
14	Normal esophageal motility	Dilatation of the esophago-gastric anastomosis

Table 3. Diagnosis of Patients Undergoing Endoscopy-Assisted HRM and Their Management/Treatment

Case no.

Diagnosis on manometry

Treatment

HRM: high-resolution manometry; EGJ: esophagogastric junction; GERD: gastroesophageal reflux disease.

Type I achalasia

Patient refused balloon dilatation and Heller’s myotomy - managed with calcium channel blocker

Type II achalasia

Heller’s myotomy

Type I achalasia

Balloon dilation, patient refused Heller’s myotomy

Type II achalasia

Patient refused balloon dilatation and Heller’s myotomy - managed with calcium channel blocker

Type II achalasia

Heller’s myotomy

Ineffective esophageal motility

Nissen’s fundoplication

Normal esophageal motility

Toupet’s 270° fundoplication

Ineffective esophageal motility

GERD management

EGJ obstruction

Observant management

EGJ obstruction

Observant management

Normal esophageal motility

Planned for the revision of the fundoplication

Type III achalasia

Heller’s myotomy

Ineffective esophageal motility

Undergoing evaluation for Nissen’s fundoplication

Normal esophageal motility

Dilatation of the esophago-gastric anastomosis

**Table 4.** Duration of Manometry Catheter Calibration, Endoscopy, Post-Sedation Recovery, Manometry Acquisition and Total Procedure Duration
Case no.	HRM catheter calibration (min)	EGD duration (min)	Post-sedation recovery (min)	HRM acquisition (min)	Total procedure duration (min)
*Catheter insertion with the sedation and no endoscopy. HRM: high-resolution manometry; EGD: esophagogastroduodenoscopy.
1	12	16	32	22	82
2	10	7	24	18	59
3	13	8	31	25	77
4	14	12	22	19	67
5	12	11	36	21	80
6	10	9	26	20	65
7	12	16	36	22	86
8	16	11	24	21	72
9	12	10	32	20	74
10	10	11	28	18	67
11	14	18	36	18	86
12	12	2*	24	16	54
13	10	16	22	18	66
14	14	4*	18	22	58

Table 4. Duration of Manometry Catheter Calibration, Endoscopy, Post-Sedation Recovery, Manometry Acquisition and Total Procedure Duration

Case no.

HRM catheter calibration (min)

EGD duration (min)

Post-sedation recovery (min)

HRM acquisition (min)

Total procedure duration (min)

*Catheter insertion with the sedation and no endoscopy. HRM: high-resolution manometry; EGD: esophagogastroduodenoscopy.

**Table 5.** Medications Used for Anesthesia Among Patients in the Study Population
Case no.	Propofol (mg)	Lidocaine (mg)	Metoprolol (mg)	Fentanyl (µg)	Midazolam (mg)
1	50	50
2	100	50	3
3	60	50
4	70	50	3
5	90	50	3
6	70	50	3
7	110	50		100
8	80	50			3
9	70	50
10	60	50	3
11	120	50	3	100
12	40
13	100	50
14	40	50

Table 5. Medications Used for Anesthesia Among Patients in the Study Population

Case no.

Propofol (mg)

Lidocaine (mg)

Metoprolol (mg)

Fentanyl (µg)

Midazolam (mg)

100

110

100

120

100

Case no.	Propofol (mg)	Lidocaine (mg)	Metoprolol (mg)	Fentanyl (µg)	Midazolam (mg)
1	50	50
2	100	50	3
3	60	50
4	70	50	3
5	90	50	3
6	70	50	3
7	110	50		100
8	80	50			3
9	70	50
10	60	50	3
11	120	50	3	100
12	40
13	100	50
14	40	50

Case no.	Propofol (mg)	Lidocaine (mg)	Metoprolol (mg)	Fentanyl (µg)	Midazolam (mg)
1	50	50
2	100	50	3
3	60	50
4	70	50	3
5	90	50	3
6	70	50	3
7	110	50		100
8	80	50			3
9	70	50
10	60	50	3
11	120	50	3	100
12	40
13	100	50
14	40	50

Case no.	Propofol (mg)	Lidocaine (mg)	Metoprolol (mg)	Fentanyl (µg)	Midazolam (mg)
1	50	50
2	100	50	3
3	60	50
4	70	50	3
5	90	50	3
6	70	50	3
7	110	50		100
8	80	50			3
9	70	50
10	60	50	3
11	120	50	3	100
12	40
13	100	50
14	40	50