Lessons learned from physician-performed high-resolution esophageal manometries

Summary

High-resolution esophageal manometry (HRM) is the gold standard test for evaluation and diagnosis of esophageal motility disorders. While the Chicago Classification offers a standardized protocol for performing and interpreting HRM studies, it does not provide guidance on catheter placement techniques, nor the specific skillset required to conduct the test. At most centers nationally and globally, HRMs are performed by a trained nurse or medical technician. However, in selected centers, physicians perform HRMs alongside a clinical care assistant. Direct physician involvement in performing HRM offers unique clinical insights that can potentially enhance diagnostic accuracy, procedural efficiency, and patient experience. Based on our more than two-decade experience with physician-performed HRMs, we share various tips and techniques to provide step-by-step guidance on performing a high-quality HRM. In addition, we provide reflections from our experience on several benefits of physician-performed manometries including continued continuity of care, real-time interpretation with ability to perform adjunctive testing, and improved patient tolerance.

HIGH-RESOLUTION ESOPHAGEAL MANOMETRY AND CHICAGO CLASSIFICATION

High-resolution esophageal manometry (HRM) is the gold standard diagnostic tool for evaluation of esophageal motility disorders.^1,2 The Chicago Classification (CC) provides a standardized protocol on how to perform high-quality HRMs and interpret the study findings using a systematic classification structure.¹ Prior to HRM, patients are counseled on the rationale for the procedure and what to expect during the study. After patient consent is obtained, the provider inserts the manometry catheter transnasally through the pharynx and esophagus with a goal of traversing both the lower esophageal sphincter (LES) and the diaphragmatic hiatus. Once the manometry catheter is placed with adequate positioning and landmark identification, the patient is instructed to complete 10 swallows in the primary position and 5 swallows in the secondary position as per CCv4.0. Based on the study findings and as requested by the referring provider, adjunctive maneuvers such as the multiple rapid swallow sequence. Rapid drinking challenge and solid food challenge may also be performed. Lastly, once data have been acquired, the physician interprets the HRM in a systematic manner using the CCv4.0 classification schema.

While CC provides a unified framework as to how to perform and interpret HRM studies, there are some differences with regards to the provider performing the study across various centers. At most centers across the United States, the HRM is performed by nurses or sometimes by medical technicians. In contrast, at some centers such as ours (Cedars-Sinai Medical Center, Los Angeles, California), the HRM is performed by a neurogastroenterologist in conjunction with a nurse. Worldwide, there is considerable variation as to who performs the HRM and performing providers may include physicians, nurses, or medical technicians.

ASSESSING THE QUALITY OF ESOPHAGEAL MANOMETRY STUDIES

The quality of the HRM is fundamental to ensuring that the esophageal motility is adequately and accurately assessed. Consequently, an imperfect study may result in incomplete or inadequate assessment of the underlying esophageal motility. While the CC provides a standardized protocol for performing and interpreting a HRM, there is no formal criteria that may be used to assess the quality of the study. Two prior studies have examined quality metrics of HRM studies.^3,4 In one single-center retrospective study consisting of 951 HRMs, a critically imperfect study defined as the manometry catheter not passing the LES was seen in 3.4% of cases.³ A non-critically imperfect study was defined as LES transversed but crura of diaphragm not transversed, or less than 10 supine swallows performed, and accounted for 13% of studies.³ In another single-center retrospective study consisting of 2000 HRMs, an imperfect study defined as fewer than 7 evaluable swallows, the catheter did not traverse the LES, and/or sensor or thermal compensation malfunction was observed in 21% of studies.⁴ Although approximately one-fifth of the HRMs were imperfect in this study, 94% of the imperfect studies could still yield the correct diagnosis when interpreted in conjunction with the clinical context.⁴ The most common causes of imperfect studies were large hiatal hernias and achalasia.^3,4 In large part due to data from these two prior studies, a quality metric of performing 80% or more technically perfect HRMs was proposed in a recent review article.² In addition, while there is no formal consensus on competency or experience required to effectively and accurately HRM, an expert panel consisting of 14 esophagologists across the USA recommended that the individual performing the HRM observe at least 20 studies and perform at least 50 studies annually.⁵

REFLECTIONS FROM OUR EXPERIENCE WITH PHYSICIAN-PERFORMED MANOMETRIES

At Cedars-Sinai Medical Center, we have performed physician-led HRMs for more than two decades, where the procedures are performed by a gastroenterologist with motility expertise, in conjunction with a registered nurse. During this timeframe, we have performed more than 6500 physician-led HRMs. In this section, we highlight our experience with physician-performed HRMs including several benefits of this approach as compared to studies that may be performed by non-physician providers. Overall, our experience with physician-performed HRMs has been remarkably positive and we have found this approach to yield positive outcomes for all parties involved including patients, performing physicians, and referring providers. As this lessons learned commentary does not report on any new patient-related information, it was institutional review board exempt.

First, physician-performed HRMs can ensure continuity of care with patients and often improves patient tolerance and satisfaction. At our center, the neurogastroenterologist who evaluates the patient in clinic also performs their HRM. This model is similar to many centers where the physician who sees a patient in clinic also performs their endoscopy. As such, providers may be better able to evaluate patients’ symptoms elicited in clinic and correlate these with manometry findings. In cases of incomplete studies due to patients’ foregut anatomy, providers can use the patient clinical history and symptoms to better reach an accurate manometric diagnosis. In the earlier mentioned study with imperfect HRMs, a diagnosis of achalasia could be made correctly in 77% of blinded cases (where provider did not have any added clinical context), and in 95% of non-blinded cases (where additional clinical history was available to the interpreting provider).⁴

In addition, we have found that patients who are often anxious about the HRM and have fears about their ability to tolerate the study, feel more at ease when the study is performed by a provider with whom they have already established care as compared to an entirely new provider whom they see for the first time on the day of their HRM. While the patient tolerance of HRMs can be variable, intolerance rates reported in prior literature can be as high as 28.7%, contributing to low patient satisfaction.^2,6 Previously, we retrospectively assessed patient tolerance of HRMs performed at our center from 2005 to 2022 including 5107 patients (60% female) with majority aged 18–79 years (93%).⁷ Of these patients, 98.9% tolerated HRM well and no serious complications were identified.⁷ At our center, patients also watch a brief, educational video of the steps involved with HRM prior to the procedure and this approach further increases patient understanding of the study and decreases procedure-related anxiety.⁸

Moreover, physician-performed HRMs allow for real-time study interpretation and correlation with patient symptoms as well as better use of adjunctive testing and maneuvers in selected cases. A physician performing the HRM can correlate manometric abnormalities with patient symptoms in real-time. For example, physicians can note whether patient is experiencing chest pain symptoms when they see a hypercontractile or spastic swallow. In addition, they can note the presence and timing of dysphagia, coughing, or belching symptoms relative to each swallow. Artifact recognition during HRM, such as pressure changes resulting from heaving, burping, position changes, coughing, talking, or sneezing, is significantly easier when the provider is present in the room during the procedure. Real-time observation allows for immediate correlation between patient behavior and manometric findings, improving the accuracy of interpretation and minimizing misclassification of abnormal motility patterns. Adjunctive testing may also be tailored to each patient based on findings from the standard manometry protocol such as addition of rapid drink challenge in cases of suspected esophagogastric junction outflow obstruction, and solid meal administration with extended monitoring when rumination is suspected.

Furthermore, providers may be more familiar with the underlying anatomy of their patients and may be better able to place the catheter in cases of suspected achalasia, moderate to large hiatal hernias, and post-bariatric surgery. In such cases, several methods may be utilized to traverse the manometry catheter through the LES including taking deep breaths, standing up, and lifting both arms.⁹

Lastly, referring providers may have more confidence in the evaluation of their patient when the study is performed by a physician with motility expertise. Conversely, providers performing the HRM may be able to provide guidance to referring providers on next steps in management of patients based on manometric findings. For example, in a patient with manometric esophagogastric junction outflow obstruction, further evaluation with a timed barium esophagram and/or EndoFLIP may be recommended.

While physician-performed HRMs have several benefits as outlined above, they may not be applicable to all settings. In general, gastroenterology, especially neurogastroenterologist, is an underserved field and patients often have wait times exceeding several months for gastrointestinal motility clinic consultation.¹⁰ In several areas, the clinical volume of patients requiring clinical and endoscopic evaluation with a motility provider may not make it feasible for these providers to also perform HRMs. Apart from availability, the associated costs could also limit the widespread use of the physician-performed HRM model. Moreover, non-physician providers, when trained adequately, may be able to perform high-quality studies for the vast majority of patients using a standardized protocol and with addition of adjunctive maneuvers when requested by the referring provider.

CLINICAL PEARLS FOR PERFORMING HIGH-QUALITY ESOPHAGEAL MANOMETRY STUDIES

Based on our more than two decades of hands-on experience performing HRM studies, we have outlined several key clinical pearls on how to perform a high-quality HRM in Table 1. This comprehensive table covers important principles related to patient preparation for the HRM including medication and dietary considerations, and tips on successfully passing the catheter through the nasal passage, upper esophageal sphincter, LES, and diaphragmatic hiatus. In selected cases where the esophageal manometry catheter cannot be placed despite utilizing the techniques and maneuvers outlined above, endoscopic placement may be considered.

Table 1.

Tips and techniques for performing a high-quality esophageal manometry study

Steps		Details	Tips/trouble shooting
1. Patient preparation	Prior to the procedure	Review medications; opioids should be held for >24 hours if possible. Patient to fast for >4 hours.	Medication review and dietary guidance prior to HRM.
	On the day of the procedure	Review procedure indication, risks, and benefits (informed consent). Review each step with manometry and what to expect.	Consider educational video of the HRM for patients to view prior to procedure. Offer stress ball or calming music.
2. Catheter insertion	Transverse the nasal ridge (first 15 cm)	Select the nostril with better airflow for catheter insertion. To assess this, occlude one nostril at a time and ask the patient to inhale through the nose; choose the side with less resistance and better inspiratory flow. Apply lidocaine gel to the selected nostril using a cotton-tipped applicator (Q-tip). Gently insert the catheter through the selected nostril, advancing it in a smooth, continuous motion while directing it toward the contralateral earlobe to follow the natural anatomical pathway. Note that asking the patient to swallow does not assist with advancing the catheter through the nasal passage and may be counterproductive during this phase of insertion as elevation of soft palate can make traversing nasopharynx more difficult.	If resistance is encountered during catheter insertion, adjust the angle or ask the patient to gently tuck their chin to help align the pathway. A common mistake is advancing the catheter too cephalad, which can direct it above the inferior turbinate. If the patient experiences severe ear pain during insertion, withdraw the catheter and attempt placement through the opposite nostril. This discomfort may indicate partial intubation of the Eustachian tube.
	Transverse the UES	Provider may feel a pop when the nasal passage is transversed. At this time, pause and ask the patient to swallow water to allow the UES to open. The catheter should be advanced while the patient is swallowing sips of water. Note that in presence of a tight cricopharyngeal bar, Zenker’s, or Killian-Jamieson diverticulum, catheter may fail to advance or even curl, seen on manometry as a butterfly sign.	If patient experiences persistent coughing, difficulty breathing, or an inability to speak during the insertion, immediately withdraw the catheter, as it may have inadvertently entered the trachea. To prevent this, ask the patient to tuck their chin or turn their face to one side while swallowing, which can help guide the catheter into the esophagus.
	Traverse the LES	Real-time observation of manometric tracings related to LES contraction and pressure inversion point (PIP) is key in assuring adequate advancement. Traversing the LES can be difficult with hiatal hernia or achalasia. Transverse though the diaphragmatic crura to assess for hiatal hernia size.	If any resistance, pause and ask patient to take a deep breath and hold, stand up, or raise hands above the head. Then, advance the catheter. In cases of achalasia, having the patient consume a small amount of carbonated beverage instead of water can help generate an esophageal ‘vent’ through gas-induced distension, which may transiently relax the LES and facilitate catheter advancement into the stomach.
3. During the procedure		Follow the Chicago Classification protocol. Perform special maneuvers if indicated. In patients with poor tolerance to the procedure, the initial swallows might not be accurate and will require additional swallows.	If patient has repeated swallowing, instruct patient to breathe through an open mouth, stick out their tongue, or sip and hold the saline in their mouth before the next swallowing.
4. Post-procedure	Post procedure communication	Ensure result reaches patient and referring provider in a timely manner.

Abbreviations: HRM: high-resolution manometry; LES: lower esophageal sphincter; UES: upper esophageal sphincter.

CONCLUSION

A high-quality HRM is fundamental in ensuring that esophageal motility is assessed adequately and accurately. The individuals performing the HRM should understand the steps involved in manometry catheter placement and have familiarity with the study protocol and classification of motility disorders as outlined in CCv4.0. In our experience, physician-performed HRMs provide several benefits including continuity of care, increased patient tolerance and comfort, real-time study interpretation and analysis, and possibly higher probability of successful study completion in technical difficult cases such as large hiatal hernias, achalasia, and post-bariatric surgery, given their familiarity with their patient’s underlying anatomy. However, physician-performed HRMs may not be applicable in many settings given limited physician availability and associated costs. Additional studies are needed to more directly compare physician and non-physician performed HRMs.

Specific author contributions: NW, AR, and AK contributed to article conception and design. NW performed the literature search. NW, AR, and AK drafted the manuscript. MP, BC, YC, JL, AH provided critical feedback. All author reviewed and approved the final manuscript.

Financial support: None.

Conflicts of interest: None.

ABBREVIATIONS

CC, Chicago Classification; HRM, High-resolution esophageal manometry; LES, Lower esophageal sphincter; UES, Upper esophageal sphincter