Purpose: High Resolution Manometry (HRM) and HRM interpretation with the Chicago Classification (HRM+CC) have theoretical technologic advantages over Standard Manometry (SM) in the diagnosis of esophageal motility disorders. However, their impact on the diagnosis and treatment of patients with dysphagia remains uncertain. The primary aim of our study was to compare SM, HRM and HRM+CC for: 1) The diagnostic yield for motility disorders 2) The resulting treatment recommendations 3) The degree of inter-observer agreement for motility disorders.
Methods: A retrospective review was performed on 101 patients with symptoms of dysphagia who underwent HRM at two tertiary care hospitals. Using Manoview 2.0 software, each study was de-identified and transformed into 3 separate files: 1) SM study using line plots derived from virtual 7 channel manometry 2) HRM study using 36-channel HRM spatial topographic plots 3) HRM+CC study utilizing calculations for key CC variables (eSleeveTM 3s-nadir, Distal Contractile Integral, Pressure Front Velocity). Each file was randomized and then analyzed by two blinded independent reviewers who recorded the diagnosis and recommended treatment.
Results: Analysis using HRM and HRM+CC resulted in statistically significant increases in the diagnostic yield for achalasia compared to SM (Figure 1). There were no significant changes in the yield for diffuse esophageal spasm, nutcracker esophagus, or non-specific motility disorders. Compared to SM, HRM and HRM+CC would have led to changes in clinical management 20% and 27% of the time respectively. HRM and HRM+CC resulted in the increased use of surgical/endoscopic therapy (HRM: 15.8%, HRM+CC: 14.9%, SM: 5%, p=0.03). There were no differences in inter-observer agreement for motility disorders using the 3 modalities except for a trend towards greater agreement for achalasia with HRM+CC (100% vs. 60% for SM, p=0.05).
Conclusion: HRM and HRM+CC have a significant impact on the diagnostic approach towards dysphagia by increasing the diagnostic yield for the one esophageal motility disorder (achalasia) that has a definitive treatment. The Chicago Classification enhances HRM by increasing the inter-observer agreement for achalasia. The use of HRM and HRM+CC has significant ramifications for the clinical management of dysphagia.