Introduction

Esophageal dysmotility may be the direct cause for esophageal diseases, the primary esophageal motility disorders (PEMD). Achalasia is certainly the disease in this category with a reasonable consensus about pathophysiology, diagnosis, and treatment ¹. Esophageal motility may be secondarily affected by other esophageal diseases as well, especially gastroesophageal reflux disease (GERD) ².

Esophageal motility evaluation is currently delegated to high-resolution manometry (HRM). This tool is more precise and objective than radiologic evaluation ³. HRM presently guides esophageal motility disorders classification and nomenclature. The most adopted classification is the Chicago Classification, periodically revised and now in its 4^th edition ⁴.

Despite a growing enthusiasm, development of new parameters, improved technology and even “discovery” of new diseases with HRM, it is elusive if HRM is only a superb tool to diagnose the same previous diseases perhaps with different names or a real therapy-changer instrument. This review aims to search current evidence for HRM as a tool for therapeutic decision changes regarding esophageal diseases.

Methods

A literature review was conducted on PubMed database restricting results to English language and studies in adults. Key terms used were “Manometry” AND “Bariatric Surgery” OR “Esophageal Motility Disorders” OR “Gastroesophageal Reflux”, with 4,843 results. References of the retrieved papers were manually reviewed. This review is not intended to be a systematic review of results but a narrative review supported by the personal experience of a panel of experts in esophageal surgery and physiology.

Achalasia

Achalasia is defined by HRM similarly to conventional manometry: incomplete relaxation of the lower esophageal sphincter (LES) associated with aperistalsis ⁵. Some ⁶, however, questioned the “all or nothing at all” concept for aperistalsis, defining achalasia variants with some sort of peristalsis. This was also contemplated by the Chicago Classification group as well ⁷. We personally have never found these variants ⁸. Latin American authors, similarly, and before these classifications, called attention to “undetermined” forms of achalasia in patients with Chagas´ disease and manometric alterations apart from aperistalsis ⁹. We never agreed with this proposal since individuals with Chagas’ disease may not necessarily present with the achalasia-like esophagopathy and may simply have GERD ¹⁰. In any case, literature is silent whether these cases deserve a different treatment or even have a distinct prognosis.

Chicago Classification classified achalasia in three types according to esophageal pressurization (Figure 1) ¹¹. Different prognoses in general were initially attributed to these types ¹². Latter studies were able to show better outcomes for specific therapies according to the type. Andolfi and Fisichella ¹³ compiled the results in a metanalysis for 1575 patients in 20 studies on a mean follow-up time ranging from 17 to 31 months depending on the type of treatment. Unfortunately, dysphagia relief was the only measured outcome. It must be remembered that GERD may be a drawback for many therapeutic alternatives and considered during clinical decision. A summary of their findings (Table 1) was that peroral endoscopic myotomy (POEM) is the modality with superior results for type I and III. POEM and Heller´s myotomy have similar outcomes for type II. Forceful endoscopic dilatation is the least efficacious treatment but similar to Heller’s myotomy for type III. A careful look at the results for Type III, however, shows that one study is an outlier for Heller´s myotomy worse results. This study ¹⁴ did not perform an extended myotomy that brings better results than the conventional length for types I and II ¹⁵.

Figure 1.
Manometric achalasia types. Type 1 is characterized by absence of esophageal pressurization with swallows; Type II has panesophageal pressurization in 20% or more swallows; and Type III is characterized by spasm (20% or more swallows with premature contraction).

Table 1.
Outcomes based on manometric achalasia types according to different treatments ¹³.

POEM: peroral endoscopic myotomy; Heller: laparoscopic Heller´s myotomy and fundoplication; Dilatation: endoscopic forceful pneumatic dilatation of the cardia.

HRM may also be useful to guide myotomy length, especially in type III that an extended myotomy is necessary. Apparently, better outcomes can be achieved when the myotomy is tailored based on HRM measurement of the spastic segment ^16,17 (Figure 2).

Figure 2.
Manometric extension of the spastic segment in type III achalasia. This extension (circle) may be used to tailor myotomy length.

Gastroesophageal reflux disease

HRM has clear advantage over conventional manometry in the evaluation of the sphincters due to the elimination of motion artifacts. The high density of sensors allows the sphincter to be always measurable despite its excursion with respiration or swallow that would place it outside the sensor range in conventional manometry. More than this, HRM allowes the creation of more complex parameters to measure lower esophageal sphincter (LES) basal and relaxation pressures ¹⁸. Even these complex parameters did not make the diagnosis of GERD by manometry only possible, even considering the interaction with the transdiaphragmatic pressure gradient ¹⁹. Lyon Consensus 2.0, however, states that abnormal esophagogastric junction morphology, a compromised barrier and esophageal hypomotility are supportive for GERD diagnosis ²⁰.

Some groups of gastroenterologists ^21,22 tried to use HRM as predictor to medication refractoriness. These studies, however, mixes patients with positive and negative pH-monitoring. We do not believe these groups are comparable or even represent the same disease, preventing further discussion here.

There are no studies using HRM parameters as indication for antireflux surgery. A tailored approach -when patients with abnormal motility undergo a partial fundoplication and cases with normal motility a total fundoplication- has been recently revived. HRM parameter used to conceptualize abnormal motility is the distal contractility integral (DCI) ²³, a logic choice to match the wave amplitude from conventional manometry ²⁴. Other authors ²⁵, strangely, even include hypercontractile conditions in the group to undergo a partial fundoplication. Tailoring in these studies is based on surgeons’ preference and there is no evidence that HRM can correctly guide therapy and bring better outcomes.

HRM has been studied as a predictor for postoperative dysphagia. Most studies, however, could not find a positive result ²⁶. Preoperative ^27,28 and postoperative ^28,29 elevated LES integrated relaxation pressure has been, however, associated with postoperative dysphagia. Curiously, impaired LES relaxation is also the main cause of post-Nissen dysphagia in patients with normal motility or endoscopy ^30,31. No study suggested or offered a different treatment in this situation though. The only study that correlated esophageal motility with dysphagia is the one by Siegal et al. ³² that did not find HRM as predictor for postoperative dysphagia, but those with preoperative dysphagia and a DCI ≥ 1000 mmHg-s-cm were more prone to be free of dysphagia after the operation. The authors suggested that a partial fundoplication could be more adequate in this setting. Interestingly, however, mean DCI is a not a parameter proposed by the current Chicago Classification ⁴. The assessment of contractile reserve through multiple rapid swallows has also been studied. Results are controversial with some showing a positive correlation between dysphagia and absent reserve ³³ while others did not evidence significance for the test ³⁴.

Similar to the results for laparoscopic fundoplication, few studies are available regarding magnetic ring LES augmentation. Some fail to correlate HRM and outcomes ³⁵, while others did not correlate DCI to dysphagia ³⁶, but found more dysphagia in patients with ineffective esophageal motility ^36,37.

Bariatric surgery

HRM has not been an explored tool to define therapy in bariatric surgery. It is even questionable if HRM should be part of the preoperative work-up ³⁸. As part of the unsolvable question if patients with GERD should undergo sleeve gastrectomy, some authors suggest that sleeve gastrectomy should be contraindicated in the setting of a hypotonic LES ³⁹ although studies with objective evaluation (pH monitoring) do not show a correlation between postoperative GERD and preoperative LES pressure ⁴⁰. It must be noted that the LES may even be hypertonic in the obese with GERD due to a possible compensation for the increased transdiaphragmatic pressure gradient ⁴¹. Bonaldi et al. ⁴² found GERD in half of the patients that underwent sleeve gastrectomy and had a mean DCI < 1600 mmHg-s-cm before the operation. It must be emphasized that no pH monitoring was performed.

Other motility disorders

We previously discussed that HRM may guide myotomy length for achalasia type III. This is also true for other spastic and hypercontractile motility disorders. In fact, we were the first to propose this tailored extent ⁴³. Also, the presence of associate abnormal relaxation of the LES ⁴³ and higher DCI (30000) ⁴⁴ favors better outcomes for surgical therapy over clinical therapy in these patients.

Conclusions

HRM certainly contributed to the diagnosis of motility disorders not much as a tool for therapeutic decision changes. Despite based on low levels of evidence, HRM seems to help in the therapeutic decisions in these situations: (a) treatment can be tailored based on achalasia manometric types; (b) cardiomyotomy may be tailored in length in spastic disorders based on the manometric extension of the spastic waves; (c) a partial fundoplication may be more adequate in patients with elevated LES integrated relaxation pressure; and (d) surgical therapy is more efficient in patients with higher distal contractility integral and abnormal LES relaxation.

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Notes

Author notes

^aCorresponding author: Fernando A. M. Herbella MD, Department of Surgery, Escola Paulista de Medicina, Rua Diogo de Faria 1087 cj 301 Sao Paulo, SP, Brazil 04037-003. Tel: +55-11-99922824. E-mail: herbella.dcir@epm.br

Conflict of interest declaration