Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / @xirurgi_2025 / @xirurgi_2025 - 566 - файл
.pdf
11 High-Resolution Esophageal Manometry with and…
https://t.me/medicina_free
161
pressure, but in this case, there is no retrograde movement of
gastric uid but only retrograde movement of gas. Patients
with supraesophageal belching show a decrease in UES pressure not associated with swallow, demonstrating esophageal
venting.
5. Post-Fundoplication HRM: HRM is useful in the evaluation
of post-fundoplication patients not only for the accurate placement of the pH probe, but also to assess patients that have persistent, recurrent, or newly developed symptoms after surgery.
HRM analyzes the efcacy of the antireux barrier (LES—
Crura), LES pressure and position, and IRP. In general, if there
is normal LES pressure and relaxation and the LES and the
crura generate a single distal high-pressure zone, it is assumed
that the fundoplication is intact and in an intraabdominal position. If there is a hypotensive LES pressure with normal relaxation and the LES and the crura generate a single distal
high-pressure zone, it is possible that the fundoplication is disrupted. On the other hand, if there is hypertensive LES pressure and incomplete relaxation, it is assumed that the
fundoplication is too tight, twisted, or misconstructed
(Fig.11.26). A dual distal high-pressure zone suggests that a
slipped fundoplication is intact and in an intraabdominal position [20] (Fig.11.27).
6. Post-Myotomy HRM: HRM is very useful for the preopera-
tive and postoperative evaluation of patients with esophageal
motility disorders with elevated IRP such as achalasia, DES,
and in some patients with EGJ outow obstruction
(Fig.11.28).
In such patients, HRM can be useful for the assessment of
patients with recurrent symptoms after either surgical or endoscopic treatment. This can be caused by an incomplete myotomy, scarring at the myotomy site, a tight partial fundoplication,
or megaesophagus. The presence of a persistent LES pressure
of >10 mmHg, elevated IRP, and failure to achieve at least
50% reduction in LES pressure from baseline have been associated with poor outcomes [21].
162
https://t.me/medicina_free
M. R. Youssef et al.
Fig. 11.26 Twisted fundoplication
11 High-Resolution Esophageal Manometry with and…
https://t.me/medicina_free
Fig. 11.27 Achalasia post-fundoplication
163
Fig. 11.28 High-resolution esophageal manometry after a failed Heller’s
myotomy with Dor fundoplication in a patient with achalasia Type II.The
patient had ongoing dysphagia. The LES does not relax appropriately (IRP
31) and suggests a persistently elevated LES pressure along with a relatively
tight wrap. There is a horizontal band of high pressure from 38 to 42cm
164
https://t.me/medicina_free
M. R. Youssef et al.
Provocative Tests
1. Multiple Rapid Swallows (MRS)
Multiple rapid swallows assess the ability of the esophageal
smooth muscle to withhold contraction during repetitive swallowing (deglutitive inhibition) and to produce a strong esophageal body peristaltic contraction following the last swallow
(peristaltic reserve). The absence of peristaltic reserve is associated with a higher likelihood of dysphagia following antireux surgery. The MRS consists of at least four 2-ml water
swallows performed in rapid succession, with ≤4-s interval
between swallows and the LES [22] (Fig.11.29).
2. Rapid Drink Challenge
The patient drinks 100 to 200mL of water through a straw
as quickly as possible. The rapid drink challenge assesses for
esophageal outow obstruction, and the increased volume of
uid can create a visible obstructive pattern with the compart-
Fig. 11.29 Multiple rapid swallow (MRS) responses. (a) Normal and repro-
ducible MRS response showing profound inhibition of the esophageal body
and lower esophageal sphincter (LES) during the swallows and rebound
esophageal body contraction with the regaining of LES tone following the
last swallow of the series. Both MRS sequences are alike and concordant. (b)
Discordant MRS response, showing normal inhibition and normal contraction response with the rst MRS sequence, and normal inhibition but absent
contraction response with the second sequence. (c) Discordant MRS response,
showing abnormal inhibition with both sequences, intact contraction with the
rst sequence and absent contraction with the second. The esophageal body
and lower esophageal sphincter (LES) during the swallows and rebound
esophageal body contraction with regaining of LES tone following the last
swallow of the series. Both MRS sequences are alike and concordant. (B)
Discordant MRS response, showing normal inhibition and normal contraction response with the rst MRS sequence, and normal inhibition but absent
contraction response with the second sequence. (C) Discordant MRS
response, showing abnormal inhibition with both sequences, intact contraction with the rst sequence and absent contraction with the second
16511 High-Resolution Esophageal Manometry with and…
https://t.me/medicina_free
166
https://t.me/medicina_free
mentalization of intrabolus pressure or panesophageal
pressurization in the esophageal body if there is an obstructive
process at the EGJ.
3. Standardized Test Meal and Postprandial Monitoring
Administration of a meal during the HRM procedure can be
useful in demonstrating an obstructive pattern in patients with
dysphagia when standard water swallows do not demonstrate
abnormality. Monitoring for 30 to 60min following a test meal
can be helpful in diagnosing rumination syndrome and supragastric belching. Upright swallows can be benecial in evaluating the reliability of the identication of esophageal outow
obstruction. Viscous swallows, bread swallows, and marshmallow swallows have been used as part of provocative testing
during HRM with stationary impedance but are not as universally utilized as multiple rapid swallows and the rapid drink
challenge.
M. R. Youssef et al.
Updates withChicago Classication v4.0
In the 5years since the publication of CCv3.0, both the clinical
and research applications of HRM have expanded, introducing
novel metrics and the widespread adoption of new therapies, particularly endoscopic myotomy. In order to update the Chicago
Classication, an International HRM Working Group consisting
of 52 diverse experts worked for 2 years and utilized formally
validated methodologies [23].
CC4 has sought to address issues regarding the patient position
that were a criticism of CC3. However, that protocol is often
insufcient to establish a denitive motility diagnosis that explains
symptoms and guides therapy. The new protocol described suggests that clinicians start with the patient in whichever position
they usually start and regard this as the “primary position.” The
study should proceed for the ten wet swallows as usual. An additional set of ve wet swallows should then be performed with the
patient in the alternate or “secondary position.” The differences in
normative values for catheter design and patient position should
be considered with some example references. Clinicians should
activity)
episodes.
11 High-Resolution Esophageal Manometry with and…
https://t.me/medicina_free
167
Table 11.2 Supportive manometric measures which may increase condence for a disorder. Adapted from CC41
Supportive measure
Multiple Rapid Swallows
(MRS)
Rapid Drink Challenge
(RDC)
Solid Test Swallows
Solid Test Meal (STM)
Post-Prandial Meal (High resolution impedance
manometry)
Protocol Normal response
Five swallows of 2-mL liquid at 2-3 s
intervals
Rapid drink of 200 ml of liquid
3
Ten swallows of ~1-cm
bread, soft boiled rice, marshmallow)
200 g of soft solid meal (eg soft boiled)
rice, bread) ingested at normal rate
for patient. Study stopped if STM not
completed in 8-min.
Administration of a STM or self-identified
symptom inducing meal followed by
extended monitoring (minimum of 10
min and occurrence of abnormal
soft solid (eg
Absense of esophageal body contractility (DCI <100 mmHg*s*cm)
with complete degulatitive inhibition of the LES during MRS and
presense of post-MRS contraction augmentation (DCI post-MRS
greater than single swallow mean DCI)
Absense of esophageal body contractility (DCI <100 mmHg*s*cm)
with complete degulatitive inhibition of the LES during RDC and
no evidence of major motility disorder post-RDC.
Presence of >20% pharyngeal swallows being followed by
an effective esophageal contraction defined by DCI
>1000 mmHg*s*cm and without a large break (>5 cm) in the
contractile front.
Presence of >20% pharyngeal swallows being followed by an
effective esophageal contraction defined by DCI >1000 mmHg s-cm and without a large break (>5 cm) in the contractile front.
No Symptoms during STM (any symptoms should be recorded in
electronic record to assess association with abnormal motility or
function). Show eating with <200 g ingested during 8 minuted also
considered abnormal.
Absense of symptoms and abnormal motility or function during
post-prandial period. Maximum 4 transient LES relaxations
(TLESRs) with belching during initial 10-min post-prandial, no
volume regurgitation, no remination or supra-gastric belching
also consider performing two provocation tests as standard. The
Multiple Rapid Swallow 2 (MRS or 5×2ml challenge) is now
well established and can indicate the peristaltic reserve [24]. The
Rapid Drink Challenge 3 (RDC or 200ml challenge) can further
assess esophagogastric junction (EGJ) outow [25]. Both are
dened in terms of execution and normative parameters within the
classication. Parameters are given for solid swallows (e.g.,
bread, rice, and marshmallow) with the suggestion given for a
solid test meal (Table11.1). However, it is stressed that any abnormal ndings should correspond to the patient’s symptoms (e.g.,
dysphagia or chest pain), the absence of which may render the
ndings clinically insignicant (Table11.2).
Motility Disorders
The use of a hierarchy of disorders is maintained in CC4 with a
note that the classication applies to normal anatomy (i.e., an
absence of previous signicant intervention/surgery or large
Hiatal hernia). The need for initial endoscopy or a Barium study
is also emphasized. A scheme for applying the classication can
be found in Fig. 11.1. Achalasia and absent contractility have
168
https://t.me/medicina_free
Fig. 11.30 Chicago Classication 4.0 Hierarchical Classication Scheme
M. R. Youssef et al.
stood the test of time and remain essentially unchanged. EGJOO
and IEM underwent a complete redenition. Changes to DES and
hypercontractile esophagus were considered, but there were insufcient data to merit major revision; however, both require further
investigation and future updates (Fig.11.30).
Conclusions
High-resolution manometry (HRM) has become the gold standard
for the diagnosis of esophageal motility disorders. This technique
has not only made esophageal manometry more comfortable and
tolerable for the patient since pull-through is not required, but also
easier and faster for the operator. The combination of HRM and
multichannel intraluminal impedance (MII) provides information
regarding esophageal motility, bolus transit, and esophageal clearance and can be valuable in the differential diagnosis of disorders
resembling GERD.
Using HRM metrics and utilizing an algorithmic scheme, the
Chicago Classication (CC) has signicantly improved the recognition and management of esophageal motor disorders. However,
the CC is a work in progress. While the manometry software pro-
11 High-Resolution Esophageal Manometry with and…
https://t.me/medicina_free
169
vides a computer-generated analysis of the study, the computerized analysis is imperfect. For that reason, an experienced
clinician must review each swallow and provide a nal interpretation since an inadequate diagnosis can adversely affect patient
outcomes.
The combination of HRM and multichannel intraluminal
impedance (MII) provides information regarding esophageal
motility, bolus transit, and esophageal clearance. For those reasons, HRIM can be valuable in the differential diagnosis of disorders resembling GERD, in patients with nonobstructive dysphagia,
post-fundoplication dysphagia, and discriminate reux episodes
associated with TLESRs.
Lastly, HRM should ideally be performed in a practice environment with therapeutic expertise in treating motility disorders.
References
1. Clouse RE, Staiano A.Topography of the esophageal peristaltic pressure
wave. Am J Physiol. 1991;261(4 Pt 1):677–84.
2. Schlottmann F, Herbella FA, Patti MG.Understanding the Chicago classication: from tracings to patients. J Neurogastroenterol Motil.
2017;23(4):487–94.
3. Conklin JL.Evaluation of esophageal motor function with high- resolution
manometry. J Neurogastroenterol Motil. 2013;19:281.
4. Kahrilas PJ, Bredenoord AJ, Fox M, Gyawali CP, Roman S, Smout
AJPM, etal. The Chicago classication of esophageal motility disorders,
v3.0. Neurogastroenterol Motil [Internet]. 2015;27(2):160–74. Available
from: http://web.a.ebscohost.com.libproxy.tulane.edu:2048/ehost/detail/
detail?vid=0&sid=0b86f1de- 375c- 4480- 85c4- 1925e20d34d3%40sdc- vsessmgr03&bdata=JkF1dGhUeXBlPWlwLHNzbyZzaXRlPWVob3N0L
WxpdmUmc2NvcGU9c2l0ZQ%3D%3D#AN=100631580&db=a9h.
5. Kahrilas PJ, Ghosh SK, Pandolno JE.Esophageal motility disorders in
terms of pressure topography: the Chicago classication. J Clin
Gastroenterol. 2008;42:627.
6. Bredenoord AJ, Fox M, Kahrilas PJ, Pandolno JE, Schwizer W, Smout
AJPM. Chicago classication criteria of esophageal motility disorders
dened in high resolution esophageal pressure topography.
Neurogastroenterol Motil. 2012;24:57.
170
https://t.me/medicina_free
7. Carlson DA, Kahrilas PJ.How to effectively use high-resolution esophageal manometry. Gastroenterology [Internet]. 2016;151(5):789–92.
https://doi.org/10.1053/j.gastro.2016.09.024.
8. Herregods TVK, Roman S, Kahrilas PJ, Smout AJPM, Bredenoord
AJ. Normative values in esophageal high-resolution manometry.
Neurogastroenterol Motil. 2015;27:175.
9. Xiao Y, Read A, Nicodème F, Roman S, Kahrilas PJ, Pandolno JE.The
effect of a sitting vs supine posture on normative esophageal pressure
topography metrics and Chicago Classication diagnosis of esophageal
motility disorders. Neurogastroenterol Motil. 2012;24:e509.
10. Patel A, Gyawali CP.How to optimally apply impedance in the evaluation
of esophageal dysmotility. Curr Gastroenterol Rep. 2016;18:60.
11. Conchillo JM, Smout AJ.Review article: intra-oesophageal impedance
monitoring for the assessment of bolus transit and gastro-oesophageal
reux. Aliment Pharmacol Ther. 2009;29:3.
12. Roman S, Lin Z, Kwiatek MA, Pandolno JE, Kahrilas PJ.Weak peristalsis in esophageal pressure topography: classication and association with
dysphagia. Am J Gastroenterol. 2011;106:349.
13. Dhawan I, O’Connell B, Patel A, Schey R, Parkman HP, Friedenberg
F.Utility of esophageal high-resolution manometry in clinical practice:
rst, do HRM.Dig Dis Sci. 2018;63:3178.
14. Roman S, Zerbib F, Belhocine K, Bruley Des Varannes S, Mion F.High
resolution manometry to detect transient lower oesophageal sphincter
relaxations: diagnostic accuracy compared with perfused-sleeve manometry, and the denition of new detection criteria. Aliment Pharmacol Ther.
2011;34:384.
15. Tutuian R, Castell DO.Combined multichannel intraluminal impedance
and manometry claries esophageal function abnormalities: study in 350
patients. Am J Gastroenterol. 2004;99:1011.
16. Koya DL, Agrawal A, Freeman JE, Castell DO. Impedance detected
abnormal bolus transit in patients with normal esophageal manometry.
Sensitive indicator of esophageal functional abnormality? Dis Esophagus.
2008;21(6):563–9.
17. Conchillo JM, Selimah M, Bredenoord AJ, Samsom M, Smout
AJPM. Assessment of oesophageal emptying in achalasia patients by
intraluminal impedance monitoring. Neurogastroenterol Motil.
2006;18:971.
18. Yigit T, Quiroga E, Oelschlager B.Multichannel intraluminal impedance
for the assessment of post-fundoplication dysphagia. Dis Esophagus.
2006;19:382.
19. Tutuian R, Vela MF, Balaji NS, Wise JL, Murray JA, Peters JH, etal.
Esophageal function testing with combined multichannel intraluminal
impedance and manometry: multicenter study in healthy volunteers. Clin
Gastroenterol Hepatol. 2003;1:174.
M. R. Youssef et al.
Соседние файлы в папке @xirurgi_2025