Endoscopically assisted water perfusion esophageal manometry with minimal sedation: technique, indications, and implication on the clinical management.

GOALS: To demonstrate feasibility and clinical utility of endoscopically assisted manometry (EAM).
BACKGROUND: Esophageal manometry performed without sedation is the standard for assessment of esophageal motility. However, some patients cannot tolerate the procedure with intranasal intubation. We have accumulated experience performing EAM with minimal sedation on patients who cannot tolerate standard esophageal manometry. STUDY: We report our single center experience of EAM in adult patients. Patient records were analyzed retrospectively. PROCEDURE PROTOCOL: Upper endoscopy is performed with minimal sedation to place a guide wire, over which a water perfusion manometry catheter is introduced and standard manometry protocol performed.
RESULTS: From 2007 to 2009, 51 patients underwent EAM, 41 (80.4%) for failed transnasal esophageal manometry and 10 (19.6%) for Zencker diverticulum, achalasia, or neurologic disease. Five patients could not tolerate the procedure despite sedation. No early or late complications were recorded and 100% of the completed procedures were diagnostic: 15 (32.6%) patients had a normal study, 13 (28.3%) were diagnosed with achalasia, 12 (26.1%) patients had low lower esophageal sphincter pressure, 10 (21.7%) patients showed ineffective esophageal motility, 3 (6.5%) patients had hypertensive lower esophageal sphincter, and 1 (2.2%) patient had nutcracker esophagus. Completed procedures resulted in treatment for achalasia (33.3%), medication changes (33.3%), completion of preoperative assessment for antireflux surgery (27.7%), or no impact clinical management (11.1%). EAM had a direct clinical impact on 89% of patients.
CONCLUSIONS: EAM is a safe, reliable, and feasible technique providing objective diagnostic information that directly impacted clinical management in many problematic patients where the standard procedure failed.