Learners favour high resolution oesophageal manometry with better diagnostic accuracy over conventional line tracings

Abstract

Background High resolution manometry (HRM) provides a colourful representation of oesophageal motility. Novice and intermediate learners were tested to compare HRM Clouse plots and conventional manometry for accuracy, ease of interpretation and knowledge retention. Methods 36 learners evaluated 60 randomised motility sequences (30 HRM Clouse plots with corresponding line tracings) 4 months apart, following a tutorial. Learners rated prior knowledge of oesophageal pathophysiology and manometry and scored ease and speed of interpretation on 10 cm visual analogue scales (VAS). Results Understanding of oesophageal pathophysiology was low in all cohorts (2.9±0.4 on VAS) and knowledge of HRM and conventional motility studies was even lower (1.9±0.4 and 1.8±0.3, respectively, p=NS). After the tutorial, diagnostic accuracy was significantly higher with HRM Clouse plots than with line tracings (p<0.001). HRM gains in diagnostic accuracy were evident over line tracings (43.1%), particularly with aperistalsis (36.1%), oesophageal body hypomotility (25.8%) and relaxation of the lower oesophageal sphincter (21.0%) (p<0.001 for each comparison); these were maintained at the second evaluation. Gains were independent of academic level (F=0.56, p=0.5) and did not correlate with prior experience of learners (r=−0.18, p=0.29). Learners favoured HRM Clouse plots (80.6%) over line tracings and reported faster interpretation (94.4%). Conclusions HRM Clouse plots provide ease of interpretation that translates into higher diagnostic accuracy and better knowledge retention in novice and intermediate learners of oesophageal manometry. These results implicate the value of pattern recognition in HRM interpretation, irrespective of academic level and prior understanding of oesophageal motor function.

Factors Determining the Inter-observer Variability and Diagnostic Accuracy of High-resolution Manometry for Esophageal Motility Disorders

“…We also suggested several explanations for the results that were not in accordance with those of previous studies reporting the advantages of HRM over conventional manometry in diagnostic accuracy. 9,17 First, according to the Chicago classification version 3.0, the number of disease entities with the HRPT format was greater than that in the CLT format (9 vs 6) in the present study. Second, providing the manometry data as captured images from 10 significant swallows with calculated essential metrics, including IRP, DCI, DL, and CFV for the HRPT format and baseline and residual LES pressures, onset velocity and distal contractile amplitude for the CLT format may have facilitated the interpretation of the manometry data, especially in the CLT format.…”

Clinical Application of Esophageal High-resolution Manometry in the Diagnosis of Esophageal Motility Disorders

“…This provides a steep learning curve for both experts and trainees. 23,26 Also, the interobserver 27 and intraobserver 28 agreement is better in HRM than in conventional manometry. In a study comparing diagnostic accuracy and interobserver variability among interpreters with and without experience, HRM provided superior diagnostic accuracy compared to conventional manometry.…”

Esophageal high resolution manometry in a community practice

“…4 Soudagar et al have demonstrated that the novice trainee can be educated with simple didactic sessions to recognize major motor disorders by pattern recognition, even without the use of software tools. 1 The new Chicago classification system does use automated software tools, and has simplified algorithms for the diagnosis of these major motor disorders, especially achalasia and esophageal outflow obstruction, disorders where effective therapy exists. 5,6 Although even experts may disagree on the exact designation of each motor abnormality, 7 and certain motor abnormalities may be overlooked by the averaging software tools used in interrogation of Clouse plots, 8 the bottom line is that disorders that have relevance to explanation of transit symptoms such as dysphagia, and to identification of contraindications for antireflux surgery, can be recognized by the average HRM user.…”

“…5 Of equal importance, a normal motor pattern is also easy to identify on HRM Clouse plots. 1 A key determinant in accurate identification of major motor disorders is a technically adequate study. This requires an experienced nurse or technician, and investment in proper instruction and training of the HRM operator will deliver results in terms of diagnostic accuracy.…”