Revisiting the Reliability of the Endoscopy and Sedation-Assisted High-Resolution Esophageal Motility Assessment

Abstract

Background Esophageal high-resolution manometry (HRM) is performed for evaluation of dysphagia or the pre-operative evaluation before esophageal surgery. The esophageal manometry parameters, interpreted as per the Chicago classification (CC), are meant to be acquired in an awake state. At times, the patient intolerance or inability to traverse the manometry catheter across the esophagogastric junction (EGJ) renders incomplete esophageal motility evaluation; hence, sedation or endoscopy assistance is required. There have been concerns raised regarding the use of sedation and resultant alteration of the manometry parameters. The aims were to study the effects of intravenous sedation on esophageal motility parameters and analyze its impact on outcomes of patients with dysphagia who are intolerant to awake manometry procedure. Methods The study population comprised patients who had sedation or the endoscopy assistance for the HRM. The indication for HRM, necessity for the sedation, manometry findings, barium esophagogram results, procedural timings and patient outcomes were reviewed. The diagnostic impact of the 10% correction in integrated relaxation pressure (IRP) was also studied. Results There were 14 patients from 179 awake manometry procedures that required the sedation or the endoscopy assistance. The mean age was 60.7 years and there was equal gender distribution. Dysphagia (n = 9) remained the predominant indication for the HRM, followed by the pre-operative evaluation for the esophageal surgery (n = 5). In eight patients, awake manometry failed due to the coiling of the catheter above the EGJ and six patients were intolerant to awake catheter insertion technique. Six patients were diagnosed with achalasia and two with EGJ obstruction. The correction of the possible 10% inflation of the IRP did not alter the final diagnosis in majority except one patient with the EGJ obstruction. The findings of the barium esophagogram corroborated the manometry diagnosis. Conclusion Esophageal HRM should be done in awake state as much as possible. Sedation may be a feasible option as against aborting the further workup in patients who fail with current techniques involving awake catheter insertion. However, one needs to be mindful of sedation effects on manometry parameters and interpret results carefully.

Performing High-resolution Impedance Manometry After Endoscopy With Conscious Sedation Has Negligible Effects on Esophageal Motility Results

“…Studies support that trans-nasal catheter placement fails in 6% to 19% of patients and this is primarily related to discomfort and abnormal anatomy. 3,4,16 Thus, endoscopic placement under conscious sedation has been used to improve comfort of placement and help place the catheter through the EGJ in patients with achalasia and large hernias. However, 2 factors related to this practice could potentially result in differences in manometry metrics and diagnosis: the impact of sedation and the impact of thermal pressure drift.…”

“…1 Additionally, previous studies have reported sedationassisted esophageal manometry, which may aid completion of manometry for patients who could not tolerate the test during awake placement of the manometry catheter. [2][3][4] Placing the catheter while the patient is under sedation can help mitigate some of the discomfort and help complete the exam. Additionally, some situations require endoscopic-guidance of the manometric catheter to achieve the necessary positioning across the esophagogastric junction, eg, esophageal tortuosity with large hiatal hernia or achalasia.…”

Same‐day opioid administration in opiate naïve patients is not associated with opioid‐induced esophageal dysfunction (OIED)

“…Consequently, this would suggest that scheduling times between EGD and HRM do not need to be delayed. Further, approximately 7% of patients undergoing HRM may require sedation for accurate placement of the HRM catheter due to intolerance or anatomic considerations, including endoscopic assistance 34,35. Our findings suggest that administration of midazolam and opiates for a same-day endoscopy in such cases likely does not undermine the validity of the HRM findings.Our study has several key limitations.…”

A Comparative Assessment of the Diagnosis of Swallowing Impairment and Gastroesophageal Reflux in Canines and Humans

“…These restraint devices can also facilitate free-feeding protocols during which the dog voluntarily consumes liquid and solid boluses (41,166,198). However, sedation could still be required to calm anxious dogs to facilitate the study, which can potentially alter esophageal motility (201) and sphincter tone (199). Furthermore, stressed, anorexic, or severely ill dogs may refuse to voluntarily prehend the bolus, requiring force-feeding practices that increase the risk of aspiration pneumonia or pre-empt a complete evaluation.…”