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

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.