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Should the reproducibility of ambulatory esophageal manometry encourage more universal use of this technology?
R.M. Bremner, T.R. DeMeester (Los Angeles)
This question is probably best answered in two parts. Is ambulatory esophageal manometry clinically useful, and, if so, is it a reproducible test? Reproducibility alone should not encourage its diagnostic use. If the study is clinically useful, is reproducible, and can be performed easily with minimal discomfort to the patient, then the test should be considered for more widespread use.
Many studies have shown the benefit of ambulatory manometry as a diagnostic aid [1-3]. Early application in patients with non-cardiac chest pain showed an increased detection of motor abnormalities with prolonged monitoring although the yield of detection was still somewhat disappointing [4-8]. One of the reasons for this was that patients frequently did not have pain during the study. Application in patients with gastroesophageal reflux disease has shown a more profound motility defect than was realized with stationary manometry [9] Some patients have an inability to increase the amplitude and prevalence of peristalsis during meals. This has important implications when tailoring antireflux surgery to the motility abnormality, since performance of a full fundoplication in a patient with severe loss of contractility may result in post-operative dysphagia [10]. Ambulatory manometry has also clarified the diagnostic dilemmas that occur with motor disorders of the esophagus [11]. The technique has shown that patients with nutcracker esophagus, diffuse esophageal spasm, or a hypertensive lower esophageal sphincter, frequently are reclassified when monitored for a full circadian cycle. This may explain, in part, the disappointing results of medical and surgical therapy for these disorders. Prolonged monitoring also enables detection of episodic disorders which are frequently missed on stationary manometry. More recently we have found it has helped detect the specific motor abnormality responsible for dysphagia in patients with non-specific motor abnormalities on stationary manometry. It has also provided unique insight into the normal clearance mechanisms of the esophagus in response to naturally occurring reflux episodes [12-14].
There are two reports of repeated studies in normal volunteers which show that ambulatory manometry is reproducible [15, 16] Emde studied 24 healthy volunteers on two occasions 1-4 weeks apart and reported marked intraindividual reproducibility for amplitude and duration of contractions as well as for velocity of wave propagation [16]. Wang et al. found similar reproducibility when studying 10 healthy volunteers 2 weeks apart [15]. In fact, the coefficients of variation for the 10 motility parameters studied was less than for the simultaneous pH studies suggesting that ambulatory manometry is at least as reproducible as pH monitoring. The reproducibility suggests that contraction characteristics are stable over time. These studies noted a significant interindividual variation but we have recently found that this is less than for stationary manometry suggesting that analysis of the 1000 or more contraction waves from ambulatory manometry is more accurate than the 10 waves from stationary manometry.
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