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Ascona 2011: Proceedings of the HRM Working Group Neurogastroenterology & Motility Neurogastroenterol Motil (2012) 24 (Suppl. 1), 1 PREFACE Ascona 2011: Proceedings of the HRM Working Group Conference–Introduction for the Proceedings of the Ascona Conference on Advances in Clinical Investigation of Esophageal Dysmotility and Reflux Disease In April 2011, a conference ÔAdvances in clinical Group that began in San Diego at Digestive Disease investigation of esophageal dysmotility and reflux Week 2008. The core content of the classification diseaseÕ was held in Ascona, Switzerland. The confer- scheme was approved by the Working Group in Ascona ence was organized by members of the High-Resolu- and the lead authors were then charged with drafting tion Manometry Working Group chaired by Associate the manuscript for publication in this supplement of Professor Dr. Mark Fox to bring together an interna- Neurogastroenterology and Motility. This classifica- tional group of physicians and scientists with the aim tion scheme is built on robust experimental data, and to: provides a clinically relevant hierarchy of diagnosis. It 1 Introduce the new ÔChicago Classification Criteria of has been endorsed by both the European and American Esophageal Motility Disorders Defined in High Neurogastroenterology and Motility Societies in addi- Resolution Esophageal Pressure TopographyÕ. tion to many other professional organizations. The 2 To present guidelines that incorporate the current authors hope that this unique consensus will not only state of the art for investigation and management of promote better understanding of esophageal motility esophageal motility disorders and gastro-esophageal disorders amongst clinicians, but also provide a solid reflux disease. foundation for future research. Additionally this sup- 3 To provide practical training to ensure best practice plement provides a collection of focused topic reviews, and maximum patient benefit wherever these tech- highlights of the Ascona conference, on specific nologies are applied. aspects of esophagology that reference the Chicago The Ascona meeting was supported by all the Classification and its use in clinical practice. leading manufacturers of diagnostic instruments uti- Thus, on behalf of the members of the High-resolu- lized in the assessment of esophageal motility and tion Manometry Working Group, the Editorial Board of gastro-esophageal reflux. Industry representatives and Neurogastroenterology and Motility and finally the engineers attended as observers because the clinical professional organizations who have provided their practice of esophagology is inseparable from develop- endorsement of the Chicago Classification, we present ments in hardware and software. the proceedings of the Ascona Conference. The key outcome of the Ascona meeting was the introduction of the ÔChicago Classification of esopha- John Pandolfino* Mark Fox geal motility disordersÕ, the culmination of a series of *Chicago, IL, USA meetings of the High-Resolution Manometry Working Nottingham & Zurich, Switzerland, UK Ó 2012 Blackwell Publishing Ltd 1 Neurogastroenterology & Motility Neurogastroenterol Motil (2012) 24 (Suppl. 1), 2–4 REVIEW ARTICLE High resolution manometry: the Ray Clouse legacy C. P. GYAWALI From the Division of Gastroenterology, Washington University School of Medicine, St. Louis, MO, USA Esophageal manometry assesses pressure phenomena, from above as a spatiotemporal plot (Fig. 1). We now peristalsis and bolus transit in the esophagus. Older recognize these plots as a characteristic of HRM. ÔconventionalÕ manometry techniques recorded esoph- Next, Clouse worked on streamlining the process of ageal peristalsis using 5–8 widely spaced water per- data acquisition. Collaboration with Dentsleeve re- fused channels in an esophageal motility catheter. Two sulted in a 0.4 cm extruded, 21 lumen silicon water significant advances in the 1990s, an increase in perfused catheter, and complementary software was pressure sensors along the catheter, and use of spatio- developed by Medical Measurement Systems (MMS, temporal plots for data display, led to what is now Enschede, Holland).2,3 The manometry procedure recognized as high-resolution manometry (HRM).1,2 remained cumbersome, the pull through maneuver HRM was the concept and innovation of a remarkable had not been eliminated, and only 75–80% of the esophagologist, researcher and educator, the late Ray esophagus could be interrogated at a time. Neverthe- Eugene Clouse, MD. less, there were significant advances in our under- HRM has its roots in conventional perfused manom- standing of esophageal peristalsis, which was now etry. Clouse decided that the esophagus was holding shown to consist of a chain of contracting segments secrets between the widely spaced recording points of his conventional manometry catheter. He tested his Table 1 Original concepts of HRM utilization hypothesis by continuing the pull through maneuver 1 cm at a time till the last recording channels reached Evaluation Applicability the upper esophageal sphincter (UES), obtaining at least one wet swallow at each station.1 When the swal- Pharyngo-UES function lows were aligned, the jumble of tracings he obtained Nature of motor disorder Clinical/research Peristaltic integrity could not be easily interpreted. It was time for another Contraction segments, Research/clinical Clouse innovation – the spatiotemporal contour plot. segmental abnormalities Clouse, along with Annamaria Staiano, MD, digitized Types of severe dysfunction Clinical/research the tracings using a hand held digitizer, and assigned New motor patterns Clinical/research colors to amplitude levels.1,2 Software programs pro- LES dysfunction Achalasia Clinical/research vided best fit data points in between the recording Incomplete obstructive Research/clinical sites. The final result was a smooth topographic map of patterns the esophageal peristaltic wave. Since amplitudes were Fundoplication errors Clinical/research color coded, topographic contours could be viewed Anatomic considerations Location of LES Clinical Esophageal length Clinical Address for Correspondence Hiatus hernia Clinical/research C. P. Gyawali MD, MRCP, Professor of Medicine, Division of Motility education Education/clinical/research Gastroenterology, Washington University School of Medicine, Future direction Campus Box 8124, 660 S. Euclid Avenue, St. Louis, MO 3D HRM Research 63110, USA. HRIM Research/clinical Tel: +314 454 8201; fax: +314 454 5107; Outcome studies Research e-mail: [email protected] Received: 4 September 2011 UES, upper esophageal sphincter; LES, lower esophageal Accepted for publication: 14 September 2011 sphincter; HRIM, high resolution impedance manometry. 2 Ó 2012 Blackwell Publishing Ltd Volume 24, Supplement 1, March 2012 HRM: the Ray Clouse legacy Figure 1 The concept of high resolution manometry (HRM). Closely spaced recording sensors on an esophageal motility catheter (A) generate multiple recordings throughout the esophagus (B). Dashed arrows point to pressure recordings from individual sensors. Computer software fills in best fit data between the recording sensors 1 cm apart, and color codes amplitude levels (C). Finally, the image is smoothed out electronically, and displayed as a topographic contour plot (D) representing the peristaltic sequence when viewed from above. The contour plots are termed Clouse plots in honor of Ray Clouse, who developed HRM. separated by troughs.4 We quickly learned that esoph- Parks, PhD, who formed a new company, Sierra ageal smooth muscle consisted of not one but two Scientific, Inc. to advance the field. The new millen- contracting segments.5 These segments merged to- nium heralded a collaborative effort which culminated gether in hypercontractile states, and demonstrated in the development of a solid state catheter, with 36 wide troughs and low amplitudes in hypomotility high fidelity circumferential sensors.9 The stationary disorders.4–6 We also learned that esophageal shorten- pull through maneuver was now obsolete, as the entire ing could move the lower esophageal sphincter (LES) esophagus from pharynx to stomach could be viewed proximal to even sleeve LES sensors, and that HRM real time. New software programs were written, and an provided higher accuracy in achalasia diagnosis be- electronic sleeve was developed to interrogate LES post cause LES excursion could be followed and abnormal swallow residual pressures (ManoViewÔ, eSleeveÔ, relaxation documented despite this shortening.7,8 Sierra Scientific, Inc., Los Angeles, CA, USA).9,10 Many motor disorders were associated with recogniz- These baby steps in the early 2000s have been able HRM patterns, and diagnoses could be made with augmented exponentially in the past 5 years, as HRM just pattern recognition in many instances. But the technology moved from St. Louis to Chicago and system was not yet optimal for widespread clinical use, beyond.11,12 HRM systems are now available from a and more work is needed to be done. handful of companies, for not just esophageal manom- As technology progressed toward solid state pressure etry (sometimes combined with stationary impedance), sensors, Clouse found a key collaborator in Thomas but also anorectal, colonic and antroduodenal manom- Ó 2012 Blackwell Publishing Ltd 3 C. P. Gyawali Neurogastroenterology and Motility etry. An even higher definition technique (3D HRM) develop uniformity in data collection and analysis. He uses tactile sensors, and has been introduced for envisioned that HRM would make a major impact on anorectal manometry; it is being researched for
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