Valores normais da manometria de alta resolução de esôfago: estudo multicêntrico brasileiro / Normal values of esophageal high-resolution manometry: a brazilian multicenter study

ABSTRACT BACKGROUND: The high-resolution manometry has been a significant advance in esophageal diagnostics. There are different types of catheter and systems devices to capture esophageal pressures that generate variable data related to Chicago Classification (CC) and consequently influence normal values results. There are not normative data for the 24-channel water-perfused high-resolution manometry system most used in Brazil with healthy volunteers in supine posture. OBJECTIVE: To determine manometric esophageal normative values for a 24-channel water-perfused high-resolution manometry catheter in supine posture using healthy volunteers according to CC 3.0 parameters. METHODS: A total of 92 volunteers with no gastrointestinal symptoms or medications affecting GI motility underwent esophageal high-resolution manometry by standard protocol. Age, gender and manometry parameters analyzed using Alacer software were collected. The median, range, and 5th and 95th percentiles (where applicable) were obtained for all high-resolution manometry metrics. Normal value percentiles were defined as 95th integrated relaxation pressure, 5th-100th distal contractile integral, and 5th distal latency. RESULTS: The mean age was 40.5±13.2 years. Our normative metrics were integrated relaxation pressure <16 mmHg and distal contractile integral (708-4111 mmHg.cm.s) distal latency was <6 s and peristaltic break size (>4 cm). For EGJ-CI the range 5th-95th was 21.7-86.9 mmHg.cm.s. CONCLUSION: This is the first report of normative data for the 24-channel water-perfused system in supine posture. It revealed higher integrated relaxation pressure and distal latency duration which suggest the need to change CC 3.0 cutoffs for this system. It is observed that there is a tendency that DCI >7000 mmHg.cm.s may represent the lower limit of hypercontractility, and when <700 mmHg.cm.s (<5% percentile) interpreted as ineffective esophageal motility or failcontraction. Also compared to Chicago 3.0, higher integrated relaxation pressure and duration of distal latency were found. We emphasize that these data must be confirmed by future studies.

RESUMO CONTEXTO: A manometria de alta resolução tem sido um avanço significativo nos diagnósticos esofágicos. Existem diferentes tipos de cateteres e sistemas dispositivos para capturar pressões esofágicas que geram dados variáveis relacionados à Classificação de Chicago (CC) e, consequentemente, podem influenciar os resultados de valores da normalidade. Não há dados normativos com voluntários saudáveis na postura supina, para o sistema manométrico sob perfusão em água de 24 canais, o mais utilizado no Brasil. OBJETIVO: Determinar os valores normativos manométricos do esôfago para um cateter sob perfusão de alta resolução de 24 canais na postura supina utilizando-se voluntários saudáveis assintomáticos de acordo com os parâmetros CC. MÉTODOS: Um total de 92 voluntários sem sintomas gastrointestinais ou medicamentos que afetassem a motilidade gastrointestinal foram submetidos à manometria de alta resolução do esôfago por protocolo padrão (Sistema Alacer Multiplex). Foram coletados parâmetros de idade, sexo e os da manometria analisados pelo software Alacer versão 6.2. A mediana, os limites, e 5% e 95% percentis (quando aplicável) foram obtidos para todas as métricas de alta resolução. Os valores normais foram definidos como percentis de 95% da integral da pressão de relaxamento (IRP), 5%-100% da integral contrátil distal (DCI), e 5% latência distal. RESULTADOS: A média de idade foi de 40,5±13,2 anos. As métricas normativas foram definidas como IRP <16 mmHg) e DCI (708-4111 mmHg.cm.s). Para a latência distal foi de 5,8-9,9 s (faixa: 5,3-10,7s). O comprimento total de quebra na contração esofágica foi de 4,0 cm (faixa: 0,1-6,8 cm). Para a EGJ-CI a faixa 5%-95% percentis foi de 21,7-86,9 mmHg.cm.s. CONCLUSÃO: Este é o primeiro relatório de dados normativos para o sistema de 24 canais perfundido por água na postura supina. A partir dos dados encontrados observa-se a possibilidade de alterar os cortes CC 3.0 para este sistema. Observa-se que há uma tendência que DCI >7000 mmHg.cm.s possa representar o limite inferior da hipercontratilidade e quando <700 mmHg.cm.s (<5% percentil) interpretada como motilidade esofágica ineficaz ou contração falha. Também em comparação com Chicago 3.0, foi encontrada maior pressão de relaxamento integrado e duração da latência distal. Ressaltamos que esses dados devem ser confirmados por estudos futuros.

NORMAL VALUES OF ESOPHAGEAL HIGH-RESOLUTION MANOMETRY: A BRAZILIAN MULTICENTER STUDY.

BACKGROUND: The high-resolution manometry has been a significant advance in esophageal diagnostics. There are different types of catheter and systems devices to capture esophageal pressures that generate variable data related to Chicago Classification (CC) and consequently influence normal values results. There are not normative data for the 24-channel water-perfused high-resolution manometry system most used in Brazil with healthy volunteers in supine posture. OBJECTIVE: To determine manometric esophageal normative values for a 24-channel water-perfused high-resolution manometry catheter in supine posture using healthy volunteers according to CC 3.0 parameters. METHODS: A total of 92 volunteers with no gastrointestinal symptoms or medications affecting GI motility underwent esophageal high-resolution manometry by standard protocol. Age, gender and manometry parameters analyzed using Alacer software were collected. The median, range, and 5th and 95th percentiles (where applicable) were obtained for all high-resolution manometry metrics. Normal value percentiles were defined as 95th integrated relaxation pressure, 5th-100th distal contractile integral, and 5th distal latency. RESULTS: The mean age was 40.5±13.2 years. Our normative metrics were integrated relaxation pressure <16 mmHg and distal contractile integral (708-4111 mmHg.cm.s) distal latency was <6 s and peristaltic break size (>4 cm). For EGJ-CI the range 5th-95th was 21.7-86.9 mmHg.cm.s. CONCLUSION: This is the first report of normative data for the 24-channel water-perfused system in supine posture. It revealed higher integrated relaxation pressure and distal latency duration which suggest the need to change CC 3.0 cutoffs for this system. It is observed that there is a tendency that DCI >7000 mmHg.cm.s may represent the lower limit of hypercontractility, and when <700 mmHg.cm.s (<5% percentile) interpreted as ineffective esophageal motility or failcontraction. Also compared to Chicago 3.0, higher integrated relaxation pressure and duration of distal latency were found. We emphasize that these data must be confirmed by future studies.

Manometria anorretal de alta resolução sob cateter de perfusão (MARAR): primeira experiência no Brasil / Water-perfused high-resolution anorectal manometry (hram-wp): the first brazilian study

ABSTRACT BACKGROUND: High resolution anorectal manometry (HRAM-WP) allows more simplified, objective, and uniform data acquisition and interpretation of the test results. OBJECTIVE: To validate a HRAM under water perfusion (Alacer Biomédica) with a 24-channel probe and to compare the results of anorectal manometry with other systems. METHODS: Individuals without critical evacuation disorders were selected. Patients with incontinence, anal surgery, dyssynergia or sphincter injury were excluded. The test was performed with an Alacer Biomédica 24 channel manometry system under water perfusion, with a probe configured with 6 levels of 4 radial channels, separated from each other by 0.8 mm. The mean pressures for the functional channel were determined, in states of rest (RMP), contention effort (CMP) and evacuation effort (EEMP). The pressure extension of the sphincter was also tabulated in cm. The results were compared with those available in recent literature. RESULTS: Fifty patients were studied (20 men; 30 women). Overall, the following results were obtained: the RMP was 76.9±3.0 mmHg, the CMP was 194.2±9.4 mmHg, and EEMP was 88.2±3.7 mmHg. When classified according to the gender, for men: RMP was 72.2±3.0 mmHg, CMP was 229.5±17 mmHg, and EEMP was 91.4±7.0. For women, RMP was 79.8±4.0 mmHg, CMP was 170.7±8, and EEMP was 86.1±4.3 mmHg. The sphincter gauge extension for both genders was 3.1±0.09 cm (men 3.3±0.1; women 3.0±0.1). DISCUSSION: Studying HRAM-WP has become much easier. Non-mobilization of the sensor causes less discomfort and artefacts with a lower assessment time. In this study, small differential values between both sexes during rest were observed, highlighting a greater containment force in men. No difference in sphincter extension was noted. The results of this study are consistent with that of existing reports and with those obtained using solid state probes. CONCLUSION: The perfusion system yielded results similar to that of solid state systems. Further studies to evaluate parameters with respect to pelvic dyssynergia and incontinence need to be conducted. Additionally, to determine if the vector volume can furnish new information in terms of functional and anatomical aspects.

RESUMO CONTEXTO: Através da manometria anorretal de alta resolução (MARAR), a aquisição dos dados e a interpretação do exame tornaram-se mais simplificadas, objetivas e uniformes. OBJETIVO: Validar um sistema de MARAR sob perfusão de água (Alacer Biomédica), com sonda de 24 canais e comparar resultados dos exames de manometria anorretal com outros sistemas em trabalhos já publicados. MÉTODOS: Selecionados indivíduos sem distúrbio evacuatório importante. Excluídos pacientes com incontinência, cirurgia orificial, dissinergia, ou lesão esfincteriana. O exame foi realizado com sistema Alacer Biomédica de manometria sob perfusão de agua de 24 canais, com sonda configurada com 6 níveis de 4 canais radiais, distanciados entre si por 0,8 mm. Estabelecidas as pressões médias para o canal funcional, nos estados de repouso (PMR), no esforço de contenção (PMC) e no esforço evacuatório (PMEE). Também foi tabulada a extensão pressórica do esfíncter em cm. Comparou-se os resultados com os disponíveis em literatura recente. RESULTADOS: Foram estudados 50 pacientes (20 masc; 30 fem). No geral, foram encontrados os seguintes resultados: a PMR foi de 76,9±3,0 mmHg; PMC foi de 194,2±9,4 mmHg e; PMEE foi de 88,2±3,7 mmHg. Quando divididos por sexo: sexo masculino: PMR 72,2±3,0 mmHg; PMC: 229,5±17 mmHg e; PMEE 91,4±7,0. Sexo feminino: PMR 79,8±4,0 mmHg; PMC: 170,7±8; PMEE 86,1±4,3 mmHg. A extensão manométrica para ambos os sexos foi de 3,1±0,09 cm (masc 3,3±0,1; fem 3,0±0,1). DISCUSSÃO: A realização do estudo da MARAR ficou muito facilitada. A não mobilização da sonda provoca menos desconforto e artefatos, com menor tempo de estudo. Em nossa série há valores diferenciais pequenos entre os sexos durante o repouso, destacando-se maior força de contenção no sexo masculino. Não houve diferença para a extensão do esfíncter. Em relação à comparação com os estudos já publicados, mesmo com sondas de solid state, há uma proximidade de valores. CONCLUSÃO: O sistema de perfusão utilizado permitiu reproduzir resultados similares a sistemas solid state. Resta estabelecer parâmetros em casos de dissinergia pélvica, incontinência e esclarecer se o estudo pelo vetor volume pode trazer novas informações nos aspectos funcional e anatômico.

WATER-PERFUSED HIGH-RESOLUTION ANORECTAL MANOMETRY (HRAM-WP): THE FIRST BRAZILIAN STUDY.

BACKGROUND: High resolution anorectal manometry (HRAM-WP) allows more simplified, objective, and uniform data acquisition and interpretation of the test results. OBJECTIVE: To validate a HRAM under water perfusion (Alacer Biomédica) with a 24-channel probe and to compare the results of anorectal manometry with other systems. METHODS: Individuals without critical evacuation disorders were selected. Patients with incontinence, anal surgery, dyssynergia or sphincter injury were excluded. The test was performed with an Alacer Biomédica 24 channel manometry system under water perfusion, with a probe configured with 6 levels of 4 radial channels, separated from each other by 0.8 mm. The mean pressures for the functional channel were determined, in states of rest (RMP), contention effort (CMP) and evacuation effort (EEMP). The pressure extension of the sphincter was also tabulated in cm. The results were compared with those available in recent literature. RESULTS: Fifty patients were studied (20 men; 30 women). Overall, the following results were obtained: the RMP was 76.9±3.0 mmHg, the CMP was 194.2±9.4 mmHg, and EEMP was 88.2±3.7 mmHg. When classified according to the gender, for men: RMP was 72.2±3.0 mmHg, CMP was 229.5±17 mmHg, and EEMP was 91.4±7.0. For women, RMP was 79.8±4.0 mmHg, CMP was 170.7±8, and EEMP was 86.1±4.3 mmHg. The sphincter gauge extension for both genders was 3.1±0.09 cm (men 3.3±0.1; women 3.0±0.1). DISCUSSION: Studying HRAM-WP has become much easier. Non-mobilization of the sensor causes less discomfort and artefacts with a lower assessment time. In this study, small differential values between both sexes during rest were observed, highlighting a greater containment force in men. No difference in sphincter extension was noted. The results of this study are consistent with that of existing reports and with those obtained using solid state probes. CONCLUSION: The perfusion system yielded results similar to that of solid state systems. Further studies to evaluate parameters with respect to pelvic dyssynergia and incontinence need to be conducted. Additionally, to determine if the vector volume can furnish new information in terms of functional and anatomical aspects.