Dr. Carla Granja’s presentation in India congress on Digestive Motility

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Hello, I’d like to congratulate the organizing comitee of this important congress

For me, it’s a great honor to participate in this session

In the next few minutes, I will present to you the technological evolution of water perfusion high resolution esophageal manometry

My name is Carla Granja, and I have been working with digestive motility for over the last twenty years.

Our motility laboratories in Brazil performs in average a hundred tests per month in addition to the continuing education activities of physicians interested in this area.

Recently I’m proud and greatfull to participate in the development of the Mohak Bariatric and Robotic Center Digestive Motility Laboratory at Indore, together with Dr. Manoel Galvão and Dr. Mohit Bhandari, with the objective to give diagnostic support to endoscopic and surgical procedures.

But, the great question is: Why think about water perfusion system?

As we know, solid state systems are the gold standard, but they are expensive, so, the first challenge is cost effectiveness.

In a country like Brazil, the cost of imported equipments restricted the use of the high resolution manometry to a few reseach centers.

This is the main stimulus to investiment in technology for the development of equivalent equipment, with lower cost. So, the second challenge, develop equivalent equipment in technology. And, the third challenge: training physicians – High quality exams.

And

Thus it makes feasible the organization of digestive motility centers through all the country.

Our group is dedicated not only in this partnership in technological development but in the training of physicians to perform high quality exams.

Talking about technological evolution, since it’s emergence in the last century, water infusion manometry has undegone advances and the high resolution manometry device we work on today presents some very interresting details.

One of them is the probe’s connection system to the device. The development of a single connector allows the rapid connection of the 36 channels probe with the high resolution manometry device, which features a closed system with electronic sensors and stainless steel capilaries that produce a low complacency perfusion system.

Another addidance is the continuous infusion pump which allows the infusion of destiled water at a continuos and stable pressure. The infusion pressure is easily adjustable through the software. This mechanism does not requires the use of the old air pressurization pump.

Another idea that was great is the fact that, differently from the non perfusion systems, the probe presents an intelligent distribution of sensors. We have here two areas of elliptical sensors prositioned in smaller intervals, and this permits to evalluate upper esophageal sphincter and specially esophagogastric junction actually.

So, we can see it’s more sensible than probes that have sensors positioned only in the longitudinal form.

All images presented in the next slides were produced from exams we performed with this device.

Here we can see the standard image at rest, with the baseline period. In the proximal part of the graphics, we see the pressure impression of the upper esophageal sphincter, and, in the distal part, we can see the pressure impression of the esophagogastric junction that respects the oscilation of the respiratory cycles.

Here is the standard image of swallowing.

The upper esophageal sphincter and it’s opening when we have the swallowing.

The proximal peristalsis where predominates striated musculature. The called “break”, in hte transition zone, and the distal peristalsis where predominates smooth muscles.

The esophagogastric junction has a peculiar movement: when the opening of the pharynx we have the relaxation and the flow through the esophageal gastric junction, and then we have an elevation of pressure that is physiological, and means the EGJ reaction post-swallow.

We can divide in fisrt segment, that includes pharynx, upper esophageal sphyncter and proximal

esophagus, second and third segments with medial esophagus and distal esophagus, and forth segment that includes the EGJ movement during the swallow.

As proposed by the (Chicago) concensus, was conducted a multicenter prospective study to define specific normality parameters for this device, and we observed a IRP of 16mmHg, very close to the observed by Chicago group, which is 15mmHg.

As we know, Chicago Classification is a classification in evolution and the last publication, the Chicago Classification version 4.0 gives to us the mission to do exam in a protocol with two positions: supine and upright.

But, in the article, we see this phrase: However, the protocol and classification can be performed with water perfused catheter if appropriate normative values are used, with the limitaion of only supine swallows and maneuvers possible with water perfused manometry.

From this publication, we felt again challeged to overcome this barrier and the brief video that you will see bellow demonstrates, in sumary, the results of a new technological advance.

This video that you will see is the resume of an exam that we realized at a course that we did with researchers that are learning how to use this device in December 2021.

Here is the last part of the supine position… and we will see, in the next part, in supine position, the contractile reserve where we realize multiple rapid swallows to evaluate the contractile reserve… and then we click on an icon that means “change of position”… and, the net image that you will see was not magic, it’s just mathematics calculation and evolution of the software.

This is the effect of the water collumn pressure when you change the patient’s position. We wait the stabilization of the position of the patient and the probe, and then we click “change” again and the software calculates mathemactically the pressure and delects the effects of the water column pressure.

Here we see the upright position, if you can observe, it’s the same image that we had in the supine position without the artifact of the changing of the position and you will see during the swallowing, and finally the rapid drink challenge.

This patiens was not a patient with disphagia, it’s just a patient we where doing during a course, and the patient was very colaborative, and we performed all the protocol during the course.

As I said before, it’s not magic, it’s only mathematics and technological evolution of the software.

We performe all the protocol proposed by the Chicago Classification 4.0. We do three deep inspirations to document the correct position of the probe to start the acquisition of the data.

We do the rest baseline of 60 seconds for a baseline stabilization, and collect the rest pressure.

Then we do 10 wet swallows of 10ml with 30s interval between swallows.

And then we perform the multiple rapid swallows to evaluate the contractile reserve.

This is the image of a positive test, when we just do one sample, and we have this image, means a failed test, we realize a minimum of three samples of the test to do a report that there is absent contractile reserve.

Then we repeat all the phases in upright position, the deep inspiration, the rest pressure, and this is the image of the upright position, the wet swallows, and then we finally perform the rapid drink challenge with 200ml of water.

This is the image of the a normal IRP, here the goal is to evaluate the IRP.

Here is the image of an EGJ, in the supine position, with an alteration of the IRP, over 16mmHg, that is our value of normality for this metrics.

Here is the upright position for the confirmation of the alteration of the IRP, and here is the image of the rapid drink challenge in the same patient.

In a patient with achalasia, we have panesophageal pressurization in supine position.

It’s the same thing that we see in the upright position: the alteration of the IRP over 16mmHg and the pan-pressurization documented. And here is the image of the worst pressurization with bigger volume of water in the rapid drink challenge.

So, Chicago Classification 4.0 supine and upright protocol performed with water perfusion high resolution esophageal manometry is possible, is feasible, it evolves high technological quality, and for us, better cost effectiveness.

I’m very proud to participate of the evolution of this history.

Thank you very much.