Teaching Surgeons How to Read High Resolution Impedance Manometry: A Successful Curriculum

Michal J Lada, MD, Dylan R Nieman, MD, PhD, Michelle Han, MD, Poochong Timratana, MD, Stefan Niebisch, MD, Christian Peyre, MD, Carolyn E Jones, MD, Thomas J Watson, MD, Jeffrey H Peters

University of Rochester Medical Center

Introduction: High Resolution Impedance Manometry (HRIM) is an increasingly utilized and important diagnostic modality in the preoperative evaluation of patients with foregut symptoms. This study evaluated the effectiveness of a standardized curriculum designed to teach surgical residents how to read HRIM including an assessment of inter-observer variability of HRIM features.

Methods and Procedures: Four novice surgical research residents reviewed a predefined selection of HRIM background literature followed by analysis of 10 studies with the assistance of an expert reader (>400 analyzed HRIMs). 20 consecutive HRIM studies were then analyzed by each of the 4 residents independently. The residents were blinded to each other’s and the expert’s analyses, which served as the gold standard correct read. Lower esophageal sphincter (LES) overall and intra-abdominal length, mean LES resting pressure (LESP), integrated relaxation pressure (IRP), intrabolus pressure (IBP), contractile front velocity (CFV), distal latency (DL), distal contractile integral (DCI), bolus clearance, Chicago Classification diagnoses of the esophagogastric junction (EGJ) and the esophageal body were recorded for each HRIM reading. Intra-class correlation (ICC) coefficients were utilized to compare the results of the residents and the experienced reader (ICC <0.2 = little agreement, >0.5 = good agreement and >0.8 = excellent agreement).

Results: One thousand swallows were assessed. ICC coefficients indicated excellent agreement for LESP, IRP, IBP, DL, DCI, EGJ diagnosis and esophageal body diagnosis. Greater variability was observed for LES total length, intra-abdominal LES length, CFV and bolus clearance (Table).

Conclusions: A structured literature review and hands-on analysis with an expert result in superb preparation for independent HRIM analysis by novice surgical residents. Inter-observer agreement was excellent for most HRIM variables. Total LES length, intra-abdominal LES length, CFV and bolus clearance had more variability likely owing to the increased subjectivity associated with their measurement. Despite this variability, the agreement in final diagnosis remained excellent. Our results suggest that clinical HRIM analysis can be integrated into surgical training curricula with reasonable effort.

Session: Poster Presentation

Program Number: P203

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