Real-world application of the chicago protocol 4.0 for esophageal manometry: A multinational survey of Asian neurogastroenterology and motility association

초록

Objectives: The recently updated Chicago Classification v 4.0 (CCv4.0) proposes a standardized high-resolution manometry (HRM) protocol and more stringent criteria for esophageal motility disorders. Moreover, timed barium esophagography (TBE) and functional lumen imaging probe (FLIP) are recommended upon inconclusion evidence for diagnosis. However, current application of the CCv4.0 protocol has yet to be investigated. We aimed to investigate the real-world application of CCv4.0 using multi-institutional surveys in Asian countries. Methods: The survey covered department activity, equipment, patient preparations, implementation, and data analysis areas. It specifically aimed to assess the adoption of major changes in CCv4.0, including positional changes, provocative tests, and additional assessments, such as TBE and FLIP. In total, 161 questionnaires were distributed to members of the Asian Neurogastroenterology and Motility Association via Google Survey from March to June 2023. Results: We received responses from 33 centers in 9 countries (18 in Korea, 5 in Japan, 2 in Taiwan, 1 in China, and 7 in other countries). Of these, 28 centers (84.8%) were tertiary centers. In the review of medication, 14 (42.4%) and 16 (48.5%) centers investigated anticholinergics and narcotic drugs, respectively. Only seven (21.2%) centers fully adhered to the CCv4.0 standard protocol for wet swallows and provocation tests. Nine centers (27.3%) had an adaptation period < 60 s, and thirteen centers (39.4%) had < 3 breaths during the adaptation period. In baseline periods, esophagogastric junction metrics were identified in 16 (48.5%) centers. During 10 wet swallows, 16 (48.5%) centers had < 30 s of swallowing intervals. In 23 centers (69.7%), patients started the study in a supine position, and position change was followed in 22 centers (66.7%). Among 26 centers (78.8%) that applied provocation tests, all applied multiple rapid swallows, whereas rapid drink challenge was only applied in 18 owing to poor patient cooperation or concerns regarding aspiration. Half of the centers repeated provocation tests after failed attempts or abnormal responses. TBE was available in 17 centers (51.5%), and FLIP was available in 6 centers (18.2%). The main reason for TBE unavailability was a problem with cooperation from the radiology department. Conclusions: We observed heterogeneity among centers concerning adherence to the standard CCv4.0 protocol. To enhance intercenter reliability and minimize diagnostic ambiguity, efforts toward training and education on standard protocols based on the CCv4.0 are essential.