Enhancing standardization in anorectal manometry testing: the impact of a national position paper

The 2019 International Anorectal Physiology Working Group published the 'London Classification', providing recommendations for anorectal manometry (ARM) and balloon expulsion testing (BET). Despite this, the extent of guideline adoption in clinical settings was unclear. This study aimed to evaluate ARM and BET practices across Israel, identify deviations from these international guidelines, and measure the impact of a newly instated national position paper.

In late 2020, gastroenterologists from 95% of Israeli centers performing ARM responded to a comprehensive 61-item survey. The survey highlighted discrepancies with international standards, prompting the formation of a national task force. This task force drafted a position paper incorporating international recommendations, followed by an educational course on ARM and BET. A subsequent survey assessed practice changes 1 year later.

Initial findings showed considerable variation in practices, including inconsistent application of the London classification, lack of standardized reference values, selective reporting on parameters like anal squeeze pressure, and differences in ARM and BET methodologies. Following the introduction of the position paper, 87% of centers altered their practices to include standardized reporting, consistent use of normal values, and uniform execution of tests like the rectoanal inhibitory reflex. Despite these improvements, variations in BET techniques persisted, particularly regarding balloon use and patient positioning.

The implementation of a national position paper and subsequent educational initiatives markedly enhanced the standardization of ARM and BET procedures in Israel, demonstrating the value of targeted educational and policy interventions in harmonizing medical practices with established international guidelines.