High-resolution Manometry Catheter Insertion During Sedated Endoscopy; A Viable Option When Standard Intubation Fails

: When high-resolution manometry (HRM) intubation is not tolerated or the catheter fails to traverse the lower esophageal sphincter, the test is often abandoned, leaving patients without a diagnosis to guide therapy. Although endoscopic placement of HRM catheters under sedation has been described, no study has directly compared this approach with routine outpatient HRM. This study provides the first direct comparison of sedated endoscopic insertion (EI) versus routine insertion (RI).

: All patients who underwent EI of the HRM catheter between January 2020 and May 2025 were retrospectively reviewed and compared with a contemporaneous cohort who had RI. Each test included the standard protocol of ten 5 mL water swallows followed by a 200 g rice meal. Demographic data, endoscopic technique, sedation levels and manometric diagnoses were evaluated. Esophageal body function was defined in accordance with the Chicago classification version 4.0.

: Of 88 patients who had EI attempted, 79 (89.8%) were successfully intubated to the stomach and 78 (88.6%) completed the full swallow protocol. Endoscopic visualization was required for passage through the cricopharynx in 47 (53.4%) and through the esophagogastric junction in 23 (26.1%), with manual guidance needed in 8 (9.1%). Intubation success was comparable to routine insertion (RI) (89.8% EI vs 80.7% RI; P = 0.089) but protocol completion was higher (88.6% EI vs 72.7%; P = 0.008). No adverse events occurred.

: Sedated EI of the HRM catheter enables protocol completion for patients unable to undergo routine testing, filling a key diagnostic gap while delivering manometric results comparable to standard, unsedated studies.