SSAT - The Chicago Classification for the Diagnosis of Esophageal Motor Disorders: a Critical Appraisal on 35 Healthy Volunteers and 400 Patients

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The Chicago Classification for the Diagnosis of Esophageal Motor Disorders: a Critical Appraisal on 35 Healthy Volunteers and 400 Patients
Tommaso Giuliani^*, Luca Maria Saadeh, Renato Salvador, Edoardo V. Savarino, Francesca Galeazzi, Loredana Nicoletti, Giovanni Capovilla, ELISA Fasolo, Stefano Merigliano, Mario Costantini

Department of Surgical, Oncological and Gastroenterological Sciences, University of Padua, Padua, Italy

Introduction: High-Resolution Manometry (HRM) has allowed the development of a new classification for esophageal motor disorders (EMDs), named the Chicago Classification (CC), still under continuous revision. The aim of our study was to compare the diagnoses of EMDs based on the last iteration of CC (3.0) with those obtained applying the traditional conventional manometric criteria.
Methods: Thirty-five healthy volunteers and 400 consecutive, untreated patients underwent esophageal HRM with a 36-channel solid-state catheter. Diagnoses were defined by applying the manometric criteria of the traditional classification and, subsequently, by using the last version of the CC (CC3), with the original Chicago threshold values. Values obtained in our volunteers were also used in case of diagnostic discrepancy. The tracings were analyzed by two expert physicians (MC, RS). Symptoms and radiologic or endoscopic data were also used for clarifying the diagnosis in case of major motility disorders (i.e. achalasia).
Results: In 276 cases (69,0%) the diagnosis obtained with both classification corresponded and the overall concordance index was good (Cohen K= 0.62). However, some clusters of mis-diagnoses were found: 44/93 (49,4%) achalasia patients were classified as esophago-gastric-junction (EGJ) outflow obstruction (for the inability of recognize 100% aperistalsis, n= 35) or as other peristaltic disorders (for the presence of a normal IRP but absent peristalsis, n=11). All these patients had a good outcome after myotomy or pneumatic dilation. In 11 patients, the diagnosis of EGJ obstruction was determined by an increased IRP (> 15 mmHg) and could be corrected in 9 by using our normal value for the same parameter (> 17 mmHg). The same was true for the diagnosis of Nutcracker Esophagus, missed in 10 patients with a DCI <5000, but correctly diagnosed with our normal limit (<3000), albeit the real value of this disorder remains unclear.
Conclusion: HRM has made possible a new classification of esophageal motor disorders. However, only further comparative studies and outcome data may clarify its diagnostic role and impact from a clinical point of view.

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