The role of high-resolution manometry in the assessment of altered foregut anatomy: scoping review and interpretation recommendations

INTRODUCTION: The Chicago Classification provides high-resolution manometry (HRM) criteria for the diagnosis of primary esophageal motility disorders but does not address HRM findings in patients with altered foregut anatomy or post-surgical states. MATERIAL AND METHODS: We performed a scoping review of three databases to identify studies reporting HRM findings in altered foregut anatomy, including anti-reflux and bariatric surgery, treated achalasia, head and neck surgery, and rarer conditions such as esophageal diverticula and esophageal atresia. The aim was to synthesize available evidence and provide pragmatic recommendations for HRM interpretation in these conditions not addressed by the Chicago Classification. RESULTS: We identified 168 articles addressing esophageal dysmotility associated with altered foregut anatomy or post-interventional states. Obesity, esophageal diverticula and esophageal strictures can all result in physiological changes in HRM metrics. HRM assesses motor function in hiatus hernia and identifies post-fundoplication outflow obstruction (PFOO) or junctional disruption. Bariatric procedures substantially alter esophagogastric junction anatomy, resulting in hypocontractile or obstructive manometric patterns. Unsuccessfully treated achalasia is defined by elevated IRP and obstruction on provocative maneuvers; the terms adequately treated achalasia (ATA) and treated achalasia with outflow obstruction (TAOO) have been proposed. Pseudo-achalasia is manometrically indistinguishable from primary achalasia. Other conditions including radiation therapy, head and neck surgery and treated esophageal atresia can result in heterogenous and often non-specific HRM findings. CONCLUSIONS: The Chicago Classification cannot be applied to motility patterns observed in patients with altered foregut anatomy or following foregut surgery. Instead, HRM interpretation in these settings should integrate anatomic information and focus on clinically actionable findings, particularly obstructive states.