Utilization of Upper Gastrointestinal Marshmallow Series Versus High-Resolution Manometry in Preoperative Esophageal Motility Assessment

Background and purpose: High-Resolution Manometry (HRM) is the gold standard in preoperative esophageal motility testing. However, HRM presents technical and patient challenges. The Upper Gastrointestinal Marshmallow series (UGIMM) has been utilized as an alternative method to identify esophageal dysmotility disorders; however, there is no standardization for test result interpretation or validated correlation of the UGIMM to HRM. The purpose of this study was to determine if the UGIMM can be used as a reliable screening tool to identify patients with significant esophageal motility disorders prior to anti-reflux surgery (ARS) or sleeve gastrectomy (SG). Methods: Receiver Operator Characteristics (ROC) was employed to compare the UGIMM to HRM. A base logistic regression model was developed using UGIMM to predict HRM. The model’s performance was assessed using ROC curve analysis. With HRM as the reference, sensitivity, specificity, and negative predictive values (NPV) of the UGIMM were calculated. Results: The sensitivity and specificity of UGIMM was 0.97 and 0.18, respectively. The AUC was 0.58 with a Kappa coefficient of 0.06. From a clinical relevance standpoint, our analysis demonstrates that the UGIMM has high sensitivity and low specificity, with an NPV of 0.97. Therefore, a normal result on UGIMM is predictive of normal motility sufficient to proceed with ARS or LSG. Conclusion: The UGIMM is a valid screening tool in preoperative ARS or LSG patients. Patients with a normal UGIMM may forgo manometric testing. An abnormal UGIMM indicates manometry testing must be completed prior to consideration of ARS or LSG.