the Management of Achalasia

Section I. Diagnosis of Achalasia:

• In patients who are initially suspected of having GERD but do not respond to acid-suppressive therapy, we suggest evaluation for achalasia, (Conditional recommendation, low certainty evidence, ⁽¹⁾).
• We recommend using High Resolution Manometry (HRM) over conventional line tracing for the diagnosis of achalasia, (Strong recommendation, moderate certainty evidence, ⁽³⁾).
• We suggest using a barium esophagogram to diagnose achalasia if manometry is unavailable, although it is less sensitive than oesophageal manometry. The working group suggests using Timed Barium Esophagogram (TBE), if available, over standard barium esophagogram, (Conditional recommendation, moderate certainty evidence, ⁽³⁾).
• We recommend performing endoscopy in all patients with symptoms suggestive of achalasia to exclude other diseases, (Strong recommendation, low certainty evidence, ⁽³⁾).
• We recommend against making the diagnosis of achalasia solely based on endoscopy, (Good practice statement).
• We suggest that classifying achalasia subtypes by the Chicago Classification may help inform prognosis and treatment choice, (Conditional recommendation, low certainty evidence, ⁽¹⁾).

Section II. Medical Treatment of Achalasia:

• We recommend against the use of calcium blockers, phosphodiesterase inhibitors or nitrates for the treatment of achalasia, (Good practice statement).
• We recommend against medical therapy or Botulinum toxin injection as definitive treatment of achalasia. (Strong recommendation, moderate certainty evidence, ⁽²⁾).

·       We recommend botulinum toxin injection as first-line therapy for patients with achalasia that are unfit for definitive therapies compared with other less-effective pharmacological therapies, (Good practice statement).

Section III. Endoscopic Treatment of Achalasia:

• We suggest that POEM, PD or LHM result in comparable symptomatic improvement in patients with early achalasia, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).
• We recommend POEM or laparoscopic Heller myotomy for management of patients with achalasia types I and II, and the treatment option should be based on shared decision-making between the patient and provider, (Strong recommendation, moderate certainty evidence, ⁽²⁾).
• We recommend tailored POEM or LHM for type III achalasia as a more efficacious alternative disruptive therapy at the LES compared to PD, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).
• We suggest that patients undergoing POEM are counselled regarding the increased risk of post procedural reflux compared with pneumatic dilation and laparoscopic Heller myotomy. The choice is based on patient preferences and physician expertise, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).

Section IV. Surgical Treatment of Achalasia:

• We recommend myotomy with fundoplication in controlling distal esophageal acid exposure, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).
• We suggest either Dor or Toupet fundoplication to control esophageal acid exposure in patients with achalasia undergoing surgical myotomy, (Conditional recommendation, moderate certainty evidence, ⁽¹⁾).
• We recommend against stent placement for management of long-term dysphagia in patients with achalasia, (Strong recommendation, moderate certainty evidence, ⁽¹⁾).

Section V. Post-Therapy Assessment:

• We recommend against obtaining routine gastrograffin esophagogram after dilatation. This test should be reserved for patients with a clinical suspicion for perforation after dilation, (Strong recommendation, low certainty evidence, ⁽¹⁾).
• We suggest that Eckardt Score (ES) or HRM alone not be used to define treatment failure in evaluating continued or recurrent symptoms after definitive therapy for achalasia, (Conditional recommendation, low certainty evidence, ⁽¹⁾).
• Patients with recurrent or persistent dysphagia after initial treatment should undergo repeat evaluation with TBE and upper endoscopy with or without oesophageal manometry, (Good practice statement).
• Post procedural management of reflux options include objective testing for esophageal acid exposure, long-term acid suppressive therapy, and surveillance upper endoscopy, (Conditional recommendation, low certainty evidence, ⁽³⁾).

Section VI. Post-Failed Initial Therapies or Megaesophagus:

• We suggest treating recurrent or persistent dysphagia after LHM with PD, POEM or redo surgery, (Conditional recommendation, low certainty evidence, ⁽³⁾).
• We suggest that PD is appropriate for patients with achalasia post-initial surgical myotomy or POEM in need of retreatment, (Conditional recommendation, low certainty evidence, ⁽³⁾).
•  We suggest that POEM is an option in patients with achalasia who have previously undergone PD or LHM, (Conditional recommendation, low certainty evidence, ⁽¹⁾).
• We suggest that Heller myotomy be considered before esophagectomy in patients who have failed PD and POEM and there is evidence of incomplete myotomy, (Conditional Recommendation, low certainty evidence, ⁽¹⁾).
• We suggest esophagectomy or cardioplasty in surgically fit patients with megaesophagus, (Good practice statement).

Section VII. Cancer Surveillance:

• We suggest against routine endoscopic surveillance for esophageal carcinoma in patients with achalasia, (Conditional recommendation, low certainty evidence, ⁽¹⁾).

Research Needs:

·       Comparison between esophagectomy with gastric pull-up and laparoscopic cardioplasty for advanced achalasia or megaesophagus

·       Comparison between POEM and LHM for the treatment of achalasia

·       Comparison between laparoscopic cardioplasty for achalasia with and without Toupet antireflux procedure

·       Should the result of HRM influence the choice of treatment modality for achalasia?