Table 2.
Summary of Recommendations/Guidelines for Primary Esophageal Achalasia
| Statement | Level of evidence | Strength of recommendation | |
|---|---|---|---|
| Definition and epidemiology of achalasia | |||
| 1. | Achalasia is a primary motor disorder of the esophagus characterized by insufficient lower esophageal sphincter relaxation and loss of esophageal peristalsis. | NA | NA |
| 2. | Achalasia is a very rare disorder of the esophagus that affects both sexes equally and is frequently diagnosed in patients aged between 40 and 60 years. | NA | NA |
| Diagnosis of esophageal achalasia | |||
| Esophageal manometry | |||
| 3. | Esophageal manometry is a gold standard test for diagnosis of achalasia. | Low | Strong |
| 4. | High-resolution manometry is superior to conventional manometry for the diagnosis of achalasia. | Low | Strong |
| 5. | The Chicago classification is a useful tool to define the clinically relevant phenotypes of achalasia. | Moderate | Strong |
| Barium esophagography | |||
| 6. | Barium esophagography is recommended to diagnose achalasia in patients with esophageal dysphagia. | Low | Strong |
| 7. | Timed barium esophagography is useful for assessing the severity of achalasia, and for evaluating treatment outcomes. | Moderate | Strong |
| Endoscopy | |||
| 8. | Endoscopic assessment is recommended for achalasia patients to rule out pseudoachalasia caused by cancer or other esophageal diseases (eg, peptic stricture with acid reflux, structural disorders such as esophageal webs and rings, or esophageal inflammation). | Low | Strong |
| Treatment of esophageal achalasia | |||
| Oral pharmacologic treatment | |||
| 9. | Oral pharmacologic therapy can be considered for achalasia whose general condition renders them unsuitable for endoscopic treatment or surgery. | Low | Weak |
| Botulinum toxin injection | |||
| 10. | Botulinum toxin injection is recommended for achalasia patients whose general condition renders them unsuitable for endoscopic treatment or surgery. | Moderate | Strong |
| Pneumatic balloon dilatation | |||
| 11. | Pneumatic balloon dilatation is recommended as an initial treatment for patients with achalasia. | Moderate | Strong |
| Peroral endoscopic myotomy | |||
| 12. | The outcomes of peroral endoscopic myotomy are comparable to those of Heller myotomy for treatment-naïve patients with achalasia. | Moderate | Strong |
| 13. | Peroral endoscopic myotomy, rather than Heller myotomy, should be considered for the treatment of type III achalasia because enables extended myotomy. | Low | Weak |
| 14. | Acid suppressive therapy is recommended for patients with reflux symptoms or esophageal erosion undergoing peroral endoscopic myotomy, to prevent esophageal stricture. | Low | Strong |
| Surgical treatment | |||
| 15. | Laparoscopic Heller myotomy can be considered as one of first-line therapies for achalasia patients, and has similar expected clinical outcomes to pneumatic balloon dilation. | Moderate | Weak |
| 16. | Partial fundoplication in addition to LHM is recommended to reduce the risk of subsequent GERD. | Low | Strong |
| Management of recurrence of achalasia after initial treatment | |||
| 17. | Peroral endoscopic myotomy is recommended for achalasia patients who failed initial endoscopic treatment. | Moderate | Strong |
| 18. | Peroral endoscopic myotomy can be considered as a rescue treatment for achalasia patients. who were not treated successfully by laparoscopic Heller's myotomy. | Low | Weak |
NA, not applicable; LHM, laparoscopic Heller myotomy; GERD, gastroesophageal reflux disease