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American Society for Gastrointestinal EndoscopyGastroenterology2020advanced

Management of Achalasia

Published by American Society for Gastrointestinal Endoscopy (ASGE) · GRADE

8Recommendations
163References
1Tables
3Figures
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Summary

AI-generated

Achalasia is a primary esophageal motor disorder characterized by degeneration of the myenteric plexus, impaired relaxation of the esophagogastric junction (EGJ), and loss of organized peristalsis. It causes dysphagia and regurgitation, and is diagnosed using high-resolution esophageal manometry.

AchalasiaPOEMPneumatic dilationHeller myotomyBotulinum toxin

Key Takeaways

  • 1
    Laparoscopic Heller myotomy, pneumatic dilation, and POEM are effective therapeutic modalities for patients with achalasia.
  • 2
    Botulinum toxin injection is not recommended as definitive therapy and should be reserved for those who are not candidates for other therapies.
  • 3
    POEM is suggested as the preferred treatment for management of patients with type III achalasia.
  • 4
    For types I and II achalasia, pneumatic dilation, laparoscopic Heller myotomy, and POEM are all comparable treatment options.
  • 5
    POEM carries an increased risk of postprocedure reflux compared with pneumatic dilation and laparoscopic Heller myotomy.

Key Recommendations

Recommendations

  • 1

    Laparoscopic Heller myotomy, pneumatic dilation, and POEM are effective therapeutic modalities for patients with achalasia. Decision between these treatment options should depend on achalasia type, local expertise, and patient preference.

    StrongEvidence: HighTreatment
  • 2

    We recommend against the use of botulinum toxin injection as definitive therapy for achalasia patients. Botulinum toxin injection may be reserved for patients who are not candidates for other definitive therapies.

    StrongEvidence: ModerateTreatment
  • 3

    We suggest POEM as the preferred treatment for management of patients with type III achalasia.

    WeakEvidence: Very lowTreatment
  • 4

    In patients with failed initial myotomy (POEM or laparoscopic Heller myotomy), we suggest pneumatic dilation or redo myotomy using either the same or an alternative myotomy technique (POEM or laparoscopic Heller myotomy).

    WeakEvidence: Very lowTreatment
  • 5

    We suggest that patients undergoing POEM are counseled regarding the increased risk of postprocedure reflux compared with pneumatic dilation and laparoscopic Heller myotomy. Based on patient preferences and physician expertise, postprocedure management options include objective testing for esophageal acid exposure, long-term acid suppressive therapy, and surveillance upper endoscopy.

    WeakEvidence: LowManagement
  • 6

    We recommend pneumatic dilation compared with botulinum toxin injection for patients with achalasia.

    StrongEvidence: HighTreatment
  • 7

    We recommend that laparoscopic Heller myotomy and pneumatic dilation are comparable treatment options 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.

    StrongEvidence: ModerateTreatment
  • 8

    We suggest that POEM and laparoscopic Heller myotomy are comparable treatment options 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.

    WeakEvidence: LowTreatment

Scope & Objectives

Clinical Topic

Achalasia

Objectives

To provide evidence-based recommendations for the treatment of achalasia, based on an updated assessment of the individual and comparative effectiveness, adverse effects, and cost of 4 achalasia therapies.

Target Patient Population

Patients with achalasia

Diagnostic Criteria

High-resolution esophageal manometry showing incomplete relaxation of the esophagogastric junction coupled with the absence of organized peristalsis.

Target Providers

GastroenterologistsEndoscopistsSurgeons

Patient Criteria & Setting

Therapeutic Area

Gastroenterology

Guideline Scope

DiagnosisTreatmentManagement

Evidence Grading

System: GRADE

Evidence Levels

Low qualityOur confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of effect.
High qualityWe are very confident that the true effect lies close to that of the estimate of effect.
Moderate qualityWe are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of effect, but there is a possibility that it is substantially different.
Very low qualityWe have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

Recommendation Strength

WeakIndicated by the phrase 'we suggest'. Based on aggregate evidence quality and an assessment of the anticipated benefits and harms.
StrongIndicated by the phrase 'we recommend'. Based on aggregate evidence quality and an assessment of the anticipated benefits and harms.

Safety & Contraindications

Monitoring Guidance

For patients undergoing POEM, postprocedure management options include objective testing for esophageal acid exposure, long-term acid suppressive therapy, and surveillance upper endoscopy.

Authors & Contributors

Mouen A. KhashabMarcelo F. VelaNirav ThosaniDeepak AgrawalJames L. BuxbaumSyed M. Abbas FehmiDouglas S. FishmanSuryakanth R. GuruduLaith H. JamilTerry L. JueBijun Sai KannadathJoanna K. LawJeffrey K. LeeMariam NaveedBashar J. QumseyaMandeep S. SawhneyJulie YangSachin Wani

Guideline Features

Based on systematic reviewMultidisciplinary

Learning Context

Difficulty

advanced

Learning Paths

AchalasiaEsophageal Motility DisordersPOEM (Peroral Endoscopic Myotomy)Pneumatic DilationLaparoscopic Heller MyotomyGastroenterologyEndoscopy