Abstract
Abstract Topic Benign Disease: Esophageal Function and Motility Background We developed multi-society recommendations addressing the question: should adult patients with achalasia receive botox, pneumatic dilation (PD), POEM, or Heller myotomy with fundoplication? Methods We performed a systematic review of randomized trials across PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials from inception to July 9th, 2025. We recruited an international, multidisciplinary panel including members from the AATS, CATS, EAES, and SAGES. The panel included four gastrointestinal surgeons, two thoracic surgeons, two gastroenterologists, and two patient partners. The panel prioritized outcomes for evaluation and set decision thresholds for absolute effect estimates of treatment comparisons. The panel performed a network meta-analysis, appraised the certainty of evidence, and developed recommendations using the core GRADE approach at an in-person consensus meeting. Results We identified 31 reports of 22 trials of patients undergoing Botox injections (n=137), PD (n=562), POEM (n=199), Heller myotomy alone (n=52), and Heller myotomy with fundoplication (n=665). In adult patients with achalasia with moderate-to-severe symptoms with an acceptable anesthetic risk, we suggest Heller myotomy with fundoplication over POEM, pneumatic dilations, and botox, while we suggest POEM over pneumatic dilation or botox for those with a high anesthetic risk, or who prefer to avoid surgery (both conditional recommendation). In adult patients with achalasia with mild symptoms and a high anesthetic risk, we suggest pneumatic dilation over botox, while we suggest POEM over pneumatic dilation or botox for those with an acceptable anesthetic risk (both conditional recommendation). Conclusion Treatment selection for achalasia should be individualized according to symptom severity and surgical fitness, with specific therapeutic modalities favored for each clinical scenario.
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