Comparison of Achalasia Classification Schemes to Predict Treatment Outcomes

Achalasia classifications, such as the Chicago Classification subtypes based on high-resolution manometry (HRM) and Japanese Esophageal Society (JES), Italian, or Brazilian classifications based on esophagram, have been described. We aimed to compare these schemes for prediction of achalasia treatment outcomes.

222 adult patients with achalasia that completed pretreatment HRM and esophagram before and after treatment were included. Pretreatment HRM achalasia subtypes were determined by the Chicago Classification and JES; Italian and Brazilian classifications were defined by pretreatment esophagram. Post-treatment outcomes were defined using the Eckardt symptom score (good outcome < 4) or timed barium esophagram (TBE; good outcome 5-min column height < 5 cm).

The Chicago Classification was a significant predictor of symptomatic outcome (p = 0.003-0.007), whereas JES, Italian, and Brazilian schemes were not. All four classifications were significant predictors of radiographic outcome, with JES demonstrating the best model fit as identified by lowest Akaike information criteria (AIC). Type III achalasia (Chicago Classification) patients had the lowest rates of good symptomatic outcomes despite treatment primarily with POEM, whereas advanced esophagram stages (JES-C, Italian IV, Brazilian 2-3) were associated with poorer radiographic outcomes.

Both HRM- and esophagram-based classification schemes predict achalasia treatment outcomes, though with different strengths. While treatment choice may impact outcomes, HRM best predicted symptomatic outcomes, while esophagram classifications better predicted objective radiographic outcomes. Utilizing both modalities may enhance prognostication of outcomes in achalasia.