Real-world management of achalasia and esophagogastric junction outlet obstruction in Italy: results from a national survey

Abstract There is significant variability in clinical guidelines for achalasia, and precise indications for Esophagogastric Junction Outflow Obstruction (EGJOO) are lacking. The recommendations provided in the published literature could be difficult to translate into the clinical practice due to the discrepancy in the available resources. This survey aims to provide insight into the different diagnostic and therapeutic approaches adopted nationwide. An electronic 31-item questionnaire was sent among the members of the Italian Society for Endoscopic Surgery of Endoscopic Surgery and New Technologies (SICE). A single response from each participating center was required. A total of 46 answers were obtained. The first approach to achalasia was Heller myotomy plus Dor fundoplication (H–D) in most cases, but there was an increased use of Per-Oral Endoscopic Myotomy (POEM) for subtype III achalasia. Botulin toxin injection (BTX) and PD were reserved for frail, older patients. Surgery was the primary approach for end-stage achalasia, mainly H–D (50.0%), esophagectomy (22.7%), and PD (20.5%). A conclusive diagnosis of EGJOO was managed through PD (32.6%), clinical observation (21.7%), H–D (17.4%), Proton Pump Inhibitors (PPIs) (13.0%), BTX (13.0%) and POEM (2.2%) while an inconclusive EGJOO diagnosis through clinical observation (39.1%), PD (23.9%), H–D (21.7%), PPIs (8.7%) and POEM (6.5%). The suggested timing was 3 months (72.7%) for clinical and 6 months (63.6%) for instrumental follow-up. In case of persistence of symptoms, the preferred treatments were H–D (50.0%) and PD (28.3%). This study provides a real-world snapshot of the management of achalasia and EGJOO in the Italian landscape, showing a wide variability in the clinical practice among the involved centers. A multidisciplinary approach is advisable, and clinical guidelines are warranted to provide shared decisions for the management of these disorders.