# Comparison of Achalasia Classification Schemes to Predict Treatment Outcomes

## TL;DR

This study compares different classification systems for achalasia to see which best predicts treatment outcomes, finding that high-resolution manometry and esophagram each predict different types of outcomes.

## Contribution

The study reveals that HRM-based classifications better predict symptom improvement, while esophagram-based ones better predict objective radiographic outcomes.

## Key findings

- The Chicago Classification (HRM-based) was a significant predictor of symptomatic treatment outcomes.
- Esophagram-based classifications (JES, Italian, Brazilian) were better predictors of radiographic outcomes.
- Combining HRM and esophagram assessments may improve outcome prediction in achalasia.

## Abstract

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.

Achalasia classification schemes using high‐resolution manometry (Chicago Classification) or barium esophagram (Japanese, Italian, or Brazilian classification schemes) has been described and may offer prognostic information regarding future treatment outcomes.The Chicago Classification based on pressurization and contractility patterns on high‐resolution manometry more strongly predicted symptom‐based treatment outcomes than esophagram‐based schemes, while the esophagram‐based schemes based on esophageal anatomy were stronger predictors for objective measures of esophageal retention.Complementary evaluation in achalasia using tools to assess esophageal physiology (such as high‐resolution manometry) and anatomy (such as esophagram) may leverage strengths for predicting treatment responses in achalasia.

Achalasia classification schemes using high‐resolution manometry (Chicago Classification) or barium esophagram (Japanese, Italian, or Brazilian classification schemes) has been described and may offer prognostic information regarding future treatment outcomes.

The Chicago Classification based on pressurization and contractility patterns on high‐resolution manometry more strongly predicted symptom‐based treatment outcomes than esophagram‐based schemes, while the esophagram‐based schemes based on esophageal anatomy were stronger predictors for objective measures of esophageal retention.

Complementary evaluation in achalasia using tools to assess esophageal physiology (such as high‐resolution manometry) and anatomy (such as esophagram) may leverage strengths for predicting treatment responses in achalasia.

Achalasia classification methods can be beneficial to help prognosticate treatment outcomes. High‐resolution manometry subtypes (Chicago Classification) predicted symptomatic outcome, whereas esophagram‐based classifications (Japanese Esophageal Society (JES), Italian, Brazilian) more strongly predicted objective emptying. This highlights the potential complementary value of dual‐modality assessment.