Achalasia Management and follow-up Choice of initial therapy Individualize the choice of initial therapy according to the patient's age, gender, personal preferences, and local institutional expertise. B Perform pneumatic dilation and surgical myotomy at high-volume centers of excellence. B Surgical myotomy ACG Q Is the patient a candidate for surgery? Q Is the patient willing to undergo surgery? Yes to all Perform either laparoscopic surgical myotomy or graded pneumatic dilatation as initial therapy for the treatment of patients with achalasia fitting and willing to undergo surgery. B Post-treatment follow-up Assess patients for symptomatic improvement after treatment for achalasia, and consider obtaining a timed barium esophagram to assess esophageal emptying. B Surveillance endoscopy Do not perform routine surveillance endoscopy to screen for esophageal cancer. D No to any Perform endoscopic botulinum toxin injection for the treatment of patients with achalasia being poor candidates for surgery or pneumatic dilatation. B Pharmacologic therapy ACG Q Is botulinum toxin injection successful? No Initiate pharmacologic therapy (CCBs or long-acting nitrates) in patients with achalasia unwilling or unable to undergo definitive treatment with either pneumatic dilatation or surgical myotomy, and failed botulinum toxin therapy. B Yes Post-treatment follow-up Assess patients for symptomatic improvement after treatment for achalasia, and consider obtaining a timed barium esophagram to assess esophageal emptying. B Surveillance endoscopy Do not perform routine surveillance endoscopy to screen for esophageal cancer. D