Short Versus Standard Peroral Endoscopic Myotomy for Esophageal Achalasia: A Meta-Analysis of Randomized Controlled Trials.

Background and aims: Peroral endoscopic myotomy (POEM) has become the treatment of choice for achalasia. However, the impact of myotomy length on POEM outcomes remains unclear. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing the outcomes of short versus standard-length myotomy in achalasia patients.

Methods: We conducted a comprehensive search in PubMed, Embase, and Web of Science databases to identify all RCTs that compared POEM using short myotomy with standard myotomy. The primary outcomes were clinical success and post-operative gastroesophageal reflux disease (GERD). The secondary outcomes were procedural time, length of hospital stay, and intraprocedural complications. Pooled odds ratio (OR) and mean difference (MD) with the corresponding 95% confidence intervals (CIs) were calculated.

Results: Three RCTs with 365 achalasia patients treated with short (n = 179) or standard (n = 186) myotomy were included. Short and standard myotomies showed similar clinical success (OR 1.95, 95% CI 0.61-6.23, p = 0.26; I² = 41%), reflux symptoms (OR 0.97, 95% CI 0.49-1.89, p = 0.92; I² = 20%), pathologic acid exposure on pH monitoring (OR 0.70, 95% CI 0.33-1.50, p = 0.36; I² = 58%), reflux esophagitis on upper endoscopy (OR 0.82, 95% CI 0.40-1.70, p = 0.59; I² = 42%), intraprocedural complications (OR 1.22, 95% CI 0.53-2.79, p = 0.65; I² = 0%), and length of hospital stay (MD - 0.01, 95% CI - 0.72 to 0.69, p = 0.97, I² = 73%). Procedural time was shorter in short myotomy (MD - 16.11 min, 95% CI - 26.04 to - 6.19, p = 0.001; I² = 84%).

Conclusions: POEM using short myotomy for achalasia is non-inferior to standard myotomy for efficacy, safety, and post-operative GERD but is associated with a shorter procedural time.