Short versus standard esophageal myotomy during peroral endoscopic myotomy for achalasia: A systematic review and meta-analysis of randomized controlled trials.

BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) is an established treatment for achalasia. Conventionally, esophageal myotomy of 6-10 cm length is performed, although its necessity in type-I and type-II achalasia remains debatable. Recent studies suggest that a shorter myotomy may offer similar efficacy with potential advantages. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) comparing short vs. standard (long) esophageal myotomy during POEM in patients with type-I and type-II achalasia.

METHODS

This review was conducted in accordance with PRISMA 2020 guidelines and registered with PROSPERO (CRD42024611252). A systematic search of PubMed, Embase and Scopus was performed to identify RCTs comparing short and long esophageal myotomy during POEM. The primary outcome was clinical success at ≥ 1 year (Eckardt score ≤ 3). Secondary outcomes included procedure time, adverse events, post-POEM integrated relaxation pressure (IRP), barium column height and gastroesophageal reflux disease (GERD). Risk of bias was assessed using the Cochrane RoB 2.0 tool and the certainty of evidence was evaluated using the GRADE framework.

RESULTS

Four RCTs including 419 patients (short, n = 206; long, n = 213) were analyzed. Clinical success at one year was comparable between the two groups (OR 2.17; 95% CI = 0.76-6.23; p = 0.15; I2 = 12%). Procedure time was significantly shorter with short myotomy (MD - 17.69 min; p < 0.001). Rates of adverse events and physiological outcomes (IRP, barium retention) were similar. While overall GERD rates were comparable, esophageal acid exposure was significantly lower in the short myotomy group (OR 0.69; p = 0.04).

CONCLUSION

Short esophageal myotomy is non-inferior to long myotomy in clinical efficacy with the added benefit of shorter procedure time and potentially reduced acid exposure. These findings support the use of short myotomy as a safe and efficient alternative in type-I and type-II achalasia.