Evaluating Myotomy Length in POEM for Achalasia: A Grade-Assessed Meta-Analysis of Randomized Controlled Trials.

Background: Peroral endoscopic myotomy (POEM) is a standard achalasia treatment, matching surgery in efficacy. However, myotomy length varies. Shorter myotomies are gaining attention for potential benefits. This study compares short versus long myotomies to identify the optimal approach.

Methods: We conducted a systematic review and meta-analysis of Randomized Controlled Trials (RCTs) retrieved from PubMed (MEDLINE), Scopus, Web of Science (WoS), and Cochrane Central Register of Controlled Trials (CENTRAL) until November 28, 2024. Pooled results were calculated using risk ratios (RR) for binary outcomes and mean differences (MD) for continuous outcomes, with 95% CI (PROSPERO ID: CRD42024621638).

Results: Four RCTs with 419 patients were included. Clinical success (Eckardt score ≤3) showed no significant difference between short and long myotomy (97.4% vs. 95.9%, RR: 1.02 with 95% CI: 0.98-1.06, P=0.33), Reflux symptoms (RR: 0.93, 95% CI: 0.60-1.47, P=0.77), and reflux esophagitis (RR: 0.83, 95% CI: 0.55-1.27, P=0.39). However, short myotomy significantly reduced pathologic acid exposure (RR: 0.57, 95% CI: 0.36-0.91, P=0.02), procedural time (MD: -16.61 min, 95% CI: -26.40 to -6.81, P<0.001), and hospital stay (MD: -2.37 d, 95% CI: -4.67 to -0.06, P=0.04). Intraprocedural complications were similar (P=0.73), as was integrated relaxation pressure (P=0.95), indicating similar postoperative esophageal function.

Conclusion: Short myotomy reduced acid exposure, procedure time, and hospital stay in POEM for achalasia without compromising clinical success or symptom improvement. It shows potential as an effective treatment, but large-scale RCTs are needed for definitive clinical endorsement.