Short Versus Long Myotomy Length in Peroral Endoscopic Myotomy for Achalasia: Comparable Efficacy with Potential Reduction in Incidence of Reflux—A Meta-Analysis of 10 Comparative Studies

Background: Shortening the myotomy length during peroral endoscopic myotomy (POEM) for achalasia has been hypothesized to reduce gastroesophageal reflux disease (GERD) incidence while maintaining procedural efficacy. This meta-analysis compares the outcomes of short POEM (S-POEM) and long POEM (L-POEM). Methods: A systematic review adhering to PRISMA guidelines identified studies directly comparing S-POEM and L-POEM. Study quality was assessed using the Risk of Bias in Non-randomized Studies of Interventions and Revised Cochrane Risk of Bias for Randomized Trials tools. A pairwise meta-analysis was conducted using the random-effects model. Results: In perioperative outcomes, S-POEM significantly reduced operative time and required fewer clips compared with L-POEM, with no significant differences in adverse events or length of stay. Regarding GERD-related outcomes, S-POEM demonstrated a statistically significant reduction in abnormal esophageal acid exposure on 24-hour pH-impedance testing, with a number needed to treat of 10. While the reduction in symptomatic GERD did not reach statistical significance (P = .06), the P value was very close to the threshold for significance (.05), and all seven included studies reported decreased symptomatic GERD with S-POEM. This is therefore considered a noteworthy finding. The rates of esophagitis and lower esophageal sphincter pressure did not differ significantly between the groups. Efficacy-related outcomes, including clinical success, Eckardt score, and barium height at 5 minutes, were comparable between S-POEM and L-POEM. However, integrated relaxation pressure was significantly higher in the S-POEM group. Conclusions: This study suggests that shortening the myotomy length may reduce GERD incidence following POEM without compromising its efficacy in achalasia treatment. In addition, a shorter myotomy length decreases operative time, potentially reducing time-related costs and improving workflow.