Short versus standard peroral endoscopic myotomy for esophageal achalasia: a systematic review and meta-analysis

Abstract

Background Peroral endoscopic myotomy (POEM) is increasingly used to treat esophageal achalasia, but is associated with a high rate of gastroesophageal reflux disease (GERD). The aim of our meta-analysis was to compare short and standard POEM in terms of clinical success and postoperative GERD. Methods We conducted a systematic review and meta-analysis of studies that compared POEM using short myotomy with standard myotomy. The primary outcome was clinical success. Secondary outcomes were postoperative GERD, perioperative complications, operation time, and length of hospital stay. A random-effects model was used to calculate the risk ratios (RR), mean differences (MD), and confidence intervals (CI). A P-value <0.05 was considered statistically significant. Results We included 5 studies involving 474 esophageal achalasia patients. Short and standard myotomies were similar in terms of clinical success (RR 1.02, 95%CI 0.97-1.09), perioperative complications (RR 0.68, 95%CI 0.26-1.75), and length of hospital stay (MD 0.25 days, 95%CI -0.14-0.63). Operation time was shorter for short myotomy (MD -15.01 mins, 95%CI -20.34 - -9.67). Although reflux symptoms were similar (RR 0.94, 95%CI 0.51-1.74), short myotomy had a lower risk of reflux esophagitis on endoscopy (RR 0.61, 95%CI 0.39-0.98), and pathologic acid exposure on pH monitoring (RR 0.58, 95%CI 0.36-0.94). Conclusions POEM using a shorter myotomy is comparable with standard myotomy in terms of efficacy and safety in the short-term setting. A short myotomy requires a shorter operation time and might reduce the occurrence of postoperative GERD.

Esophageal carcinoma in achalasia patients managed with endoscopic submucosal dissection and peroral endoscopic myotomy: Japan Achalasia Multicenter Study

“…Short myotomy was reported to be equally effective with less RE rates. 29 Adenocarcinoma was not identified in this study because the prevalence of adenocarcinoma is lower in Japan than that in western countries. 30 Therefore, the risk of Missing value for analysis: Procedure time, 69; Direction of myotomy, 17; Length of myotomy, 54; Adverse event, 2; Treatment success, reflux esophagitis, and symptomatic GERD could be analyzed in 3281, 3150, and 3162 followed-up patients.…”

“…This is because in patients with concomitant ECs, the myotomy length could be arranged shorter, not to interfere ESD for ECs, although our result did not show statistical significance of esophageal myotomy length. Short myotomy was reported to be equally effective with less RE rates 29 …”

Publication trends of peroral endoscopic myotomy during 2010–2022: a bibliometric analysis

“…For management and outcomes, prediction models for recurrence after POEM and adverse events were recently published based on large clinical datasets (23,24). Moreover, different choices in procedural details were also compared, such as a study comparing long tunnel versus short tunnel or a meta-analysis comparing the anterior approach versus the posterior approach (25,26). As GERD is a common complication after POEM, fundoplication after or with POEM also received increased attention (27).…”

Third-space endoscopy: the final frontier

“…A shorter cardiomyotomy (<2 cm) has also been suggested as a strategy to limit the risk of reflux esophagitis and abnormal acid exposure [ 30 ]. Ghazaleh et al [ 30 ] recently performed a systematic review and meta-analysis evaluating outcomes of short vs standard POEM myotomy for achalasia.…”

“…A shorter cardiomyotomy (<2 cm) has also been suggested as a strategy to limit the risk of reflux esophagitis and abnormal acid exposure [ 30 ]. Ghazaleh et al [ 30 ] recently performed a systematic review and meta-analysis evaluating outcomes of short vs standard POEM myotomy for achalasia. Five studies with 214 patients with short-length myotomy (2–6 cm esophageal and 1–3 cm gastric length) and 260 standard-length myotomy (6–20 cm esophageal and 2–5 cm gastric) were included.…”