Peroral endoscopic longer vs shorter esophageal myotomy for achalasia treatment: A systematic review and meta-analysis

BACKGROUND: Peroral endoscopic myotomy (POEM) has been demonstrated to be safe and effective in the treatment of achalasia. Longer myotomy is the standard POEM procedure for achalasia but when compared with shorter myotomy, its effectiveness is not as well known. AIM: To compare the clinical effectiveness of longer and shorter myotomy. METHODS: PubMed, EmBase, Cochrane Library, web of science and clinicaltrials.gov were queried for studies comparing shorter and longer POEM for achalasia treatment. The primary outcome was clinical success rate. Secondary outcomes comprised of operative time, adverse events (AEs) rate, gastroesophageal reflux disease (GERD) and procedure-related parameters. The Mantel-Haenszel fixed-effects model was primarily used for the analysis. Publication bias was assessed. RESULTS: Six studies were included in this analysis with a total of 514 participants. During the follow-up period of 1-28.7 mo, longer and shorter myotomy in treating achalasia showed similar excellent effectiveness [overall clinical success (OR = 1, 95%CI: 0.46-2.17, P = 1, I(2): 0%; subgroup of abstract (OR = 1.19, 95%CI: 0.38 to 3.73; P = 0.76; I(2): 0%); subgroup of full text (OR = 0.86 95%CI: 0.30 to 2.49; P = 0.78; I(2): 0%)]. Shorter myotomy had significantly reduced mean operative time compared with the longer procedure. There were no statistically significant differences in AEs rates, including GERD (overall OR = 1.21, 95%CI: 0.76-1.91; P = 0.42; I(2): 9%; subgroup of abstract OR = 0.77, 95%CI: 0.40-1.47; P = 0.43; I(2): 0%; subgroup of full text OR = 1.91, 95%CI: 0.98-3.75; P = 0.06; I(2): 0%), hospital stay (overall MD = -0.07, 95%CI: -0.30 to 0.16; P = 0.55; I(2): 24%; subgroup of abstract MD = 0.20, 95%CI: -0.25 to 0.65; P = 0.39; I(2): 0; subgroup of full text MD = -0.16, 95%CI: -0.42 to 0.10; P = 0.23; I(2): 42%), and major bleeding (overall OR = 1.25, 95%CI: 0.58-2.71; P = 0.56; I(2): 0%) between the two procedures. These differences remained statistically non-significant in all sensitivity analyses. CONCLUSION: POEM was effective in treating achalasia. Shorter and longer myotomy procedures provided similar therapeutic effects in terms of long-term effectiveness. In addition, shorter myotomy reduced the operative time.