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SHORT VERSUS LONG LENGTH OF MYOTOMY IN PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA: A META-ANALYSIS OF 10 COMPARATIVE STUDIES
Abdul-Rahman F. Diab^*2,1, Joseph Sujka¹, Salvatore Docimo¹, Christopher DuCoin^1
1University of South Florida Morsani College of Medicine Department of Surgery, Ocala, FL; ²University of Central Florida College of Medicine / HCA Healthcare GME Consortium, Ocala, FL

Background
Shortening the length of myotomy during peroral endoscopic myotomy (POEM) for achalasia has been hypothesized to reduce the incidence of gastroesophageal reflux disease (GERD) while preserving the safety and efficacy of the procedure. This study compares perioperative outcomes, GERD-related outcomes, efficacy-related outcomes, and high-resolution manometry (HRM) and timed barium esophagogram (TBE)-related outcomes between short POEM (S-POEM) and long POEM (L-POEM) through a pairwise meta-analysis of comparative studies.

Methods
A systematic literature review adhering to PRISMA guidelines was conducted to identify studies directly comparing S-POEM and L-POEM. A random-effects model was used to calculate odds ratios for dichotomous outcomes and mean differences for continuous outcomes to estimate effect sizes. Subgroup analyses were performed by categorizing studies into randomized and nonrandomized comparative studies.

Results
The analysis revealed significant differences in perioperative outcomes. Operative time and the number of clips used were significantly reduced in S-POEM compared to L-POEM. However, no significant differences were observed in adverse events or length of stay (LOS). For GERD-related outcomes, S-POEM was associated with a statistically significant reduction in the incidence of abnormal esophageal acid exposure, as shown in Figure 1A. Although the reduction in symptomatic GERD with S-POEM did not reach statistical significance (p = 0.06), the p-value approached the threshold for significance (0.05) as shown in Figure 1B. Furthermore, all the studies included in the analysis reported a decrease in symptomatic GERD with S-POEM. No significant differences were found in daily proton pump inhibitor (PPI) use or esophagitis rates.
In terms of efficacy-related outcomes, no significant differences were identified between S-POEM and L-POEM for clinical success or Eckardt score. Similarly, no significant differences were observed in HRM and TBE-related outcomes, including lower esophageal sphincter (LES) pressure, integrated relaxation pressure (IRP), and barium column height at 5 minutes. Table 1 provides a detailed quantitative description of the 13 meta-analyses conducted for the outcomes assessed.

Conclusions
This study suggests that S-POEM may reduce the incidence of GERD without compromising the efficacy of the procedure. However, further randomized studies with larger sample sizes are necessary to draw definitive conclusions.


Figure 1A and Figure 1B

Table 1

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