Background: Peroral endoscopic myotomy (POEM) has emerged as a standard and effective treatment modality for achalasia, with clinical efficacy comparable to surgery. However, pitfalls of the procedure including post-POEM GERD and blown out myotomy (BOM) have led to alterations in the technique of the procedure, including shorter lengths of esophageal myotomy for type 1 and type 2 achalasia. Our study aims to compare the outcomes of short (≤ 4 cm) versus long (≥ 7 cm) esophageal myotomy in such patients.

Methods: Between March 2019 and August 2023, all consecutive patients undergoing peroral endoscopic myotomy for type 1 and type 2 achalasia were retrospectively reviewed and analyzed. Patients were divided into two groups based on the length of esophageal myotomy. Data including patient demographics, procedure details, and clinical outcomes was compared for both groups. The primary outcome was clinical success defined as a post-procedure Eckardt score (ES) ≤3. Secondary outcomes included procedure time, post-procedure impedance planimetry and esophageal manometry results, adverse events, and GERD. Fisher’s Exact Tests were used to assess differences in categorical outcomes between the two groups; for continuous measures, Wilcoxon Two-Sample Tests were used.

Results: Fifty patients underwent POEM for type 1 and type 2 achalasia via a posterior approach using a short (n=25) vs long (n=25) esophageal myotomy technique. The median length of gastric myotomy was similar in the two groups (p=0.45). Baseline patient characteristics of the study population are summarized in Table 1. The median pre-procedure ES was higher in patients in the short myotomy group (9 vs.7, p value= 0.039). The median procedure time was shorter in the short myotomy cohort (72 minutes vs 95 minutes, p= 0.0096). There was no significant difference in peri-operative complications, clinical success, post procedure impedance planimetry, and esophageal manometry results between the two groups (Table 2). Post-procedure GERD was identified in 40% patients with long myotomy and 32% patients with short myotomy (p=0.77).

Conclusion: Short myotomy is clinically equivalent to long myotomy with an additional benefit of reduced operating time in patients with idiopathic type 1 and type 2 achalasia. The incidence of GERD is not affected by the esophageal myotomy length. Future larger prospective randomized control trials are needed to corroborate these findings.

Gregory Russell

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