Short versus long myotomy during peroral endoscopic myotomy for achalasia: a systematic review and meta-analysis

Background: Peroral endoscopic myotomy (POEM) is an established treatment modality for achalasia. This meta-analysis aimed to compare the clinically relevant outcomes of short and long myotomy during POEM for achalasia. Methods: PubMed, Cochrane Central, and ScienceDirect were systematically searched from inception to February 2025. The risk ratios (RRs) and mean differences (MDs) were pooled using the random-effects model in Review Manager. Quality assessment was conducted using the Cochrane Risk of Bias (RoB 2.0) tool and the Newcastle-Ottawa Scale. Results: Seven studies, pooling a total of 737 patients, were included in the analysis. The short myotomy showed no significant difference in clinical success [RR: 1.02; 95% CI: (0.99–1.05); P = 0.19], Eckardt score ( P = 0.45), or lower esophageal sphincter pressure ( P = 0.72) compared to the long myotomy. Similarly, the integrated relaxation pressures ( P = 0.73), duration of hospitalization ( P = 0.67), and the risk of erosive esophagitis ( P = 0.13) were comparable between the two arms. The short myotomy arm significantly reduced overall procedural duration [MD: −15.84; 95% CI: (−21.05 to −10.63); P < 0.00001]. Short myotomy was also associated with a significantly lower risk of abnormal esophageal acid exposure [RR: 0.64; 95% CI: (0.43–0.95); P = 0.03]. Conclusion: Short myotomy was associated with a significant reduction in procedural time and risk of abnormal esophageal acid exposure, whereas the remaining efficacy and safety endpoints were comparable between the two techniques.