Defining the standard length of Peroral Endoscopic Myotomy (POEM) for achalasia: a systematic review and meta-analysis

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Aims Peroral endoscopic myotomy (POEM) has revolutionized achalasia treatment. However no clear definition of “long”, “standard” or “short” POEM exists to date. Evidence suggests myotomy limited to the LES (<6cm) may be highly effective, timesaving and associated with less reflux, yet longer myotomy is commonly performed in clinical practice. Methods We conducted a systematic review with meta-analysis to define current myotomy length standards during POEM. A literature search was performed on MEDLINE-Pubmed, Embase, Scopus, and Cochrane Library (from inception to December 2022). We included prospective, retrospective studies and randomized controlled trials in which no definite or comparative myotomy length was intentionally adopted thus representing a “standard” myotomy for the operator. The primary outcome was the pooled mean total myotomy length. Secondary outcomes included clinical success and reflux symptoms. Exclusion criteria were patient age<18 years; non-high resolution manometry diagnosis, studies including motility disorders other than achalasia, comparing different myotomy lengths or adopting pre-specified myotomy lengths, type III achalasia only studies. Results From initial 7,172 records, after exclusion criteria were applied, a total of 25 articles were included. Six articles reported results in separate subgroups and were included individually, totalling 31 studies and 3023 patients for analysis. The pooled mean of total myotomy length was 10.39 cm (95% CI 10.06-10.71; I 2 99.3%). The pooled mean of esophageal and gastric myotomy length, provided by 17 studies, was 7.11 cm (95% CI 6.51-7.71; I 2 99.8%) and 2.81 cm (95% CI 2.41-3-22; I 2 99.8%) respectively. At the subgroup analysis for achalasia subtypes, pooled mean length in non-spastic achalasia (type I-II) was 10.17 cm (95% CI 9.91-10.43; I 2 94.2%), while in type III attested at 14.02 cm (95% CI 10.59-17.44; I 2 98.9%). Pooled mean myotomy length for studies conducted between 2014-2018 was 10.56 cm (95% CI 9.51-11.61; I 2 99.0%) while studies between 2019-2022 showed a mean length of 10.3 cm (95% CI 9.99.10.61; I 2 99.6%). No geographical difference was registered either between Eastern (10.2 cm, 95% CI 9.12-10.92; I 2 98.9%) and Western (10.95 cm, 95% CI 9.83-12.07; I 2 99.5%) countries. At a median follow-up of 29 months, the pooled clinical success rate was 91% (95% CI 88.9%-93.2%; I 2 67.2%), while the pooled rate of post-POEM clinical reflux was 26% (95% CI 21.0%-31.3%; I 2 89.5%). Conclusions Our meta-analysis found that the pooled mean myotomy length during a "standard” POEM is 10.4 cm, remaining over 10 cm in non-spastic achalasia. High heterogeneity confirms POEM technique needs further standardization. Publication History Article published online: 15 April 2024 © 2024. European Society of Gastrointestinal Endoscopy. All rights reserved. Georg Thieme Verlag KG Rüdigerstraße 14, 70469 Stuttgart, Germany

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