INTRODUCTION: Peroral endoscopic myotomy (POEM) has been established as a safe and effective intervention for Type I and II achalasia. Studies have shown that short POEM is non-inferior to long POEM, with some evidence of decreased incidence of gastroesophageal reflux disease (GERD). This meta-analysis aims to systematically review and analyze randomized controlled trials (RCTs) data comparing clinical and safety outcomes for long and short POEM procedures while further investigating differences in GERD and other long-term clinical outcomes. METHODS: We conducted a comprehensive search in PubMed, Embase, Cochrane, and Web of Science from inception until October 2024 for RCTs comparing long and short POEM procedures for the treatment of achalasia. Our pooled data was analyzed for clinical and objective procedural success, procedural adverse events, GERD outcomes, procedure time, and hospitalization time. A random effects model was used, and the data was presented using pooled odds ratios (OR) and mean differences (MD) with 95% confidence intervals (CI). RESULTS: Five RCTs were included with 518 achalasia patients (253 in short group and 265 in long group). Baseline characteristics of enrolled patients were similar across studies. Short and long POEM had similar clinical success (OR 1.18, 95% CI: 0.45-3.06, p = 0.73, I2 0%), procedural adverse events (OR 0.72, 95% CI: 0.33-1.54, p = 0.39, I2 0%), hospitalization time (0.14 days, 95% CI: - 0.13 to 0.40, p = 0.31, I2 0%). Short POEM had shorter procedure time (MD - 16.68 min, 95% CI: - 22.77 to - 10.59, p < 0.00001, I2 75%). The groups had similar symptomatic GERD (OR 0.86, 95% CI: 0.52-1.44, p = 0.57, I2 0%), however short POEM had significantly lower acid exposure time (OR 0.62, 95% CI: 0.38 to 0.99, p = 0.04, I2 0%) and erosive esophagitis after sensitivity analysis (OR 0.52, 95% CI: 0.27 to 1.01, p = 0.05, I2 0%). CONCLUSION: Our study demonstrates that short POEM is clinically non-inferior to long POEM but has advantages in shorter procedure time and lower odds of objective evidence of gastroesophageal reflux disease.

2nd Department of Internal Medicine Gastroenterology and Geriatrics University Hospital Olomouc Faculty of Medicine and Dentistry Palacky University Olomouc Olomouc Czech Republic

Department of Digestive Endoscopy and Gastroenterology AULSS2 Conegliano Hospital Conegliano Italy

Department of Gastroenterology and Digestive Endoscopy Masaryk Memorial Cancer Institute Brno Czech Republic

Department of Internal Medicine Baylor Scott and White Medical Center Round Rock Round Rock TX USA

Department of Surgery University Hospital Brno Faculty of Medicine Masaryk University Brno Czech Republic

Division of Gastroenterology and Hepatology Indiana University School of Medicine Indianapolis IN USA

Division of Gastroenterology and Hepatology King Faisal Specialist Hospital and Research Center Jeddah Saudi Arabia

Division of Gastroenterology Baylor Scott and White Medical Center Round Rock Round Rock TX USA

Division of Gastroenterology Department of Medicine University of Jordan Amman Jordan

Division of Gastroenterology Hepatology and Endoscopy Brigham and Women's Hospital Harvard Medical School Boston MA USA

Division of Gastroenterology South Texas VA San Antonio TX USA

Division of Gastroenterology UT Health San Antonio San Antonio TX USA

Endoscopy Unit Humanitas Clinical Center IRCCS Rozzano Italy

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