Journal Article

Long versus short peroral endoscopic myotomy for the treatment of achalasia: results of a non-inferiority randomised controlled trial

Landi, Rosario, Perri, Vincenzo, Boskoski, Ivo, Costamagna, Guido, Borrelli de Andreis, Federica, Mangiola, Francesca, Tringali, Andrea, Familiari, Pietro

2023

Overview

ObjectivePeroral endoscopic myotomy (POEM) has become standard treatment for achalasia with comparable efficacy to surgery. In most of published series, the length of myotomy is 12–13 cm. Shorter cuts could have the advantage of shorter procedure time and possibly reduced gastro-oesophageal reflux disease (GORD) rate.DesignThis single-centre, patient-blinded, randomised, non-inferiority clinical trial included 200 patients, who were randomly allocated, to receive either a long-POEM (13 cm; 101 patients) or a short-POEM (8 cm; 99 patients). Primary outcome was defined as an Eckardt symptom score of ≤3 at 24 months after the procedure; a non-inferiority design was chosen with an accepted success range of 6% between the two treatments. Secondary outcomes included operating time, complication rate, postoperative manometry, GORD rate and quality of life.ResultsIn the intention-to-treat analysis, clinical success rates were 89.1% in the long-POEM and 98.0% in the short-POEM group, resulting in an absolute between-group difference of −8.9% (90% CI −14.5 to −3.3).Procedure time was significantly reduced in the short-POEM as compared with the long-POEM group (40 vs 50 min, p<0.0001). Severe adverse events occurred in one patient in both groups.No differences were observed in postoperative GORD: acid exposure >6% on pH monitoring study at 6 months was seen in 34.3% (long-POEM) vs 31.1% (short-POEM), while endoscopic oesophagitis was diagnosed in 37.6% vs 51.5% at 6 months and in 21% vs 24.5% at 24 months. Regular proton pump inhibitor use was not different either (36.8% vs 37.5%).ConclusionsOur study demonstrates non-inferiority of a shorter cut length of POEM as compared with the standard treatment, which saved some procedural time. GORD rate was not reduced by reducing cutting length.Trial registration number NCT03450928.

• Publisher: BMJ Publishing Group Ltd and British Society of Gastroenterology,BMJ Publishing Group LTD
• Subject: Achalasia / Classification / Clinical trials / Endoscopy / Esophageal Achalasia - complications / Esophageal diseases / Esophageal Sphincter, Lower - surgery / Esophagitis / Esophagoscopy - methods / Gastroesophageal reflux / Gastroesophageal Reflux - etiology / Gastroesophageal Reflux - surgery / gastroesophageal reflux disease / Humans / Iatrogenesis / lower oesophageal sphincter / Motility / Myotomy - methods / Natural Orifice Endoscopic Surgery - adverse effects / Natural Orifice Endoscopic Surgery - methods / oesophageal disease / Patients / Proton pump inhibitors / Quality of Life / therapeutic endoscopy / Treatment Outcome