Short esophageal myotomy versus standard myotomy for treatment of sigmoid-type achalasia: results of an international multicenter study.

Background and Aims: Patients with sigmoid-type achalasia can be challenging to treat with peroral endoscopic myotomy (POEM). A short myotomy improves technical success; however, outcomes have not previously been evaluated.
Methods: This was a multicenter, international, retrospective study of patients who underwent POEM with short (≤4 cm) or standard esophageal myotomy. Outcomes included clinical and technical success, procedural adverse events, and reflux rates.
Results: A total of 109 patients with sigmoid achalasia (sigmoid, n = 74; advanced sigmoid, n = 35) underwent POEM across 13 centers (short myotomy, n = 59; standard, n = 50). Technical success was 100% across both groups. Patients who underwent short myotomy had a significantly shorter mean procedure time (57.7 ± 27.8 vs 83.1 ± 44.7 minutes, P = .0005). A total of 6 adverse events were recorded in 6 patients (5.5%; 4 mild, 2 moderate); the adverse event rate was not significantly different between short and standard groups. Ninety-eight patients had follow-up data (median, 3.6 months; interquartile range, 1-14 months). Clinical success was 94% (short, 93%; standard, 95%; P = .70) and did not differ based on achalasia subtype or sigmoid achalasia severity. Twenty-one (22%) patients reported post-POEM reflux and 44% (16 of 36) had objective evidence of pathologic reflux. Rates of pathologic reflux were significantly increased in the standard versus short group (odds ratio, 18.0; 95% confidence interval, 2.0-159.0; P = .009).
Conclusions: POEM with short myotomy is effective and safe for the short-term treatment of sigmoid and advanced sigmoid achalasia. Short myotomy may lead to less reflux than standard myotomy.
Competing Interests: Disclosure The following authors disclosed financial relationships: A. Schlachterman: Consultant for Olympus Medical, Fujifilm Healthcare, Boston Scientific, Lumendi, and Laborie. P. Kedia: Consultant for Boston Scientific, Olympus Medical, and Medtronic. R. Pawa: Consultant for Boston Scientific and Cook Medical. P.G. Arcidiacono: Consultant for Pentax Medical, Boston Scientific, and FujiFilm. Advisory Board for MediGlobe and AMBU. S. Nagi: Lecture fees from Falk Pharmaceuticals, Pfizer, and Sanofi. R Sharaiha: Consultant for Boston Scientific, Olympus, and Intuitive Surgical. S. Irani: Consultant for Boston Scientific, Conmed, and Gore. C.-R. Medranda: Key opinion leader for Pentax Medical, Steris, Micro-Tech, G-Tech Medical Supply, EndoSound, and Mdconsgroup. M. Khashab: Consultant for Boston Scientific and Olympus and he receives royalties from Elsevier and UpToDate. All other authors disclosed no financial relationships.
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