Impact of gastric length of myotomy during POEM on the incidence of gastroesophageal reflux: A randomized controlled trial.

BACKGROUND AND AIMS: Peroral endoscopic myotomy (POEM) is an effective treatment for achalasia cardia, but gastroesophageal reflux disease (GERD) remains a significant concern. The length of gastric myotomy may influence reflux outcomes, but high-quality data are lacking. This randomized controlled trial compared the incidence of GERD after short versus long gastric myotomy (SGM vs LGM) during POEM. METHODS: In this randomized trial, we compared SGM (gastric myotomy <3 cm) with LGM (gastric myotomy≥3 cm) during POEM in cases with type I or II achalasia. The primary endpoint was significant reflux esophagitis defined as Los Angeles (LA) grade B or higher esophagitis at 6 months follow-up. Secondary endpoints included esophageal acid exposure (≥6% total acid exposure time [AET]) on 24-hour pH monitoring, reflux symptoms, proton pump inhibitor (PPI) use, Eckardt score, esophageal emptying, and high-resolution manometry parameters. RESULTS: A total of 100 patients were randomly assigned to undergo either POEM with SGM (50 patients) or LGM (50 patients). Baseline characteristics were similar between groups. At 6 months, significant reflux esophagitis occurred in 24% (12/50) of SGM patients versus 44% (22/50) of LGM patients (p = 0.035; odds ratio, 2.45; 95% CI, 1.04-5.79). Upright acid exposure was significantly lower in the SGM group (median 0.75% vs 3.2%; p = 0.036). No differences were observed in reflux symptoms, PPI use, total AET, or clinical efficacy between groups. CONCLUSIONS: SGM significantly reduces the incidence of LA grade ≥B esophagitis at 6 months following POEM, without differences in symptom burden, acid exposure, or clinical efficacy. (ClinicalTrials.gov number, NCT05500196).