Shorter POEM Matches Symptom Control in Achalasia While Saving Procedure Time
A shorter cut length during peroral endoscopic myotomy produced symptom control that was not only preserved, but numerically better at 24 months than the standard approach in a randomized trial of achalasia. The result matters because the appeal of a shorter myotomy has always rested on two practical goals: less time in the procedure room and, ideally, less post-procedure reflux. This trial answers one of those goals cleanly and challenges the other.
Two hundred patients with achalasia were randomized at a single center to receive either a 13 cm long-POEM or an 8 cm short-POEM. Investigators used a non-inferiority design, with success defined as an Eckardt score of 3 or less at 24 months and an accepted margin of 6%. In that framework, the shorter approach did not merely keep pace with the standard technique; it crossed the threshold for non-inferiority on the study’s own terms. The clinical success rate reached 98.0% in the short-POEM arm versus 89.1% in the long-POEM arm, with an absolute between-group difference of -8.9% and a 90% confidence interval of -14.5 to -3.3.
That numerical spread tells a familiar story in achalasia therapy: once the lower esophageal sphincter is adequately disrupted, additional length may add little to symptom relief. Achalasia is fundamentally a disorder of outflow obstruction at the esophagogastric junction, and the therapeutic target is the high-pressure segment that prevents bolus passage. Extending the myotomy further along the esophageal body may be necessary in some patients, but this trial suggests that a fixed longer cut is not automatically superior for the typical achalasia case treated in this setting.
Procedure Time Fell, But Reflux Did Not Follow
The most immediate operational gain came in the procedure room. Mean operating time fell from 50 minutes with long-POEM to 40 minutes with short-POEM, a statistically significant reduction. Ten minutes may look modest on paper, yet in advanced endoscopy that difference can influence anesthesia exposure, scheduling throughput, and the cumulative strain on procedural teams. Shortening the intervention without sacrificing efficacy creates a narrower, more efficient technical target for endoscopists who already work under tight anatomic constraints.
One sentence captures the reflux finding plainly: reducing myotomy length did not reduce gastro-oesophageal reflux disease.
Post-procedural acid exposure remained common in both groups. At 6 months, pH monitoring showed abnormal acid exposure in 34.3% of patients in the long-POEM arm and 31.1% in the short-POEM arm. Endoscopic oesophagitis was actually more frequent in the short-POEM group at that point, 51.5% versus 37.6%, although the imbalance narrowed by 24 months, when oesophagitis was present in 24.5% versus 21.0%. Regular proton pump inhibitor use was nearly identical at 36.8% and 37.5%.
The reflux signal is biologically important because it suggests that post-POEM acid burden is driven by more than how many centimeters of muscle are cut. Disruption of the lower esophageal sphincter eliminates the anti-reflux barrier regardless of whether the myotomy is 8 cm or 13 cm, and the mucosal consequences may depend on patient anatomy, hiatal mechanics, gastric emptying, and acid suppression practices rather than on length alone. In other words, the sphincter problem is solved by myotomy; the reflux problem is created at the same time.
Why the Non-Inferiority Result Carries Weight
Non-inferiority trials demand discipline from both the design and the interpretation. Here, the accepted margin was 6%, and the observed difference favored the shorter approach rather than eroding confidence in it. For a therapy already used as a standard alternative to surgery, that matters because it shifts the discussion away from whether short-POEM is “good enough” and toward which patients truly need a longer cut.
The single-center and patient-blinded design strengthens internal consistency, although it also limits how far the results can be stretched across centers with different technical styles. Achalasia is not a uniform disease; pattern of spasticity, esophageal dilation, and prior treatment history can all affect technical strategy. Even so, the central message is straightforward: a standard-length myotomy is not required to achieve durable symptom relief in this trial population.
The safety profile did not reveal an unexpected penalty for the shorter approach in the abstracted data. Secondary outcomes included complication rate, postoperative manometry, reflux burden, and quality of life, and the report’s main signal remained procedural efficiency rather than a new adverse event pattern. For clinicians, that is a meaningful combination: preserved efficacy, less procedure time, and no meaningful reflux advantage from cutting less.
What This Means at the Bedside
For patients with achalasia, the practical implication is that a shorter POEM can be offered without sacrificing 24-month symptom control, at least in a setting that mirrors this randomized trial. For endoscopists, the result invites a more selective approach to myotomy length rather than a reflexive default to longer tunnels and longer muscle cuts. The challenge now is not whether short-POEM can work; this trial shows that it can.
The harder clinical question is selection. Some patients may still need a longer myotomy because of spastic features, procedural anatomy, or operator judgment at the time of intervention. The trial does not remove that nuance. It does, however, weaken the assumption that more myotomy is inherently better, and it does so with a clear endpoint: symptom success at 24 months was maintained, while reflux remained stubbornly common in both arms.
The trial registration number was NCT03450928. For a condition in which durable relief depends on getting the mechanics right the first time, that kind of procedural efficiency without loss of efficacy is the most concrete advance here. The reflux question remains open at the bedside, but the length question now has a much firmer answer.