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Fujiyoshi Y, Inoue H, Fujiyoshi MRA, Rodriguez de Santiago E, Nishikawa Y, Toshimori A, Tanabe M, Shimamura Y, Sumi K, Ono M, Shiwaku H, Ikeda H, Onimaru M. Learning curve for peroral endoscopic myotomy in therapeutic endoscopy experts and nonexperts: Large single-center experience. Dig Endosc 2023; 35:323-331. [PMID: 36097829 DOI: 10.1111/den.14435] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 09/11/2022] [Indexed: 02/08/2023]
Abstract
OBJECTIVES Reports on learning curve for peroral endoscopic myotomy (POEM) in therapeutic endoscopy nonexperts are limited. We aimed to assess the number of cases required to achieve POEM proficiency for endoscopic submucosal dissection (ESD) experts and nonexperts. METHODS This is a retrospective study at the largest POEM referral center in Japan. POEM between April 2014 and December 2020 were included. Nonexperts and ESD experts were divided by training phases: A, 1-20; B, 21-40; C, 41-60; D, 61-80; and E, 81-100 cases. Primary outcome was operation time, and the phase to reach target time (83 min) was investigated. Secondary outcomes were clinical success rate, adverse events, and post-POEM gastroesophageal reflux disease (GERD). RESULTS Five hundred and sixty-six cases were performed by 14 nonexperts, and 555 cases by 15 ESD experts. As the primary outcome, operation time in nonexperts was: A, 95 (79-115.8); B, 86.5 (71-105); C, 80 (70-100); D, 73 (64.5-100.5); and E, 73.5 (57.8-88.8) min, while in ESD experts: A, 90 (74-128); B, 77 (70-92); and C, 77 (70-93.5) min (median [interquartile range]). Operation time decreased significantly as experience increased in both groups (P < 0.001), and nonexperts required 41-60 cases to achieve proficiency, while experts required 21-40 cases. As secondary outcomes, in nonexperts, clinical success was 96.9-100%, adverse events were 5.0-9.2%, symptomatic GERD was 11.8-26.5%, and proton pump inhibitor (PPI) intake was 11.5-18.7% in each phase. While in experts, clinical success was 96.2-100%, adverse events were 3.0-5.8%, symptomatic GERD was 14.6-22.0%, and PPI intake was 12.6-17.9%. There were no significant differences among training phases. CONCLUSIONS Non-ESD experts require more cases to achieve proficiency in POEM. These results are useful for establishing POEM training programs and institutional implementation of the procedure.
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Affiliation(s)
- Yusuke Fujiyoshi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan.,Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Haruhiro Inoue
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mary Raina Angeli Fujiyoshi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan.,Division of Gastroenterology, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Enrique Rodriguez de Santiago
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain.,Instituto Ramón y Cajal de Investigación Sanitaria, Madrid, Spain
| | - Yohei Nishikawa
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Akiko Toshimori
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Mayo Tanabe
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Yuto Shimamura
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Kazuya Sumi
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Masashi Ono
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hironari Shiwaku
- Department of Gastroenterological Surgery, Fukuoka University Faculty of Medicine, Fukuoka, Japan
| | - Haruo Ikeda
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Manabu Onimaru
- Digestive Diseases Center, Showa University Koto Toyosu Hospital, Tokyo, Japan
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Abstract
BACKGROUND AND STUDY AIMS : Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure for the treatment of achalasia and certain spastic esophageal motility disorders, delivering excellent results in experienced hands. However, this complex and technically challenging procedure requires advanced endoscopic skills. The aim of this study was to conduct a systematic review and meta-analysis of current data to evaluate the learning curve for POEM in new adopters of this technique. METHODS : Electronic databases (PubMed, Embase, and Cochrane Library) from inception to November 2021 were searched for publications addressing the learning curve in POEM. Pooling was conducted by both fixed- and random-effects models. Secondary outcomes reviewed were clinical success defined by Eckardt score ≤ 3 when available and adverse events. RESULTS : Eight studies involving 1904 patients met the inclusion criteria. In the pooled analysis, new adopters of POEM attained proficiency at a mean of 24.67 procedures (95 %CI 23.93 to 25.41). Once proficiency was achieved, the pooled total procedure time plateaued at a mean of 85.38 minutes (95 %CI 81.48 to 89.28), the pooled mean procedure time per centimeter of myotomy was 6.25 minutes (95 %CI 5.69 to 6.82), and the pooled mean length of myotomy was 11.49 cm (95 %CI 10.90 to 12.08). CONCLUSIONS : Our analysis showed that new adopters of POEM with previous advanced endoscopy experience required about 25 procedures to attain proficiency. The average time for each procedure once proficiency was attained was about 85 minutes.
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Affiliation(s)
- Srinivas R Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - David Forcione
- Gastroenterology, Boca Raton Regional Hospital, Boca Raton, Florida, United States
| | - Harishankar Gopakumar
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
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Jawaid S, Draganov PV, Aihara H, Khashab MA, Yang D. Pilot prospective study on formal training in per-oral endoscopic myotomy (POEM) during advanced endoscopy fellowship. Endosc Int Open 2021; 9:E1890-E1899. [PMID: 34917458 PMCID: PMC8671003 DOI: 10.1055/a-1610-8962] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 07/31/2021] [Indexed: 11/20/2022] Open
Abstract
Background and study aims Gastroenterology societies have recently proposed core curricula for training in per-oral endoscopic myotomy (POEM) based on expert opinion with limited data on its applicability for advanced endoscopy fellowship (AEF) trainees. We prospectively evaluated the feasibility of a structured POEM training curriculum during a dedicated AEF and the trainee's performance during independent practice. Methods This was a single-center prospective study evaluating a trainee's performance of POEM using a structured assessment tool (POEMAT) to assess core cognitive and technical skills. The trainee's performance was then prospectively assessed during the first 12 months of independent practice. Results The trainee, who had not prior background in submucosal endoscopy, first observed 22 POEM cases followed by 35 hands-on procedures during his advanced endoscopy fellowship. Based on the POEMAT, submucosal entry and mucosal incision closure were the most challenging technical aspects, while cognitive skills were uniformly attained early in training. Overall, the trainee was able to cross the threshold for competence in his POEMAT performance score in 15 of his last 18 cases (83.3 %). The trainee performed 16 POEMs (baseline mean Eckardt 7.2) in his first 12 months of independent practice. Mean procedural time was 79.8 minutes (interquartile range: 67-94 minutes minutes) with no adverse events. Clinical success (Eckardt score < 3) was achieved in 100 % of the cases at a median follow-up of 20 weeks. Conclusions Results from this pilot study support the adoptability of the recently proposed core curricula for POEM training within the context of a dedicated AEF and provide a potential blueprint for future studies of performance in POEM among trainees.
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Affiliation(s)
- Salmaan Jawaid
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States,Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas, United States
| | - Peter V. Draganov
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
| | - Hiroyuki Aihara
- Division of Gastroenterology and Hepatology, Brigham and Women’s Hospital, Boston, Massachusetts, United States
| | - Mouen A. Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, Baltimore, Maryland, United States
| | - Dennis Yang
- Division of Gastroenterology and Hepatology, University of Florida, Gainesville, Florida, United States
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