Learning curve for peroral endoscopic myotomy in therapeutic endoscopy experts and nonexperts: Large single‐center experience

• Published in: Digestive endoscopy Vol. 35; no. 3; pp. 323 - 331
• Main Authors: Fujiyoshi, Yusuke, Inoue, Haruhiro, Fujiyoshi, Mary Raina Angeli, Rodriguez de Santiago, Enrique, Nishikawa, Yohei, Toshimori, Akiko, Tanabe, Mayo, Shimamura, Yuto, Sumi, Kazuya, Ono, Masashi, Shiwaku, Hironari, Ikeda, Haruo, Onimaru, Manabu
• Format: Journal Article
• Language: English
• Published: Australia 01-03-2023
• Subjects: achalasia; education; Endoscopy - methods; Esophageal Achalasia - surgery; Esophageal Sphincter, Lower - surgery; Gastroesophageal Reflux - etiology; Gastroesophageal Reflux - surgery; Humans; Learning Curve; Myotomy - methods; Natural Orifice Endoscopic Surgery - methods; peroral endoscopic myotomy; Proton Pump Inhibitors - therapeutic use; Retrospective Studies; Treatment Outcome; peroral endoscopic myotomy; POEM; education; achalasia; learning curve
• ISSN: 0915-5635; 1443-1661
• DOI: 10.1111/den.14435

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.