Sa1301 PERORAL ENDOSCOPIC MYOTOMY: A CONSECUTIVE CASE VIDEO BASED ASSESSMENT OF LEARNING CURVE AND OUTCOMES

Abstract

The primary aim of this study was to evaluate the learning curve of a single endoscopist performing Peroral Endoscopic Myotomy (POEM). The secondary aims were to determine the factors that affect procedure duration and the efficacy of the procedure for the treatment of achalasia and other spastic esophageal disorders. A blinded prospective video review of the first 60 consecutive patients that underwent POEM performed by a single endoscopist between December 2015 to November 2018 at a tertiary care center was conducted. Duration of time taken for entry into the submucosal space, creation of the submucosal tunnel, myotomy, closure, and total procedure time were determined. A cumulative sum analysis (CUSUM) was used to evaluate procedure competence over time by using median procedure time as the targeted time. A multivariable linear regression model was built to identify factors associated with total procedure time, including case number, length of myotomy, mucosal injury, hemostasis, and prior laparoscopic Heller myotomy (LHM) as covariates. A paired t-test was used to compare Eckardt scores before and after POEM. POEM was successfully completed in 59 out of 60 patients. There was a large degree of variance in mean procedure time (mean ± SD: 94.4 ± 25.3 mins). CUSUM peaked at 39 procedures, suggesting efficiency in procedure performance (Figure 1, Table 1). The trend in decreasing procedure time was maintained after 39 procedures. Creation of the submucosal tunnel was found to be the rate limiting step accounting for an average of 43.7% of the total procedure time. Time spent on hemostasis was not correlated with case number. 1-cm increase in length of myotomy was significantly associated with 3.8-minute increase in the procedure duration (p<0.001). Increased procedure duration was significantly associated with prior LHM (p=0.02) but was not associated with adverse events or number of POEM procedures performed. Forty-one patients underwent post-POEM pH and impedance testing with 63.4% showing an abnormal Demeester score (mean=49). The majority of post-procedural gastroesophageal reflux was successfully managed medically; 3 patients required surgical fundoplication or transoral incisionless fundoplication following POEM. The rate of adverse events was 1.7% (n=1). Patients experienced significant decrease in Eckardt score following POEM (p<0.001). In a blinded review of complete consecutive videos of POEM performed by one endoscopist, procedural competence was achieved at 39 procedures. Clinical success was achieved in all cases with only one adverse event. Time spent on hemostasis was not associated with procedure experience and may be a reflection of inherent procedure complexity. Length of myotomy and prior LHM significantly increased procedure time but did not ultimately affect the efficacy of POEM.View Large Image Figure ViewerDownload Hi-res image Download (PPT)