Tu1192 THE LEARNING CURVE OF PERORAL ENDOSCOPIC MYOTOMY IN LATIN AMERICA: A SLIDE TO THE RIGHT ?

Abstract

Per Oral Endoscopic Myotomy (POEM) is a minimally invasive option for achalasia for the past 10 years. The procedure has been increasingly used in Latin America where Chagas disease is prevalent. Studies have suggested that Chagas disease makes POEM more technically challenging due to significant submucosal scarring. The aim of this study was to determine the learning curve for POEM in Latin America. Consecutive patients undergoing POEM in Latin America by a single operator were included from a prospective registry from June 2013 to August 2017. Demographics, procedure info, post-procedure follow-up data, and adverse events were collected. Non-linear regression and CUSUM analyses was conducted for the learning curve. Technical success was successful completion of the myotomy. Clinical success was an Eckardt score of ≤ 3 at 3 months. 125 patients were included (52%M, mean age 59 years). A majority of patients had type II achalasia (n=80, 64%); 33 (26%) had type III, 9 (7%) had type I, 3 (2%) had other esophageal motility disorders. Approximately one third of patients had Chagas disease (n=38, 30%). Most patients had no prior treatment (n=84, 67%), the remaining patients were post-heller myotomy (n=18, 14%), pneumatic dilation (n=17, 13.6%), or botox injection (n=6, 4.8%). The average pre-procedure Eckardt score was 6.79. Technical success was achieved in 93.5% of patients (n=117). 99 patients had a posterior POEM, 26 had anterior. Clinical success was achieved in 88.8% of patients. The mean post-procedure Eckardt score 1.87. Adverse events were noted in 27 patients (22%): bleeding n=4 (coagulation graspers), pneumothorax n=4 (chest tube x 3), mucosal perforation n=13 (closed with clips), mediastinitis n=2 (antibiotics alone), leak n=4 (repeat endoscopy with clips). Average length of stay was 1.98 days; average follow-up was 16months. Median procedure time was 97 minutes (range 45-196 mins, mean 102.7 mins). CUSUM chart (Figure 1) shows 96 minute procedure time was achieved at the 61st procedure hence indicating efficiency. Apart from outliers, procedure durations further reduced with consequent procedures with the last 10 procedures under 50 mins almost approaching a plateau (nonlinear regression p value P<0.0001) (Figure 2). A further evaluation of the next 40-50 cases could potentially reveal a plateau indicating mastery. Endoscopists experienced in POEM are expected to achieve a reduction in procedure time over successive cases. In Latin America, efficiency was reached at 97 minutes and a learning rate of 61 cases with continuing improvement. POEM in Latin American is a technically difficult procedure requiring a higher volume of cases to reach efficiency and seems to be associated with a higher number of adverse events likely due to the increased challenges from Chagas disease patients.Tabled 1POEM demographicsN=125Gender M:F65:60Age (years)59.14 (12.48)Mean (SD)ACHALASIA-Type I-9-Type II-80-Type III-33-Jackhammer esophagus-2-Nutcracker esophagus-1Chagas disease (%)38 (30.4%)Orientation26 : 99Anterior: PosteriorDevice for closure125ClipsPre-procedureMean Eckardt score (SD)6.79 (2.05)Mean LES Pressures mmHg29.04Technical success117 (93.5%)Clinical success111 (88.8%)Complications27-Bleeding4-Pneumothorax4-Mucosal perforation13-Mediastinitis2-Leak4Interventions for complicationsHemoclips (mucosal perforations)12Overscope clips (mucosal perforations)-1Needle decompression (pneumothorax)-11Chest tubes (pneumothorax)-3Coagulation (bleeding)-1Reclips (leaks)-4Antibiotics (mediastinitis)-2Procedure time in minutes (SD)102.65 (42.48)Hospital stay in days (SD)1.98 (0.97)Follow up in months (SD)16 (12.89)Post-procedure (3 months)Mean Eckardt score (SD)1.87 (2.15)Mean LES Pressures mmHg22.56Reinterventions13-Heller myotomy5-Pneumatic dilation8 Open table in a new tab