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Endoscopy 2023; 55(04): 355-360
DOI: 10.1055/a-1935-1093
Systematic Review

Learning curve for esophageal peroral endoscopic myotomy: a systematic review and meta-analysis

Srinivas R. Puli
1   Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
,
Mihir S. Wagh
2   Division of Gastroenterology, University of Colorado School of Medicine, Aurora, Colorado, United States
,
David Forcione
3   Gastroenterology, Boca Raton Regional Hospital, Boca Raton, Florida, United States
,
Harishankar Gopakumar 
1   Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
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Author commentary on Srinivas R. Puli et al.Endoscopy 2023; 55(04): v11-v11
DOI: 10.1055/a-1956-7349

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.



Publication History

Received: 24 February 2022

Accepted after revision: 01 September 2022

Accepted Manuscript online:
01 September 2022

Article published online:
24 November 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Masadeh M, Nau P, Chandra S. et al. Experience with peroral endoscopic myotomy for achalasia and spastic esophageal motility disorders at a tertiary US. center. Clin Endosc 2020; 53: 321-327
    CrossrefPubMedGoogle Scholar
  • 2 Inoue H, Minami H, Kobayashi Y. et al. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265-271
    Google Scholar
  • 3 Petrov RV, Fajardo RA, Bakhos CT. et al. Peroral endoscopic myotomy: techniques and outcomes. Shanghai Chest 2021; 5: 14
    CrossrefPubMedGoogle Scholar
  • 4 Kurian AA, Dunst CM, Sharata A. et al. Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc 2013; 77: 719-725
    CrossrefPubMedGoogle Scholar
  • 5 Teitelbaum EN, Soper NJ, Arafat FO. et al. Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg 2014; 18: 92-98 discussion 98–99
    CrossrefPubMedGoogle Scholar
  • 6 Liu Z, Zhang X, Zhang W. et al. Comprehensive evaluation of the learning curve for peroral endoscopic myotomy. Clin Gastroenterol Hepatol 2018; 16: 1420-1426
    CrossrefPubMedGoogle Scholar
  • 7 Patel KS, Calixte R, Modayil RJ. et al. The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy. Gastrointest Endosc 2015; 81: 1181-1187
    CrossrefPubMedGoogle Scholar
  • 8 Kahaleh M, Tyberg A, Suresh S. et al. The learning curve for peroral endoscopic myotomy in Latin America: a slide to the right?. Clin Endosc 2021; 54: 701-705
    CrossrefPubMedGoogle Scholar
  • 9 Lv H, Zhao N, Zheng Z. et al. Analysis of the learning curve for peroral endoscopic myotomy for esophageal achalasia: single-center, two-operator experience. Dig Endosc 2017; 29: 299-306
    CrossrefPubMedGoogle Scholar
  • 10 El Zein M, Kumbhari V, Ngamruengphong S. et al. Learning curve for peroral endoscopic myotomy. Endosc Int Open 2016; 4: E577-582
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Tefas C, Boroș C, Ciobanu L. et al. POEM: five years of experience in a single East European center. J Gastrointestin Liver Dis 2020; 29: 323-328
    CrossrefPubMedGoogle Scholar
  • 12 Harbord RM, Egger M, Sterne JA. A modified test for small-study effects in meta-analyses of controlled trials with binary endpoints. Stat Med 2006; 25: 3443-3457
    CrossrefPubMedGoogle Scholar
  • 13 Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics 1994; 50: 1088-1101
    CrossrefPubMedGoogle Scholar
  • 14 Sterne JA, Egger M, Smith GD. Systematic reviews in health care: investigating and dealing with publication and other biases in meta-analysis. BMJ 2001; 323: 101-105
    CrossrefPubMedGoogle Scholar
  • 15 Neyeloff JL, Fuchs SC, Moreira LB. Meta-analyses and forest plots using a microsoft excel spreadsheet: step-by-step guide focusing on descriptive data analysis. BMC Res Notes 2012; 5: 52
    CrossrefPubMedGoogle Scholar
  • 16 Akintoye E, Kumar N, Obaitan I. et al. Peroral endoscopic myotomy: a meta-analysis. Endoscopy 2016; 48: 1059-1068
    Article in Thieme ConnectPubMedGoogle Scholar
  • 17 Schlottmann F, Luckett DJ, Fine J. et al. Laparoscopic Heller myotomy versus peroral endoscopic myotomy (POEM) for achalasia. Ann Surg 2018; 267: 451-460
    CrossrefPubMedGoogle Scholar
  • 18 Swanstrom LL, Kurian A, Dunst CM. et al. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012; 256: 659-667
    CrossrefPubMedGoogle Scholar
  • 19 Dacha S, Aihara H, Anand GS. et al. Core curriculum for peroral endoscopic myotomy (POEM). Gastrointest Endosc 2021; 93: 539-543
    CrossrefPubMedGoogle Scholar
  • 20 Schlachterman A, Aziz A, Alajlan B. et al. Per-oral endoscopic myotomy (POEM) training and skills evaluation tool: a pilot study. Endosc Int Open 2020; 8: E1826-E1831
    Article in Thieme ConnectPubMedGoogle Scholar
  • 21 Jawaid S, Draganov PV, Aihara H. et al. Pilot prospective study on formal training in per-oral endoscopic myotomy (POEM) during advanced endoscopy fellowship. Endosc Int Open 2021; 9: E1890-E1899
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Faulx AL, Lightdale JR, Acosta RD. et al. Guidelines for privileging, credentialing, and proctoring to perform GI endoscopy. Gastrointest Endosc 2017; 85: 273-281
    Google Scholar
  • 23 Modayil R, Stavropoulos SN. How many peroral endoscopic myotomy procedures are necessary for proficiency?. Clin Gastroenterol Hepatol 2018; 16: 1393-1397
    CrossrefPubMedGoogle Scholar
  • 24 Hungness ES, Sternbach JM, Teitelbaum EN. et al. Per-oral endoscopic myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg 2016; 264: 508-517
    CrossrefPubMedGoogle Scholar
  • 25 Reinersman JM, Wigle DA, Gostout CJ. et al. A novel strategy to initiate a peroral endoscopic myotomy program. Eur J Cardiothorac Surg 2017; 52: 686-691
    CrossrefPubMedGoogle Scholar
  • 26 Hernández Mondragón OV, Rascón Martínez DM, Muñoz Bautista A. et al. The per oral endoscopic myotomy (POEM) technique: how many preclinical procedures are needed to master it?. Endosc Int Open 2015; 3: E559-565
    Article in Thieme ConnectPubMedGoogle Scholar