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When is POEM truly equivalent to LHM? A comparison of complication rates during the learning curve

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Abstract

Introduction

Per-Oral Endoscopic Myotomy (POEM) is an effective treatment for Esophageal Achalasia Cardia (EAC) but the endoscopic technique required is complex. As competency is crucial for patient safety, we believe that its’ competency can be demonstrated when the complication rate equals that of an established procedure such as Laparoscopic Heller’s Myotomy with Fundoplication (LHM + F).

Methods

A multicentre, ambi-directional, non-randomized comparison of intra-procedural complications during the learning curve of POEM was performed against a historical cohort of LHM + F. Demographic, clinicopathological, procedural data and complications were collected. A direct head-to-head comparison was performed, followed by a population pyramid of complication frequency. Case sequence was then divided into blocks of 5, and the complication rates during each block was compared to the historical cohort.

Results

From January 2010 to April 2021, 60 patients underwent LHM + F and 63 underwent POEM. Mean age was lower for the POEM group (41.7 years vs 48.1 years, p = 0.03), but there was no difference in gender nor type of Achalasia. The POEM group recorded a shorter overall procedural time (125.9 min vs 144.1 min, p = 0.023) and longer myotomies (10.1 cm vs 6.2 cm, p = 0.023). The overall complication rate of POEM was 20.6%, whereas the historical cohort of LHM + F had a rate of 10.0%. On visual inspection of the population pyramid, complications were more frequent in the earlier procedures. On block sequencing, complication frequency could be seen tapering off dramatically after the 25th case, and subsequently equalled that of LHM + F.

Conclusion

POEM is challenging even for experienced endoscopists. From our data, complication rates between POEM and LHM + F equalize after approximately 25 POEMs.

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Data availability

Data confidentiality were handled in accordance to the Declaration of Helsinki, and approval from relevant ethical boards were obtained prior to initiation of this work.

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Funding

Personal funds, no external funding sources.

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Authors and Affiliations

  1. Upper Gastro-Intestinal Surgery Unit, Department of Surgery, Faculty of Medicine, University of Malaya, Professor Diraja Ungku Aziz Road, 50603, Kuala Lumpur, Malaysia

    Wei Jin Wong

  2. Department of Internal Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia

    Nik Arsyad Nik Muhamad Affendi, Shiaw Hooi Ho & Sanjiv Mahadeva

  3. Department of General Surgery, Sarawak General Hospital, Kuching, Sarawak, Malaysia

    Sze Li Siow

  4. Department of General Surgery, Sultanah Aminah Hospital, Johor Bahru, Malaysia

    Hans Alexander Mahendran

  5. Pantai Hospital Kuala Lumpur, Kuala Lumpur, Malaysia

    Peng Choong Lau

  6. Department of Internal Medicine, Kulliyyah of Medicine, International Islamic University of Malaysia, Kuantan, Malaysia

    Nik Arsyad Nik Muhamad Affendi

Authors
  1. Wei Jin Wong
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  3. Sze Li Siow
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  6. Shiaw Hooi Ho
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  7. Sanjiv Mahadeva
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Contributions

WJW: authorship, data analysis, conceptualization, NANMA: authorship, data collection and analysis, SLS, HAM, PCL, SHH, SM: conceptualization, supervision, data collection, performed the procedures.

Corresponding author

Correspondence to Wei Jin Wong.

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Disclosures

Sanjiv Mahadeva received support from Olympus Co Ltd (Japan) in the form of Triangle Tip Jet Knives to perform POEMs, as well as funding to conduct animal model POEM workshops. Wei Jin Wong, Nik Arsyad Nik Muhamad Affendi, Sze Li Siow, Hans Alexander Mahendran, Peng Choong Lau, and Shiaw Hooi Ho have no conflicts of interest or financial ties to disclose.

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Wong, W.J., Affendi, N.A.N.M., Siow, S.L. et al. When is POEM truly equivalent to LHM? A comparison of complication rates during the learning curve. Surg Endosc 37, 1735–1741 (2023). https://doi.org/10.1007/s00464-022-09680-2

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  • DOI: https://doi.org/10.1007/s00464-022-09680-2

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