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Training in esophageal peroral endoscopic myotomy (POEM) on an ex vivo porcine model: learning curve study and training strategy

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Abstract

Background

Peroral endoscopic myotomy (POEM) is a very effective treatment for achalasia. However, training remains non-standardized. We evaluated a training curriculum, including ex vivo cases, followed by patients’ cases under expert supervision. The objective was to establish a learning curve of POEM.

Materials and Methods

Four operators having completed advanced endoscopy fellowship were involved. They had already observed > 30 cases performed by experts. They performed 30 POEMs standardized (tunnel and myotomy lengths) procedures on ex vivo porcine model. Procedural times, number/volume of injections, mucosal and serous perforations, and myotomy length were collected. The learning curve was assessed using dissection speed (DS) and a dedicated performance score (PS), including learning rate (LR) and learning plateau (LP).

Results

The operators completed all cases within 4 months (median of 3.5 cases/week). The mean procedural time was 43.3 min ± 14.4. Mean myotomy length was 70.0 mm ± 15.6 mm. Dissection speed averaged 1.78 mm/min ± 0.78. Using DS and PS as parameter, the LR was reached after 12.2 cases (DS = 2.0 mm/min) and 10.4 cases, respectively. When comparing the LP and the plateau phase, the DS was slower (1.3 ± 0.5 mm/min versus 2.1 ± 0.54 mm/min, p < 0.005) and perforations were decreased: 0.35 ± 0.82 in LP vs. 0.16 ± 0.44 in PP. Following this training, all operators performed 10 supervised cases and are competent in POEM.

Conclusion

The association of observed cases and supervised ex vivo model training is effective for starting POEM on patients. The learning curve is 12 cases to reach a plateau.

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References

  1. Kahrilas PJ, Bredenoord AJ, Carlson DA et al (2018) Advances in management of esophageal motility disorders. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc 16:1692–1700

    Google Scholar 

  2. Eckardt VF, Aignherr C, Bernhard G (1992) Predictors of outcome in patients with achalasia treated by pneumatic dilation. Gastroenterology 103:1732–1738

    Article  CAS  PubMed  Google Scholar 

  3. Inoue H, Minami H, Kobayashi Y et al (2010) Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 42:265–271

    Article  CAS  PubMed  Google Scholar 

  4. Hernández-Mondragón OV, Solórzano-Pineda OM, González-Martínez MA et al (2019) Peroral endoscopic myotomy for the treatment of achalasia and other esophageal motor disorders: short-term and medium-term results at a Mexican tertiary care center. Rev Gastroenterol Mex 84:1–10

    Google Scholar 

  5. Teitelbaum EN, Dunst CM, Reavis KM et al (2018) Clinical outcomes five years after POEM for treatment of primary esophageal motility disorders. Surg Endosc 32:421–427

    Article  PubMed  Google Scholar 

  6. Andolfi C, Fisichella PM (2019) Meta-analysis of clinical outcome after treatment for achalasia based on manometric subtypes. Br J Surg 106:332–341

    Article  CAS  PubMed  Google Scholar 

  7. Ponds FA, Fockens P, Lei A et al (2019) Effect of peroral endoscopic myotomy vs pneumatic dilation on symptom severity and treatment outcomes among treatment-naive patients with achalasia: a randomized clinical trial. JAMA 322:134–144

    Article  PubMed  PubMed Central  Google Scholar 

  8. Werner YB, Hakanson B, Martinek J et al (2019) Endoscopic or surgical myotomy in patients with idiopathic Achalasia. N Engl J Med 381:2219–2229

    Article  PubMed  Google Scholar 

  9. Weusten BLAM, Barret M, Bredenoord AJ et al (2020) Endoscopic management of gastrointestinal motility disorders—part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 52:498–515

    Article  PubMed  Google Scholar 

  10. Bernardot L, Roman S, Barret M et al (2020) Efficacy of per-oral endoscopic myotomy for the treatment of non-achalasia esophageal motor disorders. Surg Endosc. https://doi.org/10.1007/s00464-019-07348-y

    Article  PubMed  Google Scholar 

  11. Tyberg A, Sharaiha RZ, Familiari P et al (2018) Peroral endoscopic myotomy as salvation technique post-Heller: international experience. Dig Endosc Off J Japan Gastroenterol Endosc Soc 30:52–56

    Google Scholar 

  12. Zhang X, Li Q, Xu M et al (2016) Major perioperative adverse events of peroral endo- scopic myotomy : a systematic 5-year analysis. Endoscopy 48(11):967–978

    Article  PubMed  Google Scholar 

  13. Wang Y, Liu Z-Q, Xu M-D et al (2019) Clinical and endoscopic predictors for intraprocedural mucosal injury during per-oral endoscopic myotomy. Gastrointest Endosc 89:769–778

    Article  PubMed  Google Scholar 

  14. Oscar MC, Louis L, Ambica P et al (2015) Safety and efficacy of poem for treatment of achalasia: a systematic review of the literature. Surg Endosc Other Interv Tech 29:S451

    Google Scholar 

  15. Rahmi G, Hotayt B, Chaussade S et al (2014) Endoscopic submucosal dissection for superficial rectal tumors: prospective evaluation in France. Endoscopy 46:670–676

    Article  PubMed  Google Scholar 

  16. Jacques J, Legros R, Charissoux A et al (2016) A local structured training program with live pigs allows performing ESD along the gastrointestinal tract with results close to those of Japanese experts. Dig Liver Dis Off J Ital Soc Gastroenterol Ital Assoc Study Liver 48:1457–1462

    Google Scholar 

  17. Gromski MA, Cohen J, Saito K et al (2017) Learning colorectal endoscopic submucosal dissection: a prospective learning curve study using a novel ex vivo simulator. Surg Endosc Other Interv Tech. https://doi.org/10.1007/s00464-017-5484-2

    Article  Google Scholar 

  18. Pimentel-Nunes P, Pioche M, Albéniz E et al (2019) Curriculum for endoscopic submucosal dissection training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 51:980–992

    Article  PubMed  Google Scholar 

  19. Küttner-Magalhães R, Dinis-Ribeiro M, Bruno MJ et al (2018) Training in endoscopic mucosal resection and endoscopic submucosal dissection: face, content and expert validity of the live porcine model. United Eur Gastroenterol J 6:547–557

    Article  Google Scholar 

  20. Liu Z, Zhang X, Zhang W et al (2018) Comprehensive evaluation of the learning curve for peroral endoscopic myotomy. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc 16:1420-1426.e2

    Google Scholar 

  21. Kurian AA, Dunst CM, Sharata A et al (2013) Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc 77:719–725

    Article  PubMed  Google Scholar 

  22. Hungness ES, Sternbach JM, Teitelbaum EN et al (2016) Per-oral Endoscopic Myotomy (POEM) after the learning curve: durable long-term results with a low complication rate. Ann Surg 264:508–517

    Article  PubMed  Google Scholar 

  23. Kato M, Gromski M, Jung Y et al (2013) The learning curve for endoscopic submucosal dissection in an established experimental setting. Surg Endosc 27:154–161

    Article  PubMed  Google Scholar 

  24. Feldman LS, Cao J, Andalib A et al (2009) A method to characterize the learning curve for performance of a fundamental laparoscopic simulator task: defining ‘learning plateau’ and ‘learning rate.’ Surgery 146:381–386

    Article  PubMed  Google Scholar 

  25. Cook JA, Ramsay CR, Fayers P (2007) Using the literature to quantify the learning curve: a case study. Int J Technol Assess Health Care 23:255–260

    Article  PubMed  Google Scholar 

  26. Ramsay CR, Grant AM, Wallace SA et al (2001) Statistical assessment of the learning curves of health technologies. Health Technol Assess (Rockv). https://doi.org/10.3310/hta5120

    Article  Google Scholar 

  27. Moré JJ (1978) The Levenberg-Marquardt algorithm: implementation and theory. In: Watson GA (ed) Numerical analysis. Springer, Berlin, pp 105–116

    Chapter  Google Scholar 

  28. Boda K, Oka S, Tanaka S et al (2020) Real-world learning curve analysis of colorectal endoscopic submucosal dissection: a large multicenter study. Surg Endosc 34:3344–3351

    Article  PubMed  Google Scholar 

  29. Iacopini F, Bella A, Costamagna G et al (2012) Stepwise training in rectal and colonic endoscopic submucosal dissection with differentiated learning curves. Gastrointest Endosc 76:1188–1196

    Article  PubMed  Google Scholar 

  30. El Zein M, Kumbhari V, Ngamruengphong S et al (2016) Learning curve for peroral endoscopic myotomy. Endosc Int open 4:E577–E582

    Article  PubMed  PubMed Central  Google Scholar 

  31. Lv H, Zhao N, Zheng Z et al (2017) Analysis of the learning curve for peroral endoscopic myotomy for esophageal achalasia: single-center, two-operator experience. Dig Endosc Off J Japan Gastroenterol Endosc Soc 29:299–306

    Google Scholar 

  32. Salvador R, Provenzano L, Capovilla G et al (2020) Extending myotomy both downward and upward improves the final outcome in manometric pattern III achalasia patients. J Laparoendosc Adv Surg Tech A 30:97–102

    Article  PubMed  Google Scholar 

  33. Kane ED, Budhraja V, Desilets DJ et al (2019) Myotomy length informed by high-resolution esophageal manometry (HREM) results in improved per-oral endoscopic myotomy (POEM) outcomes for type III achalasia. Surg Endosc 33:886–894

    Article  PubMed  Google Scholar 

  34. Li C, Gong A, Zhang J et al (2017) Clinical outcomes and safety of partial full-thickness myotomy versus circular muscle myotomy in peroral endoscopic myotomy for achalasia patients. Gastroenterol Res Pract 2017:2676513

    Article  PubMed  PubMed Central  Google Scholar 

  35. Haito-Chavez Y, Inoue H, Beard KW et al (2017) Comprehensive analysis of adverse events associated with per oral endoscopic myotomy in 1826 patients: an international multicenter study. Am J Gastroenterol 112:1267–1276

    Article  PubMed  Google Scholar 

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Authors and Affiliations

  1. Aix-Marseille Université, AP-HM, Hôpital Nord, Gastroenterology, Chemin Des Bourrelys, 13015, Marseille, France

    Jean-Michel Gonzalez, Elise Meunier, Véronique Vitton & Marc Barthet

  2. CHU de Montpellier, Gastroenterology, Montpellier, France

    Antoine Debourdeau

  3. CHU Rouen, Rouen, France

    Paul Basile

  4. CHU Amiens, Amiens, France

    Jean-Pilippe Le-Mouel

  5. CHU de Nîmes, Nîmes, France

    Ludovic Caillo

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Correspondence to Jean-Michel Gonzalez.

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Dr Jean-Michel Gonzalez is a consultant for Ambu and Boston Scientific. Pr Marc Barthet is a consultant for Boston Scientific. Dr Elise Meunier, Dr Antoine Debourdeau, Dr Paul Basile, Dr Jean-Philippe Le Mouel, Dr Ludovic Caillo, and Pr Veronique Vitton have no conflicts of interest or financial ties to disclose.

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Gonzalez, JM., Meunier, E., Debourdeau, A. et al. Training in esophageal peroral endoscopic myotomy (POEM) on an ex vivo porcine model: learning curve study and training strategy. Surg Endosc 37, 2062–2069 (2023). https://doi.org/10.1007/s00464-022-09736-3

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