title: Peroral endoscopic esophageal myotomy: defining the learning curve.
abstract: BACKGROUND
  Peroral endoscopic myotomy (POEM) is an endoscopic alternative to laparoscopic esophageal myotomy. It requires a demanding skill set that involves both advanced endoscopic skills and knowledge of surgical anatomy and complication management.
  
  
  OBJECTIVE
  Determine the learning curve for POEM.
  
  
  METHODS
  Prospective cohort study.
  
  
  METHODS
  Tertiary-care teaching hospital.
  
  
  METHODS
  The study involved the first 40 consecutive patients undergoing the POEM procedure under a prospective institutional review board protocol (research.gov #NCT01399476, 1056).
  
  
  METHODS
  Peroral endoscopic myotomy for esophageal motility disorders.
  
  
  METHODS
  Length of procedure (LOP) and technical errors (inadvertent mucosotomy).
  
  
  RESULTS
  A total of 40 patients underwent POEM. The mean LOP was 126 ± 41 minutes. The mean myotomy length was 9 cm (range, 6-20 cm). The LOP per centimeter myotomy and variability decreased as our experience progressed. The means (± standard deviation) of the LOP per centimeter myotomy were as follows: first cohort, 16 ± 4 minutes; second, 17 ± 5 minutes; third, 13 ± 3 minutes; fourth, 15 ± 2 minutes; and fifth, 13 ± 4 minutes. The incidence of inadvertent mucosotomy also decreased with increasing experience, to 8, 6, 4, 0, and 1, respectively. These minor complications were repaired intraoperatively with clips. There were 7 patients with capnoperitonium and another with bilateral capnothoraces that were associated with hemodynamic instability but resolved by Veress needle decompression. Two patients required endoscopy in the early postoperative period: self-limited hematemesis in one and radiologic evidence of leakage at the mucosotomy site in another.
  
  
  CONCLUSIONS
  Nonrandomized study.
  
  
  CONCLUSIONS
  Mastery of operative technique in POEM is evidenced by a decrease in LOP, variability of minutes per centimeter of myotomy, and incidence of inadvertent mucosotomies and plateaus in about 20 cases for experienced endoscopists. The learning curve can be shortened with very close supervision and/or proctoring.
authors: Providence Portland Cancer Center, Portland, Oregon, USA. ashwinkurian@hotmail.com
authors: Ashwin A
authors: AA
authors: Kurian
authors: Christy M
authors: CM
authors: Dunst
authors: Ahmed
authors: A
authors: Sharata
authors: Neil H
authors: NH
authors: Bhayani
authors: Kevin M
authors: KM
authors: Reavis
authors: Lee L
authors: LL
authors: Swanström
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002983:Clinical Competence; D015154:Esophageal Motility Disorders / Q000601:surgery*; D049630:Esophageal Sphincter, Lower / Q000601:surgery*; D005260:Female; D006801:Humans; D059032:Learning Curve; D008297:Male; D008875:Middle Aged; D009092:Mucous Membrane / Q000293:injuries; D057605:Natural Orifice Endoscopic Surgery / Q000009:adverse effects; D061646:Operative Time; D055815:Young Adult