scholarly journals Pilot prospective study on formal training in per-oral endoscopic myotomy (POEM) during advanced endoscopy fellowship

2021 ◽  
Vol 09 (12) ◽  
pp. E1890-E1899
Author(s):  
Salmaan Jawaid ◽  
Peter V. Draganov ◽  
Hiroyuki Aihara ◽  
Mouen A. Khashab ◽  
Dennis Yang
Keyword(s):  
Prospective Study ◽  
Cognitive Skills ◽  
Assessment Tool ◽  
Clinical Success ◽  
Independent Practice ◽  
Per Oral Endoscopic Myotomy ◽  
Core Curricula ◽  
Eckardt Score ◽  
Endoscopic Myotomy ◽  
Per Oral

Abstract Background and study aims Gastroenterology societies have recently proposed core curricula for training in per-oral endoscopic myotomy (POEM) based on expert opinion with limited data on its applicability for advanced endoscopy fellowship (AEF) trainees. We prospectively evaluated the feasibility of a structured POEM training curriculum during a dedicated AEF and the trainee’s performance during independent practice. Methods This was a single-center prospective study evaluating a trainee’s performance of POEM using a structured assessment tool (POEMAT) to assess core cognitive and technical skills. The trainee’s performance was then prospectively assessed during the first 12 months of independent practice. Results The trainee, who had not prior background in submucosal endoscopy, first observed 22 POEM cases followed by 35 hands-on procedures during his advanced endoscopy fellowship. Based on the POEMAT, submucosal entry and mucosal incision closure were the most challenging technical aspects, while cognitive skills were uniformly attained early in training. Overall, the trainee was able to cross the threshold for competence in his POEMAT performance score in 15 of his last 18 cases (83.3 %). The trainee performed 16 POEMs (baseline mean Eckardt 7.2) in his first 12 months of independent practice. Mean procedural time was 79.8 minutes (interquartile range: 67–94 minutes minutes) with no adverse events. Clinical success (Eckardt score < 3) was achieved in 100 % of the cases at a median follow-up of 20 weeks. Conclusions Results from this pilot study support the adoptability of the recently proposed core curricula for POEM training within the context of a dedicated AEF and provide a potential blueprint for future studies of performance in POEM among trainees.

scholarly journals Per-oral endoscopic myotomy for achalasia cardia: outcomes in over 400 consecutive patients

2017 ◽  
Vol 05 (05) ◽  
pp. E331-E339 ◽  
Author(s):  
Zaheer Nabi ◽  
Mohan Ramchandani ◽  
Radhika Chavan ◽  
Rakesh Kalapala ◽  
Santosh Darisetty ◽  
...  
Keyword(s):  
Clinical Success ◽  
Erosive Esophagitis ◽  
Sphincter Pressure ◽  
Durable Response ◽  
Achalasia Cardia ◽  
Per Oral Endoscopic Myotomy ◽  
Eckardt Score ◽  
Impedance Study ◽  
Endoscopic Myotomy ◽  
Per Oral

Abstract Background and study aims Per-oral endoscopic myotomy (POEM) has emerged as an efficacious treatment modality for the management of achalasia cardia (AC) and non-achalasia spastic esophageal motility disorders. Initial results are encouraging. We analyzed the safety and efficacy of POEM in a large cohort of patients with AC. Patients and methods The data from patients who underwent POEM (from January 2013 to June 2016) was prospectively collected and analyzed. Clinical success was defined as Eckardt score ≤ 3 after POEM procedure. Objective parameters including high-resolution manometry (HRM) and timed barium swallow (TBS) were analyzed and compared before and after the procedure. Gastroesophageal reflux was analyzed using 24-hour pH impedance study and esophagogastro-duodenoscopy. Results A total of 408 patients (mean age 40 years, range 4 – 77 years) underwent POEM during the specified period. POEM could be successfully completed in 396 (97 %) patients. Clinical success rates at 1, 2 and 3 years were 94 %, 91 % and 90 %, respectively. Mean Eckardt score was 7.07 ± 1.6 prior to POEM and 1.27 ± 1.06 after POEM (P = 0.001) at 1 year. Significant improvement in esophageal emptying on TBE (> 50 %) was documented in 93.8 % patients who completed 1-year follow up. Pre-procedure and post-procedure mean lower esophageal sphincter pressure was 45 ± 16.5 mmHg and 15.6 ± 6.1 mmHg, respectively (P = 0.001). Technical and clinical success were comparable in naïve vs prior treated cases (97.3 % vs 96.8 %, P = 0.795) (95.7 % vs 92.6 %, P = 0.275). GERD was documented in 28.3 % patients with 24-hour pH-impedance study and erosive esophagitis was seen in 18.5 % of patients who underwent POEM. Conclusions POEM is safe, effective and has a durable response in patients with achalasia cardia. Prior treatment does not influence the outcomes of POEM.

682 ENDOFLIP TAILORED PER-ORAL ENDOSCOPIC MYOTOMY (POEM): EXPERIENCE IN TWO UK CENTRES.

2021 ◽  
Vol 34 (Supplement_1) ◽  
Author(s):  
William Knight ◽  
Kaveetha Kandiah ◽  
Jennifer Couch ◽  
Nila Tewari ◽  
Krish Ragunath ◽  
...  
Keyword(s):  
Length Of Stay ◽  
Clinical Success ◽  
High Volume ◽  
Poor Responders ◽  
Per Oral Endoscopic Myotomy ◽  
Type Iv ◽  
Eckardt Score ◽  
Improved Outcomes ◽  
Endoscopic Myotomy ◽  
Per Oral

Abstract   Per-oral endoscopic myotomy (POEM) is an effective treatment for achalasia. Efficacy is equivalent to Laparoscopic Heller’s myotomy with the advantage of minimal access and shorter length of stay. Post-operative reflux rates are higher in POEM. The Functional Luminal Imaging Probe (FLIP) allows the measurement of lower oesophageal distensibility during per-oral endoscopic myotomy. In theory, this enables the operator to tailor the myotomy to ensure adequate distensibility whilst minimising post-operative reflux risk. Methods Two prospectively collected POEM databases were analysed from 2 UK tertiary upper GI centres. The operators in each centre used intraoperative FLIP measurements to ensure adequate myotomy. Outcome measures included Eckardt score (where ≤3 indicated clinical success) and proton pump inhibitor use (PPI), collected at the first post-operative appointment. Length of stay was recorded, as were complications. Results 142 patients underwent POEM between 2015 and 2019 with 90% (128/142) clinical success. This improved to 93% (68/73) in the latter half of each series. 79% of the poor responders had previous interventions compared to 55% of responders (p = 0.09). Average post myotomy distensibility was 5.2 mm2/mmHg in responders and 3.11 in non-responders(p = 0.11). DI of &gt;4.5 mm2/mmHg was associated with 100% clinical success. Myotomy length of &lt;7 cm was associated with 93% clinical success and 40% post op PPI use compared to 60% with longer myotomies. There were 2 type IIIa, 2 type IIIb and one type IV Clavien-Dindo complications. Conclusion This study represents one of the largest UK series of FLIP tailored per-oral endoscopic myotomy. FLIP allows intraoperative monitoring of oesophageal distensibility allowing tailoring of myotomies. Tailored myotomies ≤6 cm were effective and were associated with less PPI use post operatively. Early referral of patients to high volume centres, where myotomies can be tailored using FLIP may lead to improved outcomes. More collaborative data from high volume centres is needed to decipher optimal myotomy profiles.

scholarly journals Per-oral endoscopic myotomy (POEM) training and skills evaluation tool: a pilot study

2020 ◽  
Vol 08 (12) ◽  
pp. E1826-E1831
Author(s):  
Alexander Schlachterman ◽  
Ahmed Aziz ◽  
Bader Alajlan ◽  
Samuel Han ◽  
Jorge Machicado ◽  
...  
Keyword(s):  
Pilot Study ◽  
Cognitive Skills ◽  
Assessment Tool ◽  
Technical Skills ◽  
The United States ◽  
Evaluation Tool ◽  
Per Oral Endoscopic Myotomy ◽  
Hands On ◽  
Endoscopic Myotomy ◽  
Per Oral

Abstract Background and study aims Hands-on training for per-oral endoscopic myotomy (POEM) in the United States is limited and without a structured curriculum or assessment tool. Training to competency in POEM is critical and POEM trainees must acquire multiple cognitive and technical skills to achieve proficiency. The aim of this study was to develop a POEM training and skills evaluation tool. Patients and methods The training protocol included initial explant porcine models followed by live human cases, proctored by a single endoscopist experienced in POEM who prospectively graded trainees for each step (“skill”) of the procedure on a 5-point scale. Procedural skills were divided into cognitive and technical skills. Acceptable passing level was considered a score ≥ 4 for each skill. Results Three trainees completed a total of 18 cases (8 cases on animal explant models and 10 human cases). Overall, cognitive skills were acquired early in training with scores of ≥ 4 achieved by ≤ 3 cases. Technical skills required more cases and direction with scores ≥ 4 in technical skills achieved by three porcine and eight human cases. Entry of the endoscope into the submucosal space and submucosal tunneling were the most challenging steps followed by myotomy. Conclusion This pilot study introduces a POEM training and skills evaluation tool for training to competency. Submucosal entry, tunneling, and myotomy were the most challenging to learn while cognitive skills were learned early in training. Evaluation of more trainees at multiple sites will be necessary to further validate the utility of this tool.

scholarly journals Per-oral endoscopic dual myotomy for the treatment of achalasia

Esophagus ◽  
2021 ◽  
Author(s):  
Xianglei Yuan ◽  
Zhe Feng ◽  
Yanshi Zhao ◽  
Xianhui Zeng ◽  
Liansong Ye ◽  
...  
Keyword(s):  
Adverse Events ◽  
Clinical Success ◽  
Mucosal Injury ◽  
Single Session ◽  
Eckardt Score ◽  
Endoscopic Myotomy ◽  
Favorable Safety ◽  
Per Oral ◽  
Disease Questionnaire

Abstract Background Repeat per-oral endoscopic myotomy is occasionally performed for persistent/recurrent symptoms in patients with achalasia, and yields favorable outcomes. We investigated a novel technique, per-oral endoscopic dual myotomy (dual-POEM), where a second myotomy was performed during a single session to augment the efficacy and avoid repeat interventions. The aim of this study was to evaluate its feasibility, safety and efficacy. Methods Consecutive patients diagnosed with achalasia who underwent dual-POEM (1/2018–5/2019) were prospectively collected and retrospectively analyzed. Patients with baseline Eckardt score ≥ 9, ≥ 10 years of symptoms, and/or having prior interventions other than myotomy received dual-POEM. The primary outcome was clinical success (Eckardt score ≤ 3). Secondary outcomes were procedure-related adverse events, change in lower esophageal sphincter (LES) pressure, and reflux complications. Results Seventeen patients received dual-POEM. Procedure-related adverse events were observed in 2 (11.8%) patients (mucosal injury and pneumonitis). Both were minor in severity. During a median follow-up of 33 months (interquartile range, IQR [31,35]; range, 19–36), clinical success was achieved in 16 (94.1%) patients. The median Eckardt score decreased from 9 (IQR [8, 11.5]; range 7–12) to 1 (IQR [1, 2]; range 0–4) (P < 0.001), and LES pressure decreased from 25.8 mmHg (IQR [21.7, 33.5]; range 17.7–46.3) to 7.4 mmHg (IQR [6.3, 10.4]; range 2.2–12.6) (P < 0.001). Seven (41.2%) patients developed postprocedural reflux either by gastroesophageal reflux disease questionnaire or esophagitis endoscopically, all successfully treated with proton pump inhibitors. Conclusion Dual-POEM preliminarily demonstrated high efficacy with a favorable safety profile in patients with achalasia with predictors of treatment failure.

Gastric per-oral endoscopic myotomy (G-POEM) for refractory gastroparesis: results from an international prospective trial

Gut ◽  
2021 ◽  
pp. gutjnl-2020-322756 ◽  
Author(s):  
Kia Vosoughi ◽  
Yervant Ichkhanian ◽  
Petros Benias ◽  
Larry Miller ◽  
A Aziz Aadam ◽  
...  
Keyword(s):  
Gastric Emptying ◽  
Clinical Success ◽  
Short Form ◽  
Prospective Trial ◽  
Safe Procedure ◽  
Per Oral Endoscopic Myotomy ◽  
Standard Medical Therapy ◽  
Endoscopic Myotomy ◽  
Per Oral ◽  
Cardinal Symptom

ObjectiveAlthough gastric per-oral endoscopic myotomy (G-POEM) is considered a promising technique for the management of refractory gastroparesis, high-quality evidence is limited. We prospectively investigated the efficacy and safety of G-POEM in unselected patients with refractory gastroparesis.DesignIn five tertiary centres, patients with symptomatic gastroparesis refractory to standard medical therapy and confirmed by impaired gastric emptying were included. The primary endpoint was clinical success, defined as at least one score decrease in Gastroparesis Cardinal Symptom Index (GCSI) with ≥25% decrease in two subscales, at 12 months. GCSI Score and subscales, adverse events (AEs) and 36-Item Short Form questionnaire of quality of life were evaluated at baseline and 1, 3, 6 and 12 months after G-POEM. Gastric emptying study was performed before and 3 months after the procedure.ResultsOf 80 enrolled patients, 75 patients (94%) completed 12-month follow-up. Clinical success at 12 months was 56% (95% CI, 44.8 to 66.7). GCSI Score (including subscales) improved moderately after G-POEM (p<0.05). In a regression model, a baseline GCSI Score >2.6 (OR=3.23, p=0.04) and baseline gastric retention >20% at 4 hours (OR=3.65, p=0.03) were independent predictors of clinical success at 12 months, as was early response to G-POEM at 1 month after therapy (OR 8.75, p<0.001). Mild procedure-related AEs occurred in 5 (6%) patients.ConclusionG-POEM is a safe procedure, but showed only modest overall effectiveness in the treatment of refractory gastroparesis. Further studies are required to identify the best candidates for G-POEM; unselective use of this procedure should be discouraged.Trial registration numberClinicalTrials.gov Registry NCT02732821.

O26 QUALITY OF LIFE FOR ACHALASIA PATIENTS IS THE SAME AFTER PER-ORAL ENDOSCOPIC MYOTOMY (POEM) AND HELLER MYOTOMY

2019 ◽  
Vol 32 (Supplement_2) ◽  
Author(s):  
Vrakopoulou Gavriella Zoi ◽  
Di Maggio Francesco ◽  
Barbieri Lavinia ◽  
Zeki Sebastian ◽  
Dunn Jason M ◽  
...  
Keyword(s):  
Repeated Measurements ◽  
Similar Degree ◽  
Complication Rates ◽  
Mean Values ◽  
Per Oral Endoscopic Myotomy ◽  
Eckardt Score ◽  
Significant Difference ◽  
Endoscopic Myotomy ◽  
Per Oral

Abstract Aim This study aimed to compare the efficacy and safety of LHM and POEM for esophageal achalasia. Background & Methods Laparoscopic Heller’s myotomy (LHM) has been the gold standard of treatment, however per-oral endoscopic myotomy (POEM) was recently established as a treatment option for achalasia. A prospective review was performed for all patients submitted to LHM or POEM in our institution from 10/2012 to 06/2018, and have completed a minimum follow up period of 6 months. The diagnostic work-up included gastroscopy, barium study and high-resolution manometry (HRM). All patients underwent a clinical evaluation 6 weeks after treatment and a surveillance gastroscopy in the 1st postoperative year. HRM and pH studies were offered to all patients after 6 months. Standardized questionnaires evaluating Eckardt, GERD and achalasia QoL (Urbach) scores were completed pre- and postoperatively. Statistical analyses were performed with SPSS version 23.0. Repeated measurements analysis of variance was used to compare changes in mean values during follow up and between the two types of surgery. P values < 0.05 were considered significant. Results Eighty patients (34 women and 46 men) with mean age 42.6 years (16.2) underwent POEM (n=39) or LHM (n=41). QoL score was significantly improved in both study groups (p<0.001) with a similar degree of improvement (p=0.486). Eckardt scores showed a significant improvement in both groups, but repeated measurements analysis revealed a significant effect with time (p=0.038) with a greater improvement in POEM group. Moreover, Eckardt score change was similar between LHM and POEM patients without prior treatments (p=0.724), but in those with prior treatments the improvement trended higher in POEM group (p=0.087). GERD score had a similar and significant decrease in both groups (p=0.439), but in those with prior treatments the improvement was greater in LHM group (p=0.018). There was no significant difference regarding the complication rates for both groups (Clavien-Dindo I-IIIa). Conclusions POEM compares favorably with LHM as treatment for achalasia, as statistically significant improvement in QoL, GERD and Eckardt scores was recorded in both groups. In patients with prior treatments, POEM tends to achieve a greater improvement of Eckardt score and LHM a greater reduction regarding GERD score.

TP6.2.14 Outcome of POEM (Per-oral endoscopic myotomy) for achalasia

2021 ◽  
Vol 108 (Supplement_7) ◽  
Author(s):  
Annabelle White ◽  
Woochan Hwang ◽  
Alekhaya Kotta ◽  
Daniel Beasley ◽  
Katarina Chow ◽  
...  
Keyword(s):  
Clinical Success ◽  
Pneumatic Dilatation ◽  
Demeester Score ◽  
First Line Therapy ◽  
Eckardt Score ◽  
Operative Endoscopy ◽  
Endoscopic Myotomy ◽  
Oesophageal Achalasia ◽  
Per Oral

Abstract Aims Laparoscopic Heller’s myotomy (LHM) has been the surgical gold standard for treatment of oesophageal achalasia. Peroral endoscopic myotomy (POEM) has been proposed as an alternative technique. The aim of this study was to assess the safety and efficacy of POEM for achalasia in our unit. Methods We have operated on 202 patients for oesophageal achalasia since 2005: 107 had LHM, 86 had POEM, and 9 had an oesophagectomy. We assessed the clinical outcome of POEM comparing pre- and postoperative endoscopic, radiologic and manometric findings, as well as Eckardt-, GERD- and DsQoL score for achalasia. All follow-up patients were offered endoscopy. Results Data were completed for the first 45 POEM patients. The average age was 45 years. 18 patients (40%) had prior achalasia treatment. The median hospital stay was 2 days (2-5). There was no mortality, but 4 patients (9%) had post-operative complications. The median follow-up was 24 months (12-49). Clinical success (Eckardt score ≤ 3) was achieved in 39 patients (87%). Thirteen patients (29%) were taking PPIs for chest symptoms. Eleven of these underwent pH studies of whom only 1 had a DeMeester score &gt; 14.5. Of the 24 patients who had post-operative endoscopy, 40% was diagnosed with oesophagitis grade A, yet only 5 of them were symptomatic. Conclusions POEM appears to be safe and effective and warrants consideration as first-line therapy in expert achalasia centres. Longer term randomized studies comparing the outcomes of POEM with LHM and pneumatic dilatation will determine its place in the treatment of achalasia.

scholarly journals How does per-oral endoscopic myotomy compare to Heller myotomy? The Latin American perspective

2020 ◽  
Vol 08 (10) ◽  
pp. E1392-E1397
Author(s):  
Michel Kahaleh ◽  
Amy Tyberg ◽  
Supriya Suresh ◽  
Arnon Lambroza ◽  
Monica Gaidhane ◽  
...  
Keyword(s):  
Latin America ◽  
Hospital Stay ◽  
Chagas Disease ◽  
Latin American ◽  
Heller Myotomy ◽  
Initial Therapy ◽  
Per Oral Endoscopic Myotomy ◽  
Eckardt Score ◽  
Endoscopic Myotomy ◽  
Per Oral

Abstract Background and study aims Both Heller myotomy (HM) and per-oral endoscopic myotomy (POEM) are efficacious therapies for achalasia. The efficacy and safety of POEM vs HM in Latin America and specifically in patients with Chagas disease is unknown. Patients and methods Consecutive patients undergoing either HM or POEM for achalasia were included from nine Latin American centers in a prospective registry over 5 years. Technical success was defined as undergoing a successful myotomy. Clinical success was defined as achieving an Eckardt score < 3. Data on demographics, procedure info, Eckardt score, and adverse events (AEs) were collected. Student’s t test, Chi squared, and logistic regression analyses were conducted. Results One hundred thirty-three patients were included (59 male; 44 %; mean age 47). POEM was performed in 69 patients, HM in 64 patients. A total of 35 patients had Chagas disease, 17 of 69 in the POEM group, 18 of 64 in the HM group. Both groups had significant reduction in Eckardt scores (P < 0.00001), but successful initial therapy was significantly higher in the POEM group compared to the HM group (P = 0.01304). AEs were similar in both group (17 % vs 14 %) and consisted of pneumothorax (n = 3 vs 2), bleeding requiring transfusion (n = 3 vs 2), and mediastinitis (n = 3 vs 1). Hospital stay was longer in the HM group than in the POEM group (P < 0.00001). In the Chagas subgroup, post-procedure Eckardt score in the POEM group was significantly reduced by 5.71 points (P < 0.00001) versus 1.56 points in the HM group (P = 0.042793). Conclusion Both HM and POEM are efficacious for achalasia, but POEM was associated with higher initial therapy success and shorter hospital stay in Latin America. In Chagas patients with achalasia, POEM was significantly more effective than HM.

scholarly journals Tu1530 GASTRIC PER-ORAL ENDOSCOPIC MYOTOMY (G-POEM) FOR THE TREATMENT OF GASTROPARESIS (GP): A PROSPECTIVE SINGLE CENTER ASSESSMENT OF CLINICAL SUCCESS

2020 ◽  
Vol 91 (6) ◽  
pp. AB605
Author(s):  
Lennon Gregor ◽  
John M. DeWitt ◽  
John M. Wo ◽  
Martha Mendez ◽  
Anita Gupta ◽  
...  
Keyword(s):  
Clinical Success ◽  
Single Center ◽  
Per Oral Endoscopic Myotomy ◽  
Endoscopic Myotomy ◽  
Per Oral
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