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How We Learned PerOral Endoscopic Myotomy (POEM): the Observe-Train-Perform-Strategy
Joerg Filser*1, Stanislaus Reimer2, Christoph-Thomas Germer1, Burkhard H. a. Von Rahden1
1Department of Surgery, University Hospital Wuerzburg, Wuerzburg, Germany; 2Department of Gastroenterology, University Hospital Wuerzburg, Wuerzburg, Germany
Background. Peroral endoscopic myotomy (POEM) is a promising new technique for treatment of achalasia through the endoscopic route. Previous publications from different centers reported excellent short-term results (control of dysphagia, low reflux rates, control of chest pain). However, POEM is a rather complex procedure, with several technically demanding steps. Therefore a certain strategy seems necessary, prior to establishing the procedure in clinical practice. We herein evaluate our observe-train-perform-(OTG)-strategy which lead to successful implementation of POEM at our center.
Patients & Methods. The OTG-strategy encompassed: 1. Observing live POEM procedures (n=18) at the pioneer center (Showa University/ Yokohama/ Japan) and watching video presentations about complications and pitfalls; 2. Training POEM in the live porcine model (n=11); 3. Performing POEM in human achalasia patients, with (n=5) and without (n=12) expert assistance. The experiences from the animal training were analysed based on objective criteria (procedure time, number of clips used, complications, completeness of myotomy etc.) and subjective judgement on learn progress, using a specially designed scoring system. After sacrificing the animals, the esophagogastric specimens were dissected and checked for completeness of the myotomy. The results obtained in humans were analysed with differential assessment of outcome in procedures with and without expert guidance.
Results. Altogether 18 POEM procedures with different degrees of difficulty (n=16 non-sigmoid, n=2 sigmoid) were observed. Due to rarity of complications in the observed expert series, complication management could only be learned ‘in theory' and from watching sample videos. The 11 procedures performed in the live porcine model were found well-suited to train all steps of the POEM technique. The mean operating time was 107 [78 - 140] min, length of the submucosal tunnel median 15 [12-17] cm, length of the myotomy 13[10-15] cm. Results of the subjective as well as the objective evaluation depicted a step-wise improvement of technical skills and an efficient pass through of the learning curve. Judgment on completeness of myotomy (not achieved in three animals) was improved with increasing experience. There was no difference with respect of weight of the animals (90kg vs. 50kg) with smaller animals being equally suited. The influence of expert guidance was depicted by a shorter OR time (p=0.033), a trend to a lower number of clips used for mucosal closure (p=0.45) and a lower rate of minor complications (p=0.98).
Conclusions. The OTG strategy was useful for implementation in clinical practice, with good results in the initial series of patients. Training POEM in the porcine model seems to be the best currently available method for training, prior to establishing the procedure in human achalasia patients.
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