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Objectives: Reports on learning curve for peroral endoscopic myotomy (POEM) in therapeutic endoscopy nonexperts are limited. We aimed to assess the number of cases required to achieve POEM proficiency for endoscopic submucosal dissection (ESD) experts and nonexperts. Methods: This is a retrospective study at the largest POEM referral center in Japan. POEM between April 2014 and December 2020 were included. Nonexperts and ESD experts were divided by training phases: A, 1–20; B, 21–40; C, 41–60; D, 61–80; and E, 81–100 cases. Primary outcome was operation time, and the phase to reach target time (83 min) was investigated. Secondary outcomes were clinical success rate, adverse events, and post‐POEM gastroesophageal reflux disease (GERD). Results: Five hundred and sixty‐six cases were performed by 14 nonexperts, and 555 cases by 15 ESD experts. As the primary outcome, operation time in nonexperts was: A, 95 (79–115.8); B, 86.5 (71–105); C, 80 (70–100); D, 73 (64.5–100.5); and E, 73.5 (57.8–88.8) min, while in ESD experts: A, 90 (74–128); B, 77 (70–92); and C, 77 (70–93.5) min (median [interquartile range]). Operation time decreased significantly as experience increased in both groups (P < 0.001), and nonexperts required 41–60 cases to achieve proficiency, while experts required 21–40 cases. As secondary outcomes, in nonexperts, clinical success was 96.9–100%, adverse events were 5.0–9.2%, symptomatic GERD was 11.8–26.5%, and proton pump inhibitor (PPI) intake was 11.5–18.7% in each phase. While in experts, clinical success was 96.2–100%, adverse events were 3.0–5.8%, symptomatic GERD was 14.6–22.0%, and PPI intake was 12.6–17.9%. There were no significant differences among training phases. Conclusions: Non‐ESD experts require more cases to achieve proficiency in POEM. These results are useful for establishing POEM training programs and institutional implementation of the procedure. [ABSTRACT FROM AUTHOR]

Geriatric patients with existing studies on the safety and efficacy of peroral endoscopic myotomy (POEM) for achalasia involve small sample sizes and single institutions. However, multi-center, large-scale data analyses are lacking. The study aimed to clarify the characteristics of geriatric patients with esophageal motility disorders (EMDs) and determine the procedure-related outcomes and clinical course following POEM. This cohort study included 2,735 patients with EMDs who were treated at seven Japanese facilities between 2010 and 2019. The patients' characteristics and post-POEM clinical courses were compared between the geriatric (age ≥ 75 years; n  = 321) and non-geriatric (age < 75 years; n  = 2,414) groups. Compared with the non-geriatric group, the geriatric group had higher American Society of Anesthesiologists physical status scores; more recurrent cases; lower incidence of chest pain; and higher incidence of type III achalasia, distal esophageal spasm, and Jackhammer esophagus. Furthermore, the incidence of sigmoid esophagus was higher, although esophageal dilation was not severe in this group. POEM was safe and effective for geriatric patients with treatment-naïve and recurrent EMDs. Furthermore, compared with the non-geriatric group, the geriatric group had lower post-POEM Eckardt scores, fewer complaints of refractory chest pain, and a lower incidence rate of post-POEM reflux esophagitis. Geriatric patients are characterized by worse clinical conditions, more spastic disorders, and greater disease progression of EMDs, which are also the indications for minimally invasive POEM. POEM is more beneficial in geriatric patients as it has lowering symptom scores and incidence rates of reflux esophagitis. [ABSTRACT FROM AUTHOR]

Background Peroral endoscopic myotomy (POEM) is standard treatment for achalasia. Gastroesophageal reflux disease (GERD) after POEM has been a limiting factor with this procedure. Preservation of the sling fiber during POEM was reported to reduce post-POEM GERD in Japan, but there are no reports of this technique in a western population. As such, we investigated the association of sling-fiber preservation during POEM and post-POEM GERD symptoms at our institution, which is a large therapeutic endoscopy referral center in Canada. Methods This is a retrospective, single-center study of patients who underwent POEM from October 2017 to January 2023 at our center. The initial cohort of patients were treated by conventional POEM until June 2021, after which a second cohort underwent POEM with sling-fiber preservation, as the techniques advanced. The primary outcome was the rate of positive GERD symptoms after POEM. The secondary outcomes were procedure time, gastric myotomy length, clinical success rate (Eckard score of less than 3), adverse events rate and use of PPI at follow-up. Results 148 POEM cases (52.5 ± 15.6 y/o, female: 61(43%)) were included in this study. There was no significant difference in patient characteristics between the groups. The mean procedure time (108.6 ± 34.5 vs 109.1 ± 45.7 min, P = 0.93) and rate of adverse events (21% vs 14%, P = 0.36) were similar between the traditional and modified groups. In the sling fiber preservation group, gastric myotomy length was significantly longer (2.2 ± 0.7 vs 1.6 ± 0.8 cm, P < 0.05) yet the GERD symptom rate at follow-up was significantly lower (22% vs 41%, P < 0.05), although PPI use was similar (57% vs 50%, P = 0.47). Finally, the clinical success rate was similar between groups (88% vs 84%, P = 0.6). Conclusions Sling fiber preservation during POEM is safe and reduces post-POEM GERD symptoms, despite the longer gastric myotomy length. As such, sling fiber preservation may be a useful solution to reduce post-POEM GERD in western populations. [ABSTRACT FROM AUTHOR]