Peroral endoscopic myotomy: 10-year outcomes from a large, single-center U.S. series with high follow-up completion and comprehensive analysis of long-term efficacy, safety, objective GERD, and endoscopic functional luminal assessment
BACKGROUND AND AIMS/OBJECTIVE:Peroral endoscopic myotomy (POEM) is becoming the treatment of choice for achalasia. Data beyond 3 years are emerging but limited. We herein report our 10-year experience, focusing on long-term efficacy and safety including the prevalence, management, and sequelae of postoperative reflux. METHODS:This was a single-center prospective cohort study. RESULTS:Six hundred ten consecutive patients received POEM from October 2009 to October 2019 for type I achalasia in 160 (26.2%), II in 307 (50.3%), III in 93 (15.6%), untyped achalasia in 25 (4.1%), and nonachalasia disorders in 23 (3.8%). Two hundred ninety-two (47.9%) patients had prior treatment(s). There was no aborted POEM. Median operation time was 54 minutes. Accidental mucosotomies occurred in 64 (10.5%) and clinically significant adverse events (csAEs) in 21 (3.4%) patients. There were no adverse events (AEs) leading to death, surgery, interventional radiology interventions/drains, or altered functional status. At a median follow-up of 30 months, 29 failures occurred, defined as postoperative Eckardt score >3 or need for additional treatment. The Kaplan-Meier clinical success estimates at year 1, 2, 3, 4, 5, 6, and 7 were 98%, 96%, 96%, 94%, 92%, 91%, and 91%, respectively. These are highly accurate estimates because only 13 (2%) patients were missing follow-up assessments. One hundred twenty-five (20.5%) patients had reflux symptoms more than once per week. At a median of 4 months, the pH study was completed in 406 (66.6%) patients and was positive in 232 (57.1%) and endoscopy in 438 (71.8%) patients and showed reflux esophagitis in 218 (49.8%), mostly mild. CONCLUSION/CONCLUSIONS:POEM is exceptionally safe and highly effective on long-term follow-up, with >90% clinical success at â‰¥5 years.
Learning Curve for Endoscopic Submucosal Dissection With an Untutored, Prevalence-Based Approach in the United States
BACKGROUND & AIMS/OBJECTIVE:Endoscopic submucosal dissection (ESD) is widely used in Asia to resect early-stage gastrointestinal neoplasms, but use of ESD in Western countries is limited. We collected data on the learning curve for ESD at a high-volume referral center in the United States to guide development of training programs in the Americas and Europe. METHODS:/hr. RESULTS:/hr in esophagus, stomach, and colon, respectively. CONCLUSIONS:In an analysis of ESDs performed at a large referral center in the United States, we found that an untutored, prevalence-based approach allowed operators to achieve all proficiency benchmarks after âˆ¼250 cases. Compared with Asia, ESD requires more time to learn in the West, where the untutored, prevalence-based approach requires resection of challenging lesions, such as colon lesions and previously manipulated lesions, in early stages of training.