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Chen W, Yu S, Sun B, Wu C, Li T, Dong S, Ge J, Lei S. The learning curve for gasless transaxillary posterior endoscopic thyroidectomy for thyroid cancer: a cumulative sum analysis. Updates Surg 2023:10.1007/s13304-023-01492-w. [PMID: 36976499 DOI: 10.1007/s13304-023-01492-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/05/2023] [Indexed: 03/29/2023]
Abstract
Gasless transaxillary posterior endoscopic thyroidectomy (GTPET) is a new approach for thyroid cancer. It allows en bloc resection of the thyroid and central lymph nodes. Few studies have reported on the learning curve for GTPET.We examined the learning curve of GTPET for thyroid cancer by cumulative sum (CUSUM) analysis by retrospectively analyzing patients who underwent hemithyroidectomy with ipsilateral central neck dissection between December 2020 and September 2021 at a tertiary medical center, including the first patient. Moving average analysis and sequential time-block analysis were used for validation. Data on the clinical factors between the two periods were compared. In the overall cohort, the average time for GTPET for thyroid cancer was 113.25 min to harvest an average of 6.4 central lymph nodes. The CUSUM curve of the operative time indicated an inflection point after 38 patients. Moving average analysis and sequential time-block analysis validated the number of procedures needed for GTPET proficiency. (124.05 min vs. 107.63 min for the unproficient period vs. proficient period, respectively; P < 0.001) The number of retrieved lymph nodes was not associated with a certain level of proficiency per the learning curve. The main complication during the surgeon's unproficient period was transient hoarseness (3/38), which was similar to that in their proficient period (2/73, p = 0.336). Proficiency in GTPET is associated with performing more than 38 procedures. Standard course training and instruction on careful management are required prior to introducing the procedure.
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Affiliation(s)
- Weisheng Chen
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumour, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Shitong Yu
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumour, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Baihui Sun
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumour, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Cangui Wu
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumour, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Tingting Li
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumour, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Shumin Dong
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumour, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China
| | - Junna Ge
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumour, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China.
| | - Shangtong Lei
- Department of General Surgery and Guangdong Provincial Key Laboratory of Precision Medicine for Gastrointestinal Tumour, The First School of Clinical Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, Guangdong, China.
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Puli SR, Wagh MS, Forcione D, Gopakumar H. Learning curve for esophageal peroral endoscopic myotomy: a systematic review and meta-analysis. Endoscopy 2022; 55:355-360. [PMID: 36049775 DOI: 10.1055/a-1935-1093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND AND STUDY AIMS : Peroral endoscopic myotomy (POEM) is a minimally invasive endoscopic procedure for the treatment of achalasia and certain spastic esophageal motility disorders, delivering excellent results in experienced hands. However, this complex and technically challenging procedure requires advanced endoscopic skills. The aim of this study was to conduct a systematic review and meta-analysis of current data to evaluate the learning curve for POEM in new adopters of this technique. METHODS : Electronic databases (PubMed, Embase, and Cochrane Library) from inception to November 2021 were searched for publications addressing the learning curve in POEM. Pooling was conducted by both fixed- and random-effects models. Secondary outcomes reviewed were clinical success defined by Eckardt score ≤ 3 when available and adverse events. RESULTS : Eight studies involving 1904 patients met the inclusion criteria. In the pooled analysis, new adopters of POEM attained proficiency at a mean of 24.67 procedures (95 %CI 23.93 to 25.41). Once proficiency was achieved, the pooled total procedure time plateaued at a mean of 85.38 minutes (95 %CI 81.48 to 89.28), the pooled mean procedure time per centimeter of myotomy was 6.25 minutes (95 %CI 5.69 to 6.82), and the pooled mean length of myotomy was 11.49 cm (95 %CI 10.90 to 12.08). CONCLUSIONS : Our analysis showed that new adopters of POEM with previous advanced endoscopy experience required about 25 procedures to attain proficiency. The average time for each procedure once proficiency was attained was about 85 minutes.
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Affiliation(s)
- Srinivas R Puli
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
| | - Mihir S Wagh
- Division of Gastroenterology, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - David Forcione
- Gastroenterology, Boca Raton Regional Hospital, Boca Raton, Florida, United States
| | - Harishankar Gopakumar
- Department of Gastroenterology and Hepatology, University of Illinois College of Medicine at Peoria, Peoria, Illinois, United States
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Ho SH, Nik Arsyad NMA, Lau PC, Jamaludin FH, Mahadeva S. Acquiring new complex endoscopic skills: Experience from the development of peroral endoscopic myotomy (POEM) in Malaysia. JGH OPEN 2021; 5:729-733. [PMID: 34263065 PMCID: PMC8264233 DOI: 10.1002/jgh3.12598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2021] [Accepted: 06/08/2021] [Indexed: 11/30/2022]
Abstract
Peroral endoscopic myotomy (POEM) has rapidly gained popularity as an effective treatment modality for achalasia. However, POEM services in the South East Asian region are not widely available due to either a lack of expertise or interest. In this article, we describe how a POEM service can be developed through a combination of networking with regional experts, having prior experience of endoscopic submucosal dissection (ESD), attending animal model workshops, collaborating with upper gastrointestinal surgeons, and working together in a multidisciplinary team. A total of 68 POEM procedures have been performed since 2015, with a 94.1% technical and 93.4% clinical success rate, and a 21.5% minor complication rate. We believe that our model may be useful for other Endoscopy Units in the region, which are performing advanced therapeutic endoscopy, to develop a POEM service too.
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Affiliation(s)
- Shiaw Hooi Ho
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine University of Malaya Kuala Lumpur Malaysia
| | - Nik M A Nik Arsyad
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine University of Malaya Kuala Lumpur Malaysia.,Department of Medicine International Islamic University Malaysia Kuantan Malaysia
| | - Peng Choong Lau
- Department of Surgery, Faculty of Medicine University of Malaya Kuala Lumpur Malaysia.,Department of Surgery Pantai Hospital Kuala Lumpur Kuala Lumpur Malaysia
| | - Fadhil H Jamaludin
- Department of Anaethesia, Faculty of Medicine University of Malaya Kuala Lumpur Malaysia
| | - Sanjiv Mahadeva
- Division of Gastroenterology, Department of Medicine, Faculty of Medicine University of Malaya Kuala Lumpur Malaysia
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Assessment of the learning curve for EUS-guided gastroenterostomy for a single operator. Gastrointest Endosc 2021; 93:1088-1093. [PMID: 32991868 DOI: 10.1016/j.gie.2020.09.041] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS EUS-guided gastroenterostomy (EUS-GE) is increasingly used as an alternative to surgery and enteral stent placement to manage gastric outlet obstruction (GOO). However, no data are available on the learning curve (LC) for EUS-GE. Defining the LC is necessary to create adequate subspecialty training programs and quality assurance. METHODS This study is a retrospective analysis of a prospectively maintained dataset of patients who underwent EUS-GE at 1 tertiary referral center. Primary outcome was the LC for EUS-GE defined by the number of cases needed to achieve proficiency and mastery using cumulative sum (CUSUM) analysis. Moving average graphs and sequential time-block analysis were also performed to assess procedural time. Secondary outcomes included efficacy and safety of EUS-GE. RESULTS Eighty-seven consecutive patients underwent EUS-GE, mostly for malignant GOO. For consistency, 14 patients were excluded from analysis (noncautery-assisted EUS-GE, 11; surgical anatomy, 3). The same endoscopist performed all procedures using the same freehand technique. Technical success was achieved in 68 of 73 patients (93%). Immediate adverse events occurred in 4 patients (5.5%), whereas late adverse events occurred only in 1 patient (1%), all managed conservatively or endoscopically. All immediate adverse events occurred during the first 39 cases. Clinical success (defined as resuming at least an oral liquid diet within a week) was achieved in 97% of patients. The mean procedural time was 36 minutes (standard deviation, 24). Evaluation of the CUSUM curve revealed that 25 cases were needed to achieve proficiency and 40 cases to achieve mastery. These results were confirmed with the average moving curve and sequential time-block analysis. CONCLUSIONS We report, for the first time, data on the LC for EUS-GE. About 25 procedures can be considered as the threshold to achieve proficiency and about 40 cases are needed to reach mastery of the technique.
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Response. Gastrointest Endosc 2021; 93:989-990. [PMID: 33741096 DOI: 10.1016/j.gie.2020.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Accepted: 12/09/2020] [Indexed: 02/08/2023]
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Mendo R, Barreiro P, Rodrigues J, Félix C, O'Neill C, Carina I, Chivia J, Chagas C. Peroral Endoscopic Myotomy for Esophageal Achalasia in Portugal: Outcomes of the First Prospective Series. GE-PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 28:162-169. [PMID: 34056038 DOI: 10.1159/000511528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Accepted: 08/16/2020] [Indexed: 11/19/2022]
Abstract
Background Peroral endoscopic myotomy (POEM) is an innovative achalasia treatment procedure that involves myotomy of the lower esophageal sphincter through a submucosal tunneling approach, combining the efficacy of surgical myotomy with the benefit of being a less invasive treatment. At this time, no data are available of POEM in Portugal. This study aimed to examine the safety and short-term outcomes of POEM in a Portuguese center. Methods Fifty POEM were performed on 49 consecutive patients at our institution between January 2017 and January 2020. A prospective study of a consecutive series of patients was conducted, including procedure time, myotomy location and length, adverse events and clinical success. An Eckardt score of ≤3 after POEM was deemed as a successful outcome. Gastroesophageal reflux disease (GERD) was evaluated based on symptoms and on upper endoscopy, which was performed at 3-6 months postoperatively to check for reflux esophagitis. Results POEM was successfully completed in all cases: 70% (n = 35) were naïve and 30% (n = 15) had previous treatments. The mean procedure time was 73.4 ± 22.6 min (range 45-125 min). There were no major adverse events. Minor adverse events were rare (8%), and there was no perioperative mortality. The Eckardt score significantly decreased from 6.9 ± 2.4 preoperatively to 0.5 ± 1.0 postoperatively (p < 0.05). Overall clinical success was documented in 98, 98 and 95.2% at 1, 3 and 6 months, respectively. These short-term outcomes after POEM were independent of previous treatments. Symptomatic GERD was seen in 22.4% of patients. Conclusions Our results confirm the safety and excellent short-term efficacy of POEM in a Portuguese center. This supports POEM as one of the first-line achalasia therapies in Portugal when performed by experienced operators.
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Affiliation(s)
- Rui Mendo
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Pedro Barreiro
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal.,Department of Gastroenterology, Hospital dos Lusíadas, Lisbon, Portugal
| | - José Rodrigues
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Catarina Félix
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Catarina O'Neill
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Iala Carina
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Joyce Chivia
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
| | - Cristina Chagas
- Department of Gastroenterology, Centro Hospitalar Lisboa Ocidental, Hospital de Egas Moniz, Lisbon, Portugal
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