Surgical Endoscopy (2018) 32:3046–3054
Outcomes and quality of life assessment after per oral endoscopic
myotomy (POEM) performed in the endoscopy unit with trainees
· Lei Wang
· Xaioyu Li
· Yueping Jiang
· George Philips
· Steven A. Keilin
· Field F. Willingham
Received: 3 September 2017 / Accepted: 19 December 2017 / Published online: 29 January 2018
© Springer Science+Business Media, LLC, part of Springer Nature 2018
Background Per oral endoscopic myotomy (POEM) has emerged as a promising option for the treatment of achalasia. This
study assessed POEM training process, outcomes, and improvement in quality of life after POEM performed by an inter-
ventional endoscopist (mentor) with trainees.
Methods We performed a retrospective review of data for patients who underwent POEM with involvement of trainees.
Trainees were trained in performing mucosotomy, submucosal dissection, creating submucosal tunnel, identifying gastroe-
sophageal junction, myotomy, and closure of mucosal incision in a step-by-step fashion. Trainees’ performance on each step
was evaluated by the mentor based on several key points in each step. The short form 36 (SF36) was obtained before and
certain times after the primary POEM procedure was performed.
Results Sixty-two patients, 26 males and 36 females with a mean age of 59 years, who underwent POEM were enrolled. A
checklist included all related items for each step was established. All trainees obtained competence within 6 cases for each
step. 61/62 (98.3%) patients had a signiﬁcant improvement in the Eckardt’s score post POEM: 9.3 ± 1.5 prior to POEM and
2.6 ± 1.2 after the POEM (P = 0.001) and a decrease in mean lower esophageal sphincter pressure (LES): pre- and post-
procedure mean LES pressures were 28.5 ± 11.4 and 12.1 ± 4.5 mmHg, respectively (P = 0.001). The SF-36 questionnaire
demonstrated a signiﬁcant improvement in quality of life and comparable with those without trainees in other studies.
Conclusion This preliminary study showed for the ﬁrst time that training for POEM can be performed in a step-by-step fash-
ion, learning mucosal incision, submucosal dissection, myotomy, and mucosal incision closure from an expert interventional
endoscopist without increasing adverse events. The checklist for each step could be used as an important guide in training
POEM. The outcomes of POEM in this study were similar to those reported by others without trainees. Further multiple
center studies are needed to verify this training process and to establish a formal training protocol.
Keywords POEM · Achalasia · Dysphagia · Quality of life assessment
Patients with esophageal motility disorders present with pro-
gressive dysphagia to solids and liquids, regurgitation, chest
pain, and weight loss. Achalasia cardia is the best deﬁned
of the esophageal motility disorders characterized by failure
of lower esophageal sphincter (LES) relaxation and aperi-
stalsis of the esophageal body [1–4]. Traditionally it has
been treated either medically, endoscopically by botulinum
injection into LES and pneumatic dilation or surgically with
disruption of the lower esophageal sphincter [1–5]. The
eﬀect of botulinum injection is short lived and it is used
only in patients who are poor candidates for other therapies.
Pneumatic dilation and surgical myotomy have been eﬀec-
tive in the treatment of achalasia, and have been shown to
have similar outcomes at 2 years of follow-up [2, 4, 6–8].
Pneumatic dilation has been eﬀective with type 1 and type 2
achalasia but loses durability in long term, and is associated
with 2–4% risk of esophageal perforation. Surgical disrup-
tion of the LES with laparoscopic Heller myotomy has been
and Other Interventional Techniques
* Qiang Cai
Division of Digestive Diseases, Department of Internal
Medicine, Emory University School of Medicine, 1365
Clifton Road, B1262, Atlanta, GA 30322, USA
Department of Gastroenterology, Nanjing Drum Tower
Hospital, Nanjing, Jiangsu, China
Department of Gastroenterology, The Aﬃliated Hospital
Qingdao University, Qingdao, Shandong, China