Proficiency in Esophageal Peroral Endoscopic Myotomy

Introduction: Our analysis examines the learning curve of peroral endoscopic myotomy (POEM) training using procedure duration as a key indicator of proficiency. Methods: We searched PubMed, Embase, Cochrane, and Web of Science from inception until November 2024 for studies evaluating the learning curve of POEM. We divided the data into 0-20, 20-40, and 40-60 cumulative procedure phases of learning. Analysis of variance was performed with Tukey HSD post hoc tests to analyze differences in procedure time between groups. We also calculated means from the pooled data for the number of procedures to achieve proficiency, plateau procedure time postproficiency, plateau myotomy speed, and myotomy length. In addition, an analysis based on an inverse curve regression was also performed to assess the proficiency threshold. Results: Eleven studies, including 3197 POEM procedures, were included. Mean procedure time for the first, second, and third phases of learning were 99.4±35.2, 87.4±23.1, and 85.4±23.1 minutes, respectively. The 0-20 group had significantly higher mean procedure time than the 20-40 group ( P <0.0001) and the 40-60 group ( P <0.0001). Mean procedure time was not significantly different between the 20-40 and 40-60 groups ( P =0.69). Mean number of procedures to achieve proficiency was 33.29. Mean plateau procedure time following achievement of proficiency was 80.25 minutes. Mean postproficiency plateau myotomy speed was 7.71 minutes per cm of myotomy. Mean length of myotomy was 10.43±1.86 cm. Conclusion: POEM learners achieved proficiency in procedure speed in the 20-40 learning phase with no significant change with further experience.