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Influence of learning curve and perioperative factors on the clinical success of gastric peroral endoscopic myotomy

      To the Editor:
      We read with interest the article by Hernández Mondragón et al
      • Hernández Mondragón O.V.
      • Contreras L.F.G.
      • Velasco G.B.
      • et al.
      Gastroparesis peroral endoscopic myotomy outcomes after 4 years of follow-up in a large cohort of patients with refractory gastroparesis (with video).
      presenting the long-term outcomes of gastric peroral endoscopic myotomy (G-POEM) for refractory gastroparesis. They identified diabetic gastroparesis, diagnosis <24 months, nausea/vomiting symptoms, Gastroparesis Cardinal Symptom Index of 1.5 to 2.5 at 6 months, and a retention percentage at 4 hours <10% at 6 months as significant predictors of long-term success.
      • Hernández Mondragón O.V.
      • Contreras L.F.G.
      • Velasco G.B.
      • et al.
      Gastroparesis peroral endoscopic myotomy outcomes after 4 years of follow-up in a large cohort of patients with refractory gastroparesis (with video).
      However, we would like to highlight certain points related to this study.
      First, it should be highlighted that the G-POEM learning curve is critical for successful clinical outcomes but was not considered in the predictive model of this study. G-POEM is a technically challenging endoscopic procedure with a specific learning curve,
      • Reja M.
      • Mishra A.
      • Tyberg A.
      • et al.
      Gastric peroral endoscopic myotomy: a specific learning curve.
      but there are limited data for the G-POEM learning curve. A comparable treatment, peroral endoscopic myotomy (POEM), has been widely studied. Teitelbaum et al
      • Teitelbaum E.N.
      • Soper N.J.
      • Arafat F.O.
      • et al.
      Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM).
      found a negative correlation between case numbers and post-POEM outcomes, demonstrating that the operator’s learning curve was a key predictor of clinical success. Thus, the learning curve should be considered for predicting the clinical outcomes of G-POEM.
      Second, it should be mentioned that perioperative parameters crucial for successful clinical outcomes, such as intraprocedural adverse events, tunnel length, and total procedure time, were not included in this predictive model. Liu et al
      • Liu X.Y.
      • Cheng J.
      • Chen W.F.
      • et al.
      A risk-scoring system to predict clinical failure for patients with achalasia after peroral endoscopic myotomy.
      conducted a study to create a risk-scoring system, which enrolled several perioperative factors such as intraoperative injury, operation time, and adverse events to predict POEM outcomes, indicating that intraprocedural mucosal injury was a risk factor for clinical failure. These similar parameters should also be analyzed in the study by Hernández Mondragón et al.
      • Hernández Mondragón O.V.
      • Contreras L.F.G.
      • Velasco G.B.
      • et al.
      Gastroparesis peroral endoscopic myotomy outcomes after 4 years of follow-up in a large cohort of patients with refractory gastroparesis (with video).
      Even though we may not yet have found a crystal ball to anticipate G-POEM outcomes, the authors of this study deserve our congratulations for their efforts in building a prediction model for the clinical success of G-POEM and for giving a foundation for further prospective work.

      Disclosure

      All authors disclosed no financial relationships.

      References

        • Hernández Mondragón O.V.
        • Contreras L.F.G.
        • Velasco G.B.
        • et al.
        Gastroparesis peroral endoscopic myotomy outcomes after 4 years of follow-up in a large cohort of patients with refractory gastroparesis (with video).
        Gastrointest Endosc. 2022; 96: 487-499
        • Reja M.
        • Mishra A.
        • Tyberg A.
        • et al.
        Gastric peroral endoscopic myotomy: a specific learning curve.
        J Clin Gastroenterol. 2022; 56: 339-342
        • Teitelbaum E.N.
        • Soper N.J.
        • Arafat F.O.
        • et al.
        Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM).
        J Gastrointest Surg. 2014; 18: 92-99
        • Liu X.Y.
        • Cheng J.
        • Chen W.F.
        • et al.
        A risk-scoring system to predict clinical failure for patients with achalasia after peroral endoscopic myotomy.
        Gastrointest Endosc. 2020; 91: 33-40

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