S2203 Learning Curve in Peroral Endoscopic Myotomy for Achalasia: A Retrospective Study From South India

Introduction: Achalasia cardia is a motility disorder of the esophagus characterised by dysfunctional lower esophageal sphincter relaxation and peristalsis. Per oral endoscopic myotomy (POEM) is a technically complex procedure that has emerged as a promising option for the treatment of achalasia. Numerous studies have shown immediate and sustained clinical improvement following POEM. A notable adverse effect of the procedure is development of post POEM gastroesophageal reflux disease (GERD). This study aims to evaluate the learning curve of POEM and its relation to procedural and clinical outcomes in a high volume tertiary care hospital in South India. Methods: Ninety-six consecutive patients undergoing POEM for achalasia before May 2025 were enrolled. Four operators performed the procedures. Data was extracted from electronic records. Patients were divided into 2 sequential groups of 48. Patients with minimum follow up of 1 month were included with most having 6–12 months of follow up. Main outcomes compared between groups were Eckardt score and development of post POEM GERD. Procedural measures like myotomy length and intra/postoperative complications were also assessed. Results: Ninety-six patients were enrolled, 48 (50%) man. A majority (80.2%) had type 2 achalasia and most (92.8%) were treatment naive. No significant differences in age, gender, pre-POEM Eckardt score, achalasia subtype or operator distribution were seen between groups. Post-POEM Eckardt score was significantly reduced in the second group (0.92 vs 0.40, P = 0.03). Dysphagia also reduced (25% vs 4.1%, P = 0.002). Chest pain and repeat procedures showed no significant difference. Rate of intraoperative (2.1% vs 0%, P = 0.36) and postoperative (10.4% vs 4.2%, P = 0.418) complications were not significantly different. Myotomy length was similar (7.42 vs 7.21, P = 0.22). Post-POEM GERD occurred in 20.1% vs 6.3% (P = 0.07). Conclusion: Our study suggests improvement in certain operator outcomes after 48 procedures; however, improvement seems limited to parameters like Eckardt score and dysphagia. There seems to be no significant relation between operator experience and development of post POEM GERD. The findings suggest a smaller learning curve with early plateauing of key procedural outcomes after completion of a limited number of cases.