We have analyzed the outcomes of our initial experience with POEM, including phased-in adoption by surgical trainees. Starting in October 2010, all patients with esophageal motility disorders who were candidates for a laparoscopic myotomy were offered POEM as part of a prospective, institutional review board–approved outcomes study. The current study examined the first 40 consecutive patients in our database, which covers the period in screening assay which one experienced senior surgeon performed all cases and then progressively transitioned

primary surgical responsibility to fellow-level trainees. Patient exclusion criteria included previous esophageal or mediastinal surgery, age <18 years, inability to tolerate general anesthesia, a body mass index (BMI) >40 kg/m2, or a need for an associated intra-abdominal procedure. Previous large-caliber achalasia dilations

(>30 mm) or botulin toxin injections were not considered as exclusion criteria. Preoperative assessment was the same as for any surgical achalasia patient and included a standardized validated symptom assessment, esophageal manometry, EGD, and a timed barium swallow. Data collected prospectively were as follows: basic demographic information, preoperative diagnosis, prior endoscopic interventions, American Association of Anesthesiologists Physical Status Classification System grade, BMI, primary surgeon (attending vs trainee), length of procedure (LOP), length of myotomy, intraoperative and postoperative complications, and length of stay. Time signature video recordings of the procedures were available for each case. Because the length of the Histone Methyltransferase inhibitor myotomy

varied depending on the underlying diagnosis, the corrected LOP per centimeter myotomy was calculated. This allowed for comparison controlling for variations in the length of myotomy required for each patient and diagnosis. The LOP per centimeter myotomy and the incidence of inadvertent mucosotomy was trended in our consecutive first 40 POEM procedures and used as a marker to determine the learning curve for the procedure. The 40 patients Dipeptidyl peptidase were divided into 5 groups of consecutive 8 patients, based on primary surgeon. These groups were determined in retrospect while we analyzed the cohort of the initial consecutive 40 patients. The senior surgeon is a GI surgeon with fellowship training in interventional endoscopy. He has had a 20-year clinical experience with laparoscopic Heller myotomy in addition to an extensive experience with advanced endoscopic procedures, in particular endoscopic submucosal dissection (ESD)/EMR. He and his team have been primary investigators in advancing NOTES techniques. As part of this procedure development experience, including investigating transesophageal NOTES mediastinal approaches and procedures, the senior investigator had performed >30 endoscopic myotomies in animal and cadaver models.