CSA - Launching a per-oral pyloromyotomy (POP) practice - a framework for introducing endoscopic surgery within a hospital system.

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Launching a per-oral pyloromyotomy (POP) practice - a framework for introducing endoscopic surgery within a hospital system.
Seung Hyeon Shim^*¹, Kevin El-Hayek², Jennifer Colvin³
¹School of Medicine, Case Western Reserve University, Cleveland, OH; ²Department of Surgery, The MetroHealth System, Cleveland, OH; ³Department of Surgery, University of Cincinnati, Cincinnati, OH

Objectives
Endoscopic per-oral pyloromyotomy (POP), also known as gastric peroral endoscopic myotomy (G-POEM), is a novel therapy for medically refractory gastroparesis, but requires advanced endoscopic skill. This study describes an effective POP learning framework using combined in-person and video-based proctoring.

Methods
Retrospective data were collected for consecutive patients with refractory gastroparesis who underwent POP by a single surgeon trained through a structured program: 4 case observations, 4 animal-model practices, 9 in-person proctoring cases, and 8 video-based proctoring cases - via live communication or asynchronous video review (Figure 1). Patient demographics, gastroparesis cardinal symptom index (GCSI) score, gastric emptying scintigraphy (GES), and procedural details were collected. Data was analyzed using a two-tailed, unpaired t-test with unequal variance to compare the safety and effectiveness of video-based to the traditional, in-person proctoring. Short-term clinical outcomes, GSCI, and GES were measured.

Results
POP was performed on 17 patients (12 female and 5 male, mean age 53.8 years). Etiologies included diabetic (n=6, 35.3%), idiopathic (n=9, 52.9%), and post-surgical (n=2, 11.8%). Median procedure time was 42.7 minutes (mean, 45.3 minutes; range, 29 to 65 minutes). Throughout both proctoring methods, the surgeon demonstrated safe, effective performance without immediate postoperative complications or reintervention. There were no significant differences between in-person proctoring compared to video-based feedback in total operative duration (p>0.227). Patients exhibited expected clinical improvements with a GSCI score reduction of 2.41 units (70.9% reduction, p<4.16^-8).

Conclusion
Through the integration of a novel learning framework, this single institution study showed minimal time and outcome differences upon video-proctoring versus direct supervision. Steps requiring cognitive training unique to endoscopic surgery (mucosotomy and tunneling) and transferable myotomy skill between laparoscopic and endoscopic surgeries had no statistical difference (Table 1). This study supports an integrated in-person and video-proctoring framework as a safe and effective method to introduce advanced endoscopic surgery.

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