As peroral endoscopic myotomy (POEM) indications expand, proactive identification and management of technically challenging cases are critically important. This study comprehensively evaluated characteristics, perioperative outcomes, and predictors of technically difficult POEM. In this retrospective cohort study (2011–2023), consecutive POEM procedures for esophageal motility disorders at a tertiary center were analyzed. Technically difficult POEM was defined as procedure time ≥ 90 min or aborted POEM. Characteristics and operation parameters were compared between the technically difficult and non-difficult groups. Weighted logistic regression, with stabilized inverse probability of treatment weighting controlled for operator- and technique-related confounders, was used to identify predictors of technically difficult POEM. The final cohort included 676 POEM procedures, comprising 34 (5.0%) technically difficult POEM (3 aborted) and 642 (95.0%) non-difficult POEM. Technically difficult POEM demonstrated significantly higher hemostatic forceps utilization (79.4% vs. 48.8%), prolonged postoperative stays (4 vs. 3 days), and increased hospital costs (¥21,542 vs. ¥19,490) ( P < 0.01). Clinically significant adverse events were more frequent in the technically difficult group (17.7% vs. 1.6%, P < 0.001). Weighted multivariable analysis identified prior pneumatic dilation, prior POEM, and prolonged disease duration as independent risk factors for technically difficult POEM ( P < 0.05). Technically difficult POEM was associated with higher incidence of perioperative adverse events, increased healthcare utilization, and significant financial burdens. Prior pneumatic dilation, prior POEM, and prolonged disease duration were the independent risk factors for technically difficult POEM. Centralized referral of high-risk patients to expert centers may optimize patient outcomes and enhance procedural safety.
Huang et al. (Wed,) studied this question.