I had always wanted to be the kind of physician who is not afraid to be impacted by emotionally difficult cases. Yet I began to recognize how I had intellectualized my own uncle's diagnosis and death and how a demanding schedule had kept me from attending to my own grief. I recognized how my unaddressed grief was, in part, influenced by this informal curriculum of medical culture, and it could impact my future role as physician. When we fail to allow grief to occur in the hospital workplace, we become burned out and less able to care for ourselves and our patients. Death and dying are ubiquitous in medicine. Therefore, it is imperative to teach medical trainees how to acknowledge and attend to our own grief.After that patient's death, as a team, we were able to acknowledge and address its impact on all of us through a team debrief. It is through such conversations about difficult clinical scenarios and personal struggles that we can grow as future physicians and learn to better cope with the immense loss and suffering we bear witness to in medicine.

Background: Gastroparesis is a debilitating medical condition with limited treatment options. Gastric per-oral pyloromyotomy (G-POEM) has emerged as a promising treatment option with remarkable short-term clinical success shown in multiple studies. While the post-procedure protocol is not standardized across many centers, the majority of the centers observes these patients in the hospital after the procedure for monitoring. In this single-center prospective study, we evaluated the safety and feasibility of same day discharge after the G-POEM procedure. Methods: All the patients with refractory gastroparesis undergoing G-POEM from October 2019 to March 2020 were enrolled. A total of 25 patients were enrolled in the procedure. Based on the pre-defined criteria, patients were either discharged on the same day after the procedure or admitted to the hospital for further observation. The patient and procedure-related data were extracted from the chart review. Univariate analysis was performed (chi-squared test) on categorical variables after organizing categorical variables as numeric counts or percentages. The student t test was performed on continuous variables after reporting as mean and standard deviation. For analysis with a smaller sample size, Fisher exact and Mann–Whitney tests were used. Results: A total of 25 patients were enrolled. The technical success of G-POEM was 100% and clinical success was 80% (20/25) at 1-month follow-up. Of the 25 patients, 9 patients (36%) were discharged on the same day according to the procedure from the recovery unit. Of the remaining 16 patients who were admitted to the hospital post-procedure, 10 (40%) were admitted due to procedure-related causes while other admissions were either pre-planned or due to social reasons. The average Charlson comorbidity index was lower in the same day discharge group ( P < 0.05). The number of patients requiring double myotomy was higher in the same day discharge group ( P < 0.05). The overall complication rate of G-POEM in the study cohort was 12% (3/25) with all complications being mild without any severe adverse events. Conclusion: G-POEM is a safe and effective method of treatment for refractory GP with higher clinical success in short-term follow-up. The same day discharge after G-POEM is safe and feasible in >50% of patients with close periprocedural monitoring.

Introduction: Numerous studies have shown that per oral endoscopic myotomy (POEM) is a very effective treatment for patients with achalasia. Limited data has also indicated that POEM is effective in treatment for some non-achalasia esophageal motility disorders, such as esophageal-gastric outlet obstruction and diffuse esophageal spasm. We report for the first time the outcome of POEM for patients with atypical chest pain. Methods: Three patients were enrolled: a 72yo female, 87yo male and 73yo female. All patients had a long history of chest pain for at least 5 years. They ranked the pain from 2 to 8 on a 1 to 10 pain scale. The pain was not associated with physical activity, but it was occasionally associated with eating. Only one patient had some dysphagia and no patients reported regurgitation symptoms. All patients were evaluated by multiple doctors over the years, including primary care providers, cardiologists, and gastroenterologists. Cardiac chest pain was ruled out by their cardiologists. They all tried maximal anti-acid therapy, including proton pump inhibitors twice a day for a prolonged period, without any significant improvement. They also tried anti-spasmodic medications, such as hyoscyamine, with limited effect. All patients had esophageal manometry without conclusion. Barium swallow studies showed tertiary contraction and therefore suggested esophageal dysmotility. POEM was discussed with the patients who then provided consent to undergo the procedure (Table ). Results: All three POEMs were successful; the average procedure time was 20 minutes. Only circular muscle myotomy was performed and longitudinal muscle was left intact. Each myotomy was 10 cm in length. There were no postprocedural complications. Postop day 1, all patients were chest pain free and were discharged in the afternoon. Follow up times were 93, 42, and 5 days; pts continued to remain chest pain free. One out of 3 patients described a burning type of chest pain consistent with heartburn and was promptly relieved with anti-acid therapy. Conclusion: From this pilot study, POEM may be a therapeutic modality for patients with refractory atypical chest pain. Further studies with increased sample size and long-term outcome assessments are needed to determine the efficacy of POEM in the treatment of atypical chest pain.

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