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Endoscopy 2025; 57(08): 912-941
DOI: 10.1055/a-2569-7634
Position Statement

Curriculum for training in peroral endoscopic myotomy (POEM) in Europe (Part II) – Best Practice Techniques: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

David J. Tate  ‡   ‡
 1   Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
 2   Faculty of Medicine and Health Sciences, University of Ghent, Ghent, Belgium
,
Enrique Rodriguez de Santiago  ‡   ‡
 3   Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
 4   Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
 5   Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
,
Michele Montori
 1   Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
 6   Università Politecnica delle Marche, Ancona, Italy
,
Vikash Lala
 7   University of the Witwatersrand, Johannesburg, South Africa
 8   Charlotte Maxeke Johannesburg Academic Hospital, Johannesburg, South Africa
 9   Wits Donald Gordon Medical Centre, Johannesburg, South Africa
,
Lynn K. Debels 
 1   Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
10   University Hospital of Brussels, Brussels, Belgium
,
Eduardo Albéniz 
11   Gastroenterology Department, Hospital Universitario de Navarra. Navarrabiomed, UPNA, IdiSNA, Pamplona, Spain
,
Isis K. Araujo
12   Endoscopy and Motility Unit, Gastroenterology Department, Hospital Clinic de Barcelona, Barcelona, Spain
,
Eduardo Guimarães Hourneaux de Moura 
13   Gastrointestinal Endoscopy Unit, Hospital das Clínicas of the University of São Paulo Medical School, São Paulo, Brazil
,
Alanna Ebigbo
14   Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
,
Pietro Familiari
15   Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
,
Paul Fockens
16   Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, The Netherlands
17   Waikato Hospital, Hamilton, New Zealand
,
Henriette Heinrich
18   Clarunis, Universitäres Bauchzentrum, Basel, Switzerland
,
Oleksandr Kiosov 
19   University Clinic, Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine
,
Helmut Messmann
14   Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
,
Sandra Nagl
14   Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
,
João Santos-Antunes 
20   Gastroenterology Department, Centro Hospitalar S. João, Porto, Portugal
,
Amrita Sethi
21   Pancreatobiliary Endoscopy Services, Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, New York, USA
,
Marcel Tantau
22   University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
,
Zuzana Vackova
23   Department of Gastrointestinal Endoscopy, The Military University Hospital Prague, Prague, Czech Republic
,
Jan Martinek 
24   Department of Gastroenterology and Hepatology, St. Anne University Hospital, Brno, Czech Republic
,
Roy M. Soetikno
25   Clinical Medicine, University of California, San Francisco, California, USA
,
Ian M. Gralnek∗   *
26   Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
27   Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
,
Tony C. Tham  ∗   *
28   Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland
› Author Affiliations
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Previous part of this series:

Curriculum for training in peroral endoscopic myotomy (POEM) in Europe (Part I): European Society of Gastrointestinal Endoscopy (ESGE) Position StatementEndoscopy 2025; 57(07): 778-795
DOI: 10.1055/a-2568-7473

Main Recommendation

1 A POEM equipment checklist should be used before commencing the procedure to ensure the availability and proper functioning of all necessary materials.

2 A thorough esophageal cleansing before mucosal incision is mandatory. There should be no residual dietary liquid or food in the lumen.

3 Use at least 5–10 mL of lifting agent, which should be injected using a needle at the desired point where the mucosotomy will commence.

4 To create the mucosotomy, the first incision should be made at the site of previous injection with the fewest possible taps on the electrosurgical unit using a cutting mode, with the knife tip at 45–80° to the mucosal surface.

5 After adequate submucosal injection (through a needle or knife), the incision should be extended by 1.5–2 cm in the longitudinal axis from cranial to caudal, in the planned direction of the tunnel.

6 Dissection within the tunnel should be performed using sequential injection of saline and chromic dye (if available using the knife jet function) and dissection with the knife. Pushing the endoscope forward gently against the advancing submucosa–muscularis propria interface is important to facilitate mucosal tunneling.

7 The myotomy should be performed in a cranial to caudal manner, starting 2 cm or more below the caudal extent of the mucosotomy site.

8 ESGE recommends that the myotomy should be extended 2–3 cm distal to the gastroesophageal junction to allow complete disruption of the lower esophageal sphincter.

9 ESGE recommends that POEM can be performed on either the anterior (1–2 o’clock in supine position) or posterior (5–6 o’clock) side.

10 ESGE recommends that the myotomy length should be tailored to the disease being treated, with evidence favoring short esophageal-side myotomy if indicated because of decreased adverse events and procedure times.

11 ESGE recommends the use of through-the-scope clips for mucosal closure owing to their high efficacy and availability, and lower price compared with other closure methods.

12 Mucosal injury during POEM should be proactively sought during the procedure and particularly before completion. Mucosal injury can be represented on a spectrum from whitening of the overlying mucosa to a full-thickness perforation.

13 ESGE recommends performing POEM using low flow CO2 insufflation.

14 In the absence of adverse events, resume fluids on day 1, soft diet on day 3, and normal diet on day 7 post-POEM.

15 ESGE recommends against the routine use of standard or computed tomography fluoroscopic esophagrams after POEM in asymptomatic patients.

‡ joint first co-authorship.


* joint senior authors.


Supplementary Material



Publication History

Article published online:
28 May 2025

© 2025. European Society of Gastrointestinal Endoscopy. All rights reserved.

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

 

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