This manuscript represents the outcome of a formal Delphi process resulting in an
official Position Statement of the ESGE and provides a framework to develop and maintain
skills in POEM. This curriculum is set out in terms of the prerequisites for training,
the theoretical knowledge and practical skills required for completion of training,
and how competence should be defined and evidenced prior to independent practice.
Abbreviations
AE:
adverse event
EMR:
endoscopic mucosal resection
ESD:
endoscopic submucosal dissection
ESGE:
European Society of Gastrointestinal Endoscopy
GERD:
gastroesophageal reflux disease
GRADE:
Grading of Recommendations Assessment, Development and Evaluation
PICO:
population/problem, intervention, comparison, outcome
POEM:
peroral endoscopic myotomy
1 Introduction
Achalasia is an esophageal motility disorder, characterized by the failure of the
lower esophageal sphincter to relax properly, associated with loss of peristalsis,
leading to impaired transit of food from the esophagus into the stomach [1 ]. The incidence of achalasia is approximately 1.6 cases per 100 000 and it usually
presents between the ages of 25 and 60, with men and women equally affected [2 ].
The treatment of achalasia is aimed at lowering the resting pressure of the lower
esophageal sphincter [3 ]. Recent European guidelines suggest that peroral endoscopic myotomy (POEM) has comparable
efficacy to graded pneumatic dilation and laparoscopic Heller’s myotomy, and treatment
decisions in achalasia should be made based on patient-specific characteristics, patient
preferences, possible adverse events (AEs), and a center’s expertise [4 ]
[5 ].
Promoting quality in endoscopy is of great importance for the European Society of
Gastrointestinal Endoscopy (ESGE) to ensure effective treatment and optimal patient
outcomes. Achieving high quality endoscopic procedures requires a well-trained and
competent endoscopist. Training programs should focus on both technical and cognitive
skills, including an understanding of the indications, limitations, underlying pathophysiology,
and alternatives, plus the recognition of AEs and their management. At present, there
are no such standards for training in POEM in Europe. This curriculum sets out recommendations
for an optimal training program in POEM that should produce an endoscopist competent
in this procedure [6 ].
2 Methods
The development of the POEM curricula aligns with the current ESGE Publications Policy
and the methodology of the ESGE curricula development for postgraduate training in
advanced endoscopic procedures [6 ]
[7 ]. A Position Statement format was considered appropriate given the educational significance
of the topic and the limited expected body of evidence. This document focused on POEM
training, irrespective of the specific esophageal motility disorder being addressed
because the technical and theoretical principles involved are highly similar.
In May 2023, an email invitation to participate in the curricula was sent to all individual
ESGE members. Applicants were required to submit a motivation letter and an updated
curriculum vitae. The selection of participants was carried out by the project leaders
and the chair of the Curricula Working Group based on applicants’ expertise in POEM,
clinical and research background, experience in curricula development and educational
activities, and diversity. The ESGE Executive Committee subsequently approved the
final list of 23 panelists.
In June 2023, the project leaders (E.R.d.S. and D.T) proposed a preliminary list of
questions and topics to all panelists, forming five taskforces (Appendix 1 s , see online-only Supplementary material). Questions were structured using a PICO
(Population/Problem, Intervention, Comparison, Outcome) format. In cases where framing
a PICO question was not feasible or appropriate, questions were addressed through
expert-based reviews. A virtual online meeting was held on 3 July 2023, during which
panelists provided feedback on the preliminary list of questions and the curricula's
structure. A final list of questions was approved, leading to the following sections:
pre-adoption
training
autonomous implementation and assessment of proficiency
best practice technique – a "state-of-the-art" section was deemed suitable to facilitate
the learning and implementation of the technique; this section is presented as a separate
document (Part II).
To standardize the literature search and methodology, a structured template was developed.
Taskforces conducted systematic literature searches in a minimum of two databases
from inception to August 2023. Appendix 2 s details the PICO questions and search strategies used. Subsequently, taskforces evaluated
the available literature (Table 1 s ) using the Grading of Recommendations Assessment, Development and Evaluation (GRADE)
system. The GRADE system was used to assess the quality of evidence by study outcome
and overall certainty, as well as to grade the recommendations. The quality and risk
of bias of individual studies were assessed using the ROB-2 scale for randomized controlled
trials, the Newcastle–Ottawa Scale or Robins-I for observational studies, and the
QUADAS-2 tool for diagnostic accuracy studies. In cases where evidence was lacking
or insufficient to use GRADE, taskforces were requested to formulate Good Practice
Statements to represent ESGEʼs position [8 ]. Where applicable, statements were updated from previous ESGE guidelines on endoscopic
treatment for gastrointestinal motility disorders to address our PICO questions [5 ]
[9 ].
Taskforces initially drafted a list of statements and the evidence-based text supporting
the recommendations. These documents were shared with the entire group, and a second
online meeting was convened. Taskforces were asked to consider all comments but not
to modify statements during the meeting, to prevent the authority, personality, or
reputation of some participants from interfering in the Delphi process. In February
2024, panelists voted on and provided feedback in a free-text box for each statement.
Prior to voting, all members were instructed to consider the clinical benefits and
harms for patients and healthcare systems, the costs, evidence quality, and the environmental
impact of the statements.
The consensus on statements was determined through an anonymous and iterative Delphi
process. All individuals who applied for the taskforce but were not selected for the
core group were invited to vote and provide written comments. A maximum of three voting
rounds was established to reach consensus. Statements were graded using a 5-point
Likert scale (1, Strongly disagree; 2, Disagree; 3, Neither agree nor disagree; 4,
Agree; 5, Strongly agree) via a web-based platform. Consensus was defined as ≥ 80 %
agreement (the sum of Agree and Strongly agree) on each statement. Prior to the second
voting round, statements were reviewed and revised based on suggestions. The second
and third voting rounds occurred between March and September 2024 (Appendix 3 s ). Subsequently, the project leaders prepared a preliminary manuscript, which was
shared with all members for feedback. At this stage, no modifications were allowed
in the content of statements that achieved consensus during the anonymous voting ([Table 1 ]).
Table 1
List of agreed statements.
Statement number
Statement
Pre-adoption
1
POEM trainees should acquire a comprehensive theoretical knowledge of achalasia and
other esophageal motility disorders that encompasses pathophysiology, diagnostic tool
proficiency, clinical outcome assessment, potential adverse events, and periprocedural
management. Good practice statement
2
POEM trainees should attend conferences and courses related to POEM before starting
POEM procedures. Good practice statement
3
POEM trainees should develop and integrate endoscopic nontechnical skills, including
communication and teamwork, situational awareness, leadership, judgment, and decision-making.
Good practice statement
4
POEM trainees should have completed general upper gastrointestinal endoscopy training
and be proficient in management of endoscopic adverse events prior to initiating POEM
training. Good practice statement
5
Experience in advanced endoscopic procedures (EMR and/or ESD) is encouraged as a beneficial
prerequisite for POEM training. Good practice statement
Training
6
POEM trainees without previous experience in submucosal endoscopy may benefit from
training on either simulation models for POEM or ESD to familiarize themselves with
the complexity and the essential steps of submucosal endoscopy. Good practice statement
7
ESGE suggests that POEM trainees without ESD experience should perform an indicative
minimum number of 20 cases on ex vivo or animal models before advancing to human POEM
cases with an experienced trainer. The last five cases should be completed without
perforating the gastric mucosa at the gastroesophageal junction and achieve complete
mucosal closure. Good practice statement
8
ESGE recommends that the trainee should observe an indicative minimum number of 20
live cases at expert centers before starting to perform POEM in humans. Good practice
statement
9
ESGE suggests that both stepwise progress and performing all POEM steps from the beginning
are acceptable during the learning phase of the procedure. Good practice statement
10
ESGE recommends that the trainee should undertake an indicative minimum number of
10 cases under expert supervision for the initial human POEM procedures, ensuring
that trainees can complete all POEM steps independently. Good practice statement
11
ESGE recommends avoiding complex POEM cases during the early training phase. Good
practice statement
12
A POEM trainer should have expertise in managing adverse events of complex resection
techniques such as bleeding and perforation. The trainer should have performed at
least 100 unsupervised cases including difficult POEM cases (i. e. sigmoid esophagus,
prior Heller’s myotomy). Good practice statement
13
A POEM training center should maintain a sufficient case load to initiate a training
program. Additionally, the center should possess adequate infrastructure for diagnosing
esophageal motility disorders and facilitating the endoscopic, radiological, and surgical
management of adverse events associated with POEM. Good practice statement
14
A POEM training program should range between an indicative 6 and 18 months in a high-
or medium-volume POEM Western endoscopy unit. Good practice statement
15
POEM trainees should actively participate in patient selection processes for POEM
at multidisciplinary team meetings. Good practice statement
Autonomous implementation and assessment of proficiency
16
POEM competence should reflect the technical success rate, both the short- and long-term
clinical success rates, and the rate of true adverse events
17
A minimum of 15 POEM procedures per endoscopist annually is advisable to maintain
proficiency. Good practice statement
18
A minimum of 25 POEM procedures per center annually is advisable to maintain proficiency.
Good practice statement
19
A POEM center should maintain a prospective registry of all procedures performed,
including patient work-up and outcomes, procedural techniques, and adverse events.
Good practice statement
20
The absolute number of procedures performed is not an accurate marker for competency
in POEM. It should be combined with thresholds of procedural outcomes, including the
technical and clinical success, and adverse event rates
EMR, endoscopic mucosal resection; ESD, endoscopic submucosal dissection; ESGE, European
Society of Gastrointestinal Endoscopy; POEM, peroral endoscopic myotomy.
The peer review process for ESGE policy documents was followed. The ESGE board, the
core members of the Curricula Working Group, and external experts reviewed the manuscript.
The document was circulated to all national society members and individual ESGE members
for feedback. The final ESGE curricula for POEM was approved by all authors and was
submitted to the journal Endoscopy for publication.
3 Pre-adoption
3.1 What is the theoretical knowledge needed before starting POEM training?
POEM trainees should acquire a comprehensive theoretical knowledge of achalasia and
other esophageal motility disorders that encompasses pathophysiology, diagnostic tool
proficiency, clinical outcome assessment, potential adverse events, and periprocedural
management.
Good practice statement.
Level of agreement 100 %.
POEM trainees should attend conferences and courses related to POEM before starting
POEM procedures.
Good practice statement.
Level of agreement 86 %.
Some studies have emphasized the importance of cognitive skills (indication and diagnostic
assessment) for the POEM procedure, but none have directly assessed the influence
of theoretical knowledge or educational programs on POEM trainees or POEM outcomes
[10 ]
[11 ]
[12 ]
[13 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]. To address this gap, ESGE has established and summarized good practice recommendations
for the requisite theoretical knowledge prior to commencing POEM training. These recommendations
fall into four categories: (i) clinical understanding and procedural context, (ii)
diagnostic assessment, (iii) outcome assessment, and (iv) preprocedural and procedural
requirements and settings ([Table 2 ]).
Table 2
Theoretical knowledge needed prior to commencing peroral endoscopic myotomy (POEM)
procedures.
Area of knowledge
Requirement
Clinical understanding and procedural context
Pathophysiology of motility disorders
Understanding of the pathophysiology of esophageal motility disorders
Knowledge of different types of achalasia
Indications and contraindications
Knowledge of the indications and contraindications for performing POEM in different
motility disorders
Knowledge of the indications and challenges of POEM in advanced (such as sigmoid achalasia)
or pretreated motility disorders
Ability to formulate an endoscopic plan for the POEM procedure based on prior surgical
and/or endoscopic treatments
Knowledge of potential adverse events during and after POEM procedure
Other treatment modalities
Knowledge of alternative treatment options
Comparative understanding of POEM versus alternative treatment modalities
Diagnostic assessment
Pretherapeutic examinations
Competence in interpretation of HRM and TBE to identify types of motility disorders
amenable for POEM
Understanding of the role of EGD to rule out early squamous lesions and other causes
of dysphagia
Adjunctive diagnostic tool
Familiarity with impedance planimetry (the endoluminal functional lumen imaging probe
[EndoFLIP])
Post-POEM diagnostics
Knowledge of the incidence of GERD following POEM and the role of clinical reflux
symptoms, EGD, and 24-hour pH impedance studies in its assessment and interpretation
Outcome assessment
Clinical outcome
Understanding of the expected clinical outcomes of POEM for different motility disorders
Ability to assess clinical treatment outcomes using the Eckardt score and understand
its limitations
Outcome assessment with different diagnostic modalities
Knowledge about the role of HRM and the esophagogram in the assessment of treatment
outcomes
Knowledge about EndoFLIP as a tool to assess treatment outcome after POEM in real
time
Preprocedural and procedural requirements and settings
Prerequisites
Understanding of periprocedural antiplatelet and anticoagulation management
Anesthesia
Understanding of the requirement for general anesthesia during the POEM procedure
Equipment and settings
Understanding of the importance of using a distal attachment cap
Understanding of the importance of using low-flow CO2
Knowledge about the different types of endoscopic knives, coagulation graspers, electrosurgical
generators, and appropriate electrosurgery settings for POEM
Procedure-related proficiency
Understanding of the principles of third-space endoscopy, including mediastinal, esophageal,
and intratunnel anatomy
Understanding of the prevention, management, and consequences of POEM-related adverse
events
Recognition of the anatomical landmarks to identify the anterior and posterior walls
of the esophagus and landmarks at the gastroesophageal junction
Identification of the orientation of mucosa and muscle layers in the submucosal tunnel
EGD, esophagogastroduodenoscopy; GERD, gastroesophageal reflux disease; HRM, high
resolution manometry; TBE, timed barium esophagogram.
Prior to commencing POEM procedures, experts suggest that trainees participate in
POEM-related congresses, attend didactic training courses, and engage in self-directed
online learning. Trainees should grasp the pathophysiology of motility disorders,
distinguish between various types of achalasia, and comprehend the indications and
contraindications for performing POEM, as well as esophageal disorders that can mimic
achalasia. They should also be aware of the indications and challenges associated
with POEM in advanced cases (e. g. sigmoid achalasia) or previously treated motility
disorders. Furthermore, they must possess knowledge of the potential AEs during and
after the POEM procedure.
The ability to devise an endoscopic plan for POEM based on anticipated clinical outcomes,
prior surgical and/or endoscopic treatments, and patient expectations is crucial [10 ]
[14 ]
[15 ]
[16 ]
[17 ]
[18 ]. Trainees should also possess a comparative understanding of POEM versus alternative
treatment modalities, such as pneumatic balloon dilation, botulinum toxin injection,
and laparoscopic Heller’s myotomy.
Competence in the interpretation of high resolution manometry, radiological esophagograms,
and esophagogastroduodenoscopy is essential. Trainees should also understand the principles
of the endoluminal functional lumen imaging probe (EndoFLIP), although its clinical
relevance remains unknown.
Trainees should be knowledgeable about the incidence of gastroesophageal reflux disease
(GERD) following POEM and the significance of clinical reflux symptoms, endoscopy,
and 24-hour pH/impedance studies for assessment and their interpretation. Understanding
expected clinical outcomes for different motility disorders and the ability to assess
these outcomes using the Eckardt score is imperative. Additionally, a comprehension
of the relative role of high resolution manometry, EndoFLIP, and the esophagogram
in evaluating treatment outcomes is necessary.
Trainees should be proficient in obtaining detailed medical histories and understand
periprocedural antithrombotic management. Familiarity with POEM equipment is crucial.
Trainees should also be well versed in the electrosurgical generator settings used
during the various POEM steps and understand the advantages and disadvantages of different
types of endoscopic knives.
A solid understanding of third-space endoscopy principles, including mediastinal anatomy
and recognition of anatomical landmarks, such as the anterior and posterior esophageal
walls and gastroesophageal junction landmarks, is indispensable. Recognition of the
spine, aortic arch, and left main bronchus is also advisable. Trainees should consistently
recognize mucosa, muscle layer orientation, and spindle veins within the submucosal
tunnel. Additionally, POEM trainees should promptly identify and understand the management
of AEs.
3.2 What are the nontechnical skills needed for POEM training?
POEM trainees should develop and integrate endoscopic nontechnical skills, including
communication and teamwork, situational awareness, leadership, judgment, and decision-making.
Good practice statement.
Level of agreement 93 %.
Technical and patient outcomes after any endoscopic procedure are affected by the
endoscopic nontechnical skills (ENTS) of the performing team. ENTS involve all nontheoretical
knowledge regarding good communication and the decision-making abilities of the endoscopist
[19 ]
[20 ]
[21 ]
[22 ]
[23 ]
[24 ]
[25 ]
[26 ]
[27 ]. There are four recognized skills that should be assessed, and it has been suggested
that each skill should be graded as either poor, marginal, acceptable, or good [28 ]. Performance measures for the team are also related to better outcomes, and quality
principles as per the SACRED team-centered approach [29 ] are recommended. ESGE has adapted these methodological frameworks for POEM training
([Table 3 ]). As part of the nontechnical skills, the POEM practitioner should be able to discuss
in detail the patient’s informed consent form, the advantages of the procedure related
to other interventions, and possible AEs and morbidity associated with the technique
and anesthesia [30 ]
[31 ]
[32 ].
Table 3
Endoscopic nontechnical skills for peroral endoscopic myotomy (POEM) training.
Element
Descriptor
a The endoscopic nontechnical skills (NETS) system.
Communication and teamwork
Exchanging information
Gives clear and timely information and instructions (including an appropriate informed
consent)
Seeks previous information to aid the procedure (e. g. clinical history, manometry/esophagogram/endoscopy
report)
Listens and responds to team input
Confirms team preparation including equipment availability
Maintaining a shared understanding
Clarifies and confirms shared information with team (e. g. type of procedure, length
of myotomy)
Talks about the progress of the procedure, including difficulties and concerns
Calmly indicates when a situation requires urgency
Maintaining a patient-centered approach
Greets patient and introduces self and team
Regularly checks patient comfort
Explains findings to patient and/or relatives clearly
Situation awareness
Preparation
Checks indications are appropriate, and the patient is fit for the procedure
Checks if assistants are adequately trained
Ensures equipment present and functioning correctly
Optimizes environmental conditions before starting (e. g. equipment positioning)
Does not perform any procedure beyond own level of skill (e. g. avoiding difficult
POEM cases during the early training period)
Continuous assessment
Uses all available techniques to inform the decision-making process
Monitors results from therapy (e. g. bleeding)
Re-evaluates risk regularly depending on current status
Problem recognition
Identifies issues quickly and highlights them to the team
Recognizes increased risk due to unexpected findings
Focus
Minimizes interruptions
Stops distracting behavior by staff
Keeps focus on the screen
Leadership
Supporting others
Maintains a relaxed atmosphere
Gives praise for tasks done well
Does not rush staff when not necessary
Maintaining standards
Follows unit procedures and protocols
Ensures privacy and patient dignity
Adequately documents procedure
Dealing with problems
Emphasizes urgency if needed and gives clear directions
Delegates tasks to achieve goals
Remains calm under pressure and assumes responsibility
Judgement and decision-making
Considering options
Generates options to resolve problems
Seeks help or opinion of colleagues
Making decisions
Reaches and clearly communicates decisions and implements plan effectively
Reviewing the situation
Re-evaluates outcomes
Ensures appropriate follow-up and checks for complications
Makes changes based on reflection to improve practice
b The SACRED team-centered approach to advanced gastrointestinal endoscopy.
Principle
Descriptor
Selection
An MDT evaluates the case prior to the POEM procedure
Acceptance
Recognition of increased risk for AEs related to diagnostic procedures
Complications
Establishes pathways to deal with AEs and regular conferences to discuss cases with
MDT
Reconnaissance
Establishes a communication system – verbal conscious competence may be relevant
Envelopment
The report should be available for the patient, along with instructions in case an
AE occurs
Documentation
The outcome should be discussed with the MDT
AE, adverse event; MDT, multidisciplinary team.
3.3 What are the technical skills required before starting POEM training?
POEM trainees should have completed general upper gastrointestinal endoscopy training
and be proficient in management of endoscopic adverse events prior to initiating POEM
training.
Good practice statement.
Level of agreement 95 %.
Experience in advanced endoscopic procedures (endoscopic mucosal resection and/or
endoscopic submucosal dissection) is encouraged as a beneficial prerequisite for POEM
training.
Good practice statement.
Level of agreement 87 %.
POEM is a challenging advanced endoscopic procedure requiring extensive endoscopic
expertise. Some authors and expert societies have addressed the need for prior adoption
of specific technical skills, as well as experience in submucosal endoscopy [11 ]
[13 ]
[14 ]
[18 ]
[33 ]
[34 ]. However, neither the definition nor the evaluation of these skills has been formalized,
and the published assessment tools have focused on the actual training rather than
previous endoscopic expertise [13 ]
[35 ]. There is a lack of randomized evidence directly assessing technical skills requirements
before entering dedicated POEM training and its impact on the POEM learning curve
or treatment outcome. Therefore, we have produced good practice recommendations for
mandatory and recommended endoscopic and nonendoscopic technical skills for future
POEM trainees ([Table 4 ]).
Table 4
Technical skills required before peroral endoscopic myotomy (POEM) training.
Skill
Endoscopic skills
Mandatory
Proficiency in general upper gastrointestinal endoscopy
Endoscopic management of adverse events (bleeding)
Maintaining stable scope position and manipulating the scope (precise targeting, tip
control, torque)
Competence in different methods of hemostasis (adrenalin injection, coagulation techniques
with electrosurgical knife or with coagulation forceps, hemoclip placement, and use
of endoscope/cap for tamponade)
Practical use of different endoscopic accessories that are required during a POEM
procedure (different endoscopic knives, electrocoagulation forceps, injection needle)
Recommended
Competence in colonoscopy
Competence in snare polypectomy
Competence in endoscopic resection techniques (EMR, ESD) in the upper and/or lower
gastrointestinal tract
Competence in mucosal closure and perforation management
Experience with OTS clips and endoscopic suture devices
Esophageal stenting
Endoscopic balloon dilation (in achalasia)
Not required
ERCP and/or EUS
Other technical skills
Mandatory
Setting of the electrocautery unit
Puncture of a capnoperitoneum
Knowledge of other CO2 -related complications (in cooperation with other medical specialists)
Recommended
Use of endoscopic tools from the nurse’s perspective including basic troubleshooting
EMR, endoscopic mucosal resection; ERCP, endoscopic retrograde cholangiopancreatography;
ESD, endoscopic submucosal dissection; EUS, endoscopic ultrasound; OTS, over-the-scope.
POEM trainees should have completed structured general endoscopic training in upper
gastrointestinal endoscopy and achieved competence in specific skills including maintaining
a stable scope position and tip control, and endoscopic hemostasis (injection, coagulation
techniques, clipping, defect closure). Trainees should be familiar with the practical
use of all necessary endoscopic instruments (various endoscopic knives, distal attachment
cap, hemostatic tools, clips), setting of the electrosurgical unit and insufflation
pump, and basic troubleshooting of these devices. Competence in colonoscopy and polypectomy
is beneficial, but not an absolute prerequisite. Competency in endoscopic retrograde
cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) are not required.
Most of the studies on the POEM learning curve have involved endoscopists who have
completed advanced fellowships, with a highly heterogeneous experience in submucosal
endoscopy. Nevertheless, competence in endoscopic mucosal resection (EMR) and/or endoscopic
submucosal dissection (ESD) could accelerate the learning curve for POEM, potentially
increasing the safety and effectiveness of the procedure [36 ]. One retrospective study has assessed the influence of prior ESD experience in gaining
proficiency in POEM, with endoscopists with greater experience in ESD acquiring proficiency
in POEM faster, although there was no difference with regard to clinical outcomes
or AEs [37 ].
It is required that trainees can recognize capnoperitoneum in a timely manner and
adequately relieve it by puncture if needed. Although it should not be viewed as a
requirement, it is advisable to be competent in alternative endoscopic treatment modalities
for achalasia, such as botulinum toxin injections and pneumatic dilation.
4 Training
4.1 Steps to acquire competence
4.1.1 Is simulation and ex vivo/animal training recommended before starting POEM in
humans?
POEM trainees without previous experience in submucosal endoscopy may benefit from
training on either simulation models for POEM or ESD to familiarize themselves with
the complexity and the essential steps of submucosal endoscopy.
Good practice statement.
Level of agreement 94 %.
ESGE suggests that POEM trainees without ESD experience should perform an indicative
minimum number of 20 cases on ex vivo or animal models before advancing to human POEM
cases with an experienced trainer. The last five cases should be completed without
perforating the gastric mucosa at the gastroesophageal junction and achieve complete
mucosal closure.
Good practice statement.
Level of agreement 84 %.
Evidence-based curricula and standardized training protocols do not exist for POEM.
For POEM trainees without previous experience in submucosal endoscopy, ESGE recommends
a step-up approach with initial hands-on training on ex vivo models and/or POEM/ESD
simulators, after which trainees can advance to in vivo animal models and, in a final
step, clinical cases supervised by an experienced trainer.
Mechanical simulators and virtual reality computer simulators are available for various
endoscopic procedures and are frequently used during early training for novice endoscopists.
Simulation training provides a risk-free solution that introduces trainees to new
procedures and enables them to learn specific skills at an individual pace; however,
the tactile feedback and visual reality are inferior to training on animal models
or clinical cases [38 ]
[39 ]
[40 ]. Most studies evaluating simulation training have primarily focused on novice learners,
revealing some advantages in terms of performance and procedure time; however, there
is no high quality evidence to demonstrate a definitive contribution to competency
acquisition [38 ]
[41 ]. Some studies have even shown that simulation training without expert feedback does
not enhance trainee skills, so an experienced trainer is always needed [42 ]. A novel simulation-based training model called EndoGel (Sunarrow Co. Ltd., Tokyo,
Japan) replicates the characteristics of the gastrointestinal tract, serving as a
realistic and feasible model for training in mucosal marking, submucosal injection,
and dissection [43 ]. With respect to POEM, there is a lack of evidence demonstrating that simulation
training improves outcomes.
Although prospective comparative studies are lacking, evidence suggests that preclinical
training using ex vivo and live animal models can prepare trainees to perform POEM
safely and effectively in human cases [39 ]. Ex vivo models are a cost-effective alternative to simulators and offer superior
haptic and visual realism for advanced endoscopic procedures [40 ]
[44 ]. Animal models provide the highest degree of realism and can simulate conditions
such as intraprocedural bleeding, perforation, and pneumoperitoneum/pneumomediastinum;
however, the associated costs and ethical concerns around animal research limit their
utility in training [39 ]
[45 ]
[46 ]. Published studies provide little information on the number of animal procedures
required for preclinical training, which varies widely (five to 12) and may also depend
on prior endoscopy experience [47 ]
[48 ]
[49 ]
[50 ]
[51 ]. Studies on the learning curve in ex vivo or animal models have shown that approximately
26 POEM cases are needed before mastery is achieved in terms of AEs and speed [52 ]. Given the potential for serious AEs and the availability of alternative training
options, initiating POEM training in humans is strongly discouraged. In expert centers
with close supervision, initial training experience in humans may be considered for
endoscopists with sufficient ESD experience; however, clinical evidence supporting
this strategy is lacking.
In summary, the existing evidence supports the use of preclinical models and underscores
the importance of specialized training programs, aligning with the recommendation
for a step-up training approach within the POEM curriculum [53 ]
[54 ]
[55 ]
[56 ]
[57 ].
4.1.2 Is the observation of live cases at expert centers recommended before starting
POEM in humans?
ESGE recommends that trainees should observe an indicative minimum number of 20 live
cases at expert centers before starting to perform POEM in humans.
Good practice statement.
Level of agreement 96 %.
The available evidence suggests that observing cases before engaging in POEM procedures
is crucial in acquiring proficiency. Although none of the studies directly compared
the outcomes of those who observed cases with those who did not, a unanimous consensus
exists among all the studies regarding the significance of this observational phase.
The studies, which are all observational [13 ]
[33 ]
[34 ]
[37 ]
[49 ]
[58 ]
[59 ]
[60 ]
[61 ]
[62 ]
[63 ]
[64 ], uniformly stress the importance of observing expert practitioners performing POEM
to gain insights into the procedural workflow and grasp the technique's subtleties.
The number of cases recommended for observation varied, with some studies indicating
the observation of as few as two cases [61 ], while others suggested up to 22 cases as an adequate learning experience [49 ]. Furthermore, these studies evaluated endoscopists actively engaged in endoscopy
training programs. The results consistently revealed high rates of clinical success
and a low incidence of AEs, underscoring the safety and efficacy of the procedure
when performed by adequately trained individuals.
4.1.3 Is stepwise POEM training recommended?
ESGE suggests that both stepwise progress and performing all POEM steps from the beginning
are acceptable during the learning phase of the procedure.
Good practice statement.
Level of agreement 83 %.
Stepwise POEM learning entails training in the procedure in a step-by-step manner,
repeating each procedure step as many times as necessary to achieve competence, before
performing a complete POEM procedure. A suggested order is proposed for the completion
of each stage, determined by the difficulty level of each step rather than the sequence
of procedures performed. It is suggested that the first step should be learning dissection/tunneling,
followed by learning myotomy, and finally learning to create a submucosal tunnel orifice
[13 ]
[64 ]
[65 ]. Training in mucosal closure and the management of perforation, including stent
placement, are key parts of POEM training. Once proficient in each stage, the trainee
would be ready to commence training in the next step.
No studies have directly compared different POEM training methodologies, complete
procedure versus stepwise training. Both methods are cited as a safe and suitable
approach for learning [13 ]
[64 ]
[65 ].
4.1.4 Is expert supervision needed during the first POEM cases?
ESGE recommends that the trainee should undertake an indicative minimum number of
10 cases under expert supervision for the initial human POEM procedures, ensuring
that trainees can complete all POEM steps independently.
Good practice statement.
Level of agreement 94 %.
Several observational studies [33 ]
[34 ]
[37 ]
[49 ]
[60 ] have reported on the role of experienced endoscopists' supervision during the initial
stages of performing the POEM technique. All identified studies advocate for the importance
of supervision during the early stages of POEM, emphasizing its potential benefits
[33 ]
[34 ]
[37 ]
[49 ]
[60 ]. It is worth noting that none of these studies directly compared the outcomes of
supervised versus unsupervised procedures; however, it is common sense to be supervised
during training in a new invasive procedure. Likewise, there is a lack of comparative
analysis regarding the optimal number of procedures that should be conducted under
supervision, and the recommendations provided in these articles vary considerably
in this regard. The cutoff of 10 cases was agreed upon as reasonable by this expert
panel.
4.1.5 Should complex POEM cases be avoided during the early training phase?
ESGE recommends avoiding complex POEM cases during the early training phase.
Good practice statement.
Level of agreement 93 %.
For the POEM training program in Japan, the initial 2 months of training are dedicated
to laying a solid foundation [66 ]. During this period, trainees focus on studying the anatomical features of the disease
and assisting experts in performing the procedure. In the subsequent months, trainees
gradually transition to performing POEM on uncomplicated cases. As they develop the
necessary skills, they progress to handling more complex cases, such as sigmoid-type
achalasia, prior Heller’s myotomy, elderly patients with co-morbidities, type III
achalasia, and those with distal esophageal spasm or hypercontractile esophagus.
Regarding the selection of cases during the training curve, only Zein et al. found
no statistically significant association between procedural time and pre-POEM patient
factors (age and baseline Eckardt score) [61 ]; however, other studies reported that case selection was crucial in influencing
endoscopic operative time and AEs, notably increasing the risk of mucosal perforation
during the procedure [60 ]
[63 ]. In this regard, defining a case as complex is essential, and there are some tools
that can be used for case selection. Complex achalasia patients are usually defined
as those with multiple prior treatments, prior myotomy, achalasia type III, and sigmoid-type
achalasia [67 ]. Other models have found age, disease duration, antithrombotic use, severe esophageal
dilatation, mucosal edema, submucosal fibrosis, and tunnel length to be predictors
of difficult POEM [68 ]
[69 ].
Considering these findings, it becomes evident that careful patient case selection
is paramount during the initial stages of POEM training. This approach ensures trainees
develop their POEM skills safely and progressively as they navigate the learning curve.
4.2 Requisites for training modules, trainers, and training centers
4.2.1 What are the requirements for a POEM trainer?
A POEM trainer should have expertise in managing adverse events of complex resection
techniques such as bleeding and perforation. The trainer should have performed at
least 100 unsupervised cases including difficult POEM cases (i. e. sigmoid esophagus,
prior Heller’s myotomy).
Good practice statement.
Level of agreement 86 %.
Our search did not find studies directly evaluating the skills and case load required
to serve as a POEM trainer, mentor, or proctor. Previously, the case load defining
an expert, mentor, or trainer has ranged from 50 to 300 cases [37 ]
[59 ]. All studies mentioned that trainers were experienced in ESD and the management
of AEs. The cutoff of 100 cases was agreed upon as reasonable by the expert panel.
4.2.2 What are the requirements for a POEM training center?
A POEM training center should maintain a sufficient case load to initiate a training
program. Additionally, the center should possess adequate infrastructure for diagnosing
esophageal motility disorders and facilitating the endoscopic, radiological, and surgical
management of adverse events associated with POEM.
Good practice statement.
Level of agreement 80 %.
No studies have been published evaluating the necessary infrastructure, standards,
and case load for POEM training. In addition, there are no accreditation procedures
specifically for POEM training centers. Most studies reporting on training or on the
establishment of a POEM service relate to large tertiary care centers with experience
in interventional endoscopy and ESD, and access to emergency thoracic and abdominal
surgery, interventional radiology, and an intensive care unit. In Japan, the Ministry
of Health, Labor, and Welfare requires the following institutional criteria to perform
POEM [70 ]:
designation as a specialized institution of gastroenterology, gastroenterological
surgery, and anesthesiology
more than 10 cases of POEM to have been treated
at least one full-time doctor with over 5 years of clinical experience in gastroenterological
surgery or gastroenterology and more than 20 cases of esophageal ESD; the surgeon
should have treated over 15 cases of POEM as the primary surgeon or as an assistant
more than three full-time doctors, including at least one gastroenterological surgeon,
on the POEM clinical team
a full-time designated specialist anesthesiologist
capability for urgent surgery.
4.2.3 How long should a POEM training program take?
A POEM training program should range between an indicative 6 and 18 months in a high-
or medium-volume POEM Western endoscopy unit.
Good practice statement.
Level of agreement 83 %.
A POEM training program encompasses observing real cases, attending courses about
POEM, theoretical self-learning, practicing on ex vivo or animal models, and performing
procedures on human patients under supervision [11 ]
[13 ]
[18 ]
[33 ]
[34 ]
[36 ]
[37 ]
[49 ]
[50 ]
[52 ]
[58 ]
[59 ]
[60 ]
[61 ]
[62 ]
[63 ]
[70 ]
[71 ]
[72 ]. Considering that several of these activities may or may not overlap, and that learning
is conditioned by previous experience in therapeutic endoscopy and ESD [37 ], learning curves can be highly variable. Accordingly, a minimum training duration
of 6 months is advised in high-volume Western endoscopy units, which typically handle
60–100 POEM cases annually. In contrast, for units with lower case volumes, an extended
training period ranging from 1 to 1.5 years is recommended. Additionally, this timeframe
may vary depending on whether the trainee is involved in a dedicated POEM program,
if the program is combined with other ESD or third-space endoscopy techniques, or
if the trainee intermittently attends the expert center.
4.2.4 Should POEM trainees be involved in the selection of patients for POEM?
POEM trainees should actively participate in patient selection processes for POEM
at multidisciplinary team meetings.
Good practice statement.
Level of agreement 97 %.
A formalized multidisciplinary team (MDT) approach is recommended in advanced endoscopy
[29 ]. The selection of patients for POEM is a complex procedure that involves an understanding
of the various types of achalasia and their treatment options, while at the same time
taking patient factors into account. At best, an MDT comprising an interventional
endoscopist, a surgeon, a radiologist, and a (neuro-)gastroenterologist should be
involved in the discussion of cases. Involving trainees within an MDT has the potential
to improve their understanding of achalasia and POEM. POEM trainees will profit from
the discussions around the process of case selection and gain deeper insights into
the indications and contraindications for POEM.
4.2.5 What are the minimum requirements for a POEM endoscopy report?
A summary with the key elements that should be included in a POEM endoscopy report
is provided in [Table 5 ].
Table 5
ESGE’s recommended peroral endoscopic myotomy (POEM) report template.
Items to be included
Basic information
Basic data
Patient identification, operators (including trainees)
Indication
Type of achalasia, hypercontractile disorder, etc.
Procedure time
Start of procedure till closure of mucosotomy
Medication
General anesthesia, intraprocedural antibiotics, others
Equipment
Endoscope, accessories, electrosurgical unit, and settings
Esophageal preparation
Describe presence of food remnants/time required for cleaning the esophagus
Anatomical landmarks
Lower esophageal sphincter
Description of endoscopic appearance, location relative to the incisors
Esophageal anatomy
Description of appearance of the esophagus, tortuosity, sigmoid-type, straight lumen,
spastic segments
Other landmarks
Visualization of the spine, aortic arch, left main bronchus
POEM steps
Submucosal injection and mucosotomy
Type of submucosal solution
Mucosotomy length and distance from the incisors
Tunnel length and intratunnel anatomical landmarks
## to ## cm from incisors
Visualization of spindle veins, oblique muscle, and penetrating vessels
Esophageal myotomy length
## to ## cm from incisors
Gastric myotomy length
## cm
Type of myotomy
Selective vs. full-thickness myotomy
Location of myotomy
Anterior, posterior, greater curvature
Intraprocedural assessment of the LES
EndoFLIP, double-scope method, other
Mucosal closure
Number and type of clips, additional closure methods
Factors pertaining to difficulty
Fibrosis, orientation, distensibility of the tunnel, tortuosity, esophageal spasms,
etc.
Adverse events
Adverse events
Type, severity, and management of adverse events (bleeding, CO2 -related adverse events, mucosal perforation, etc.) specified
Summary and follow-up recommendations
Summary
Diagnosis and summary of the procedure
Recommendations
Short term: post-procedural pharmacotherapy and diet plan
Mid-term: clinical, endoscopic, and manometric follow-up
EndoFLIP, endoluminal functional lumen imaging probe; LES, lower esophageal sphincter.
5 Autonomous implementation and assessment of proficiency
5 Autonomous implementation and assessment of proficiency
5.1 What is the definition of POEM competence? What volume of POEM procedures is recommended
to maintain proficiency?
POEM competence should reflect the technical success rate, both the short- and long-term
clinical success rates, and the rate of true adverse events.
Level of agreement 100 %.
A minimum of 15 POEM procedures per endoscopist annually is advisable to maintain
proficiency.
Good practice statement.
Level of agreement 94 %.
A minimum of 25 POEM procedures per center annually is advisable to maintain proficiency.
Good practice statement.
Level of agreement 80 %.
A POEM center should maintain a prospective registry of all procedures performed,
including patient work-up and outcomes, procedural techniques, and adverse events.
Good practice statement.
Level of agreement 97 %.
There are no data assessing how to define competence in performing POEM, and no performance
measures or quality indicators have been defined thus far. Likewise, there are no
data about the number of procedures needed to maintain proficiency.
A prospective registry that includes all procedures performed is an essential component
for all POEM training centers to assess proficiency and outcomes. This registry serves
several critical purposes.
Quality control and improvement Training centers must monitor the quality of the procedures performed. This enables
them to identify trends, both positive and negative, and implement changes to improve
outcomes.
Research, training, and education For trainees, having access to a comprehensive registry of procedures is a valuable
tool. It allows them to learn from past cases, understand the variety of scenarios
that can occur, and appreciate the nuances of different approaches.
Accountability and transparency Keeping a record of all procedures ensures accountability. It shows that the training
center is committed to maintaining high standards and is transparent about its practices.
5.2 Is the number of POEM cases an adequate marker of POEM competence?
The absolute number of procedures performed is not an accurate marker for competency
in POEM. It should be combined with thresholds of procedural outcomes, including the
technical and clinical success, and adverse event rates.
Level of agreement 97 %.
Studies evaluating the learning curve to establish proficiency in POEM suggest that
7–70 cases are needed to master the technique [34 ]
[36 ]
[37 ]
[50 ]
[60 ]
[62 ]
[63 ]
[66 ]
[71 ]; however, these studies exhibit several limitations. Firstly, they are all retrospective
and conducted at single centers. Moreover, they encompass heterogeneous patient populations
and procedures of different complexity. Predominantly, these studies focus on the
learning curve of experienced endoscopists, which may not be representative of all
POEM trainees. A significant concern is their reliance on procedural time, either
total or per cm of myotomy, as a surrogate marker of competence. This approach is
problematic because controlled studies have not demonstrated a correlation between
procedural time and the clinical success or safety of POEM. Lastly, the consideration
of AEs as a metric for assessing competence is often overlooked, which could lead
to an incomplete evaluation of an endoscopist's proficiency.
Therefore, ESGE does not favor using a threshold number of procedures performed to
define an endoscopist as being competent in POEM, advocating instead for a comprehensive
assessment of skills, knowledge, and outcomes. A formal assessment tool to assess
technical proficiency is provided in the POEM Curriculum Part II (Best Practice Technique).
6 Conclusions
This ESGE Position Statement was crafted by an international working group with diverse
POEM-related expertise from Europe, Brazil, and the USA, including specialists in
neurogastroenterology, educational methods, POEM techniques, and medical and educational
research. Notably, the consensus-based statements, derived using the Delphi method,
are mainly grounded in expert opinion rather than evidence-based data and are designed
to guide best training practices without carrying legal weight.
The document offers current insights that are crucial for creating a structured POEM
curriculum aimed at fostering expertise and competence in a standardized step-by-step
approach ([Fig. 1 ]). It outlines theoretical and technical prerequisites for POEM trainees and trainers,
and underscores the importance of ongoing proficiency evaluation. We propose a set
of indicators that require validation in prospective studies. This groundwork paves
the way for future creation of an evidence-based educational framework [73 ]. Part II of the curriculum delivers a comprehensive technical guide, providing trainees
with a detailed description of best practice techniques for performing POEM procedures.
Fig. 1 Illustration of a standardized step-by-step approach to learning in peroral endoscopic
myotomy (POEM).
Disclaimer
ESGE Position Statements represent a consensus of best practice based on the available
evidence at the time of preparation. This is NOT a guideline but a proposal for training
in POEM. The statements may not apply in all situations and should be interpreted
in the light of specific clinical situations and resource availability. Further studies
may be needed to clarify aspects of these statements, and revision may be necessary
as new data appear. Clinical considerations may justify a course of action at variance
with these recommendations. This ESGE Position Statement is intended to be an educational
device to provide information that may assist gastrointestinal endoscopists in providing
care to patients. The recommendations made are not rules and should not be construed
as establishing a legal standard of care or as encouraging, advocating, requiring,
or discouraging any particular treatment. The legal disclaimer for ESGE guidelines
applies to the present position statement [74 ].
