Training pathways and competency assessment in peroral endoscopic myotomy (POEM)

Peroral endoscopic myotomy (POEM) is a minimally invasive natural orifice endoscopic surgical procedure initially developed for treatment of achalasia. Recent studies have shown excellent clinical and safety outcomes in all types of achalasia, and even spastic esophageal disorders. POEM is a complex and technically challenging procedure with risk of potentially serious adverse events. Hence, appropriate training is essential for POEM, even for advanced endoscopists with extensive experience in interventional endoscopy. A few studies have suggested preclinical training using ex vivo and live animal models, with successful transition to human cases but standardized training pathways have not been defined yet. As with other new techniques, there is a learning curve for training in POEM and the number of procedures required to master the technique varies depending on prior endoscopic experience and skill. Procedure time has been shown to improve with case volume, though competence may not be defined only by procedure time and number of procedures performed. In this report, we evaluate training avenues for POEM and suggest competency assessment metrics. Further studies are required to define objective measures of performance and quality metrics for this new endoscopic surgical procedure.