Download PDF
Endoscopy
DOI: 10.1055/a-2568-7473
Position Statement

Curriculum for training in peroral endoscopic myotomy (POEM) in Europe (Part I): European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Enrique Rodríguez de Santiago  ‡   ‡
 1   Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
 2   Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
 3   Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
,
David J. Tate‡   ‡
 4   Department of Gastroenterology and Hepatology, University Hospital of Ghent, Ghent, Belgium
,
João Santos-Antunes 
 5   Gastroenterology Department, Centro Hospitalar S. João, Porto, Portugal
,
Sandra Nagl
 6   Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
,
Zuzana Vacková
 7   Department of Gastrointestinal Endoscopy, Military University Hospital Prague, Prague, Czech Republic
,
Marcel Tantau
 8   University of Medicine and Pharmacy “Iuliu Hatieganu”, Cluj-Napoca, Romania
,
Isis K. Araujo
 9   Endoscopy and Motility Unit, Gastroenterology Department, Hospital Clinic de Barcelona, Barcelona, Spain
,
Eduardo Guimarães Hourneaux de Moura 
10   Gastrointestinal Endoscopy Unit, Hospital das Clínicas of the University of São Paulo Medical School, São Paulo, Brazil
,
Pietro Familiari
11   Digestive Endoscopy Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Università Cattolica del Sacro Cuore, Rome, Italy
,
Helmut Messmann
 6   Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
,
Alanna Ebigbo
 6   Department of Gastroenterology, University Hospital Augsburg, Augsburg, Germany
,
Paul Fockens
12   Department of Gastroenterology and Hepatology, Amsterdam UMC, Amsterdam, The Netherlands
13   Waikato Hospital, Hamilton, New Zealand
,
Raf Bisschops 
14   Department of Gastroenterology and Hepatology, UZ Leuven, Leuven, Belgium
15   Department of Translational Research in Gastrointestinal Diseases (TARGID), KU Leuven, Leuven, Belgium
,
Henriette Heinrich
16   Clarunis, Universitäres Bauchzentrum, Basel, Switzerland
,
Eduardo Albéniz 
17   Gastroenterology Department, Hospital Universitario de Navarra, Navarrabiomed, UPNA, IdiSNA, Pamplona, Spain
,
Amrita Sethi
18   Pancreatobiliary Endoscopy Services, Division of Digestive and Liver Disease, Columbia University Irving Medical Center, New York, New York, USA
,
Oleksandr Kiosov 
19   University Clinic, Zaporizhzhia State Medical and Pharmaceutical University, Zaporizhzhia, Ukraine
,
Jan Martinek 
20   Department of Gastroenterology and Hepatology, St. Anne University Hospital, Brno, Czech Republic
,
Roy Soetikno
21   Clinical Medicine, University of California San Francisco, California, USA
,
Ian M. Gralnek∗   *
22   Ellen and Pinchas Mamber Institute of Gastroenterology and Hepatology, Emek Medical Center, Afula, Israel
23   Rappaport Faculty of Medicine, Technion Israel Institute of Technology, Haifa, Israel
,
Tony C. Tham  ∗   *
24   Division of Gastroenterology, Ulster Hospital, Belfast, Northern Ireland
› Author Affiliations
› Further Information
Also available at
   Permissions and Reprints

Main Recommendations

Peroral endoscopic myotomy (POEM) is an advanced endoscopic procedure that has become a first-line treatment for esophageal achalasia and other esophageal spastic disorders. Structured training is essential to optimize the outcomes of this technique. The European Society of Gastrointestinal Endoscopy (ESGE) has recognized the need to formalize and enhance training in POEM. This Position Statement presents the results of a systematic review of the literature and a formal Delphi process, providing recommendations for an optimal training program in POEM that aims to produce endoscopists competent in this procedure. In a separate document (POEM curriculum Part II), we provide technical guidance on how to perform the POEM procedure based on the best available evidence.

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.

2 Experience in advanced endoscopic procedures (endoscopic mucosal resection and/or endoscopic submucosal dissection [ESD]) is encouraged as a beneficial prerequisite for POEM training.

3 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.

4 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.

5 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.

6 ESGE recommends avoiding complex POEM cases during the early training phase.

7 POEM competence should reflect the technical success rate, both the short- and long-term clinical success rates, and the rate of true adverse events.

8 A POEM center should maintain a prospective registry of all procedures performed, including patient work-up and outcomes, procedural techniques, and adverse events.

‡ Joint first co-authorship.


* Joint senior authors.


Supplementary Material



Publication History

Article published online:
09 April 2025

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

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

 

  • References

  • 1 Vaezi MF, Pandolfino JE, Vela MF. ACG clinical guideline: diagnosis and management of achalasia. Am J Gastroenterol 2013; 108: 1238-1249 quiz 1250
    CrossrefPubMedSearch in Google Scholar
  • 2 Sadowski DC, Ackah F, Jiang B. et al. Achalasia: incidence, prevalence and survival. A population-based study. Neurogastroenterol Motil 2010; 22: e256-e261
    CrossrefPubMedSearch in Google Scholar
  • 3 Boeckxstaens GE, Zaninotto G, Richter JE. Achalasia. Lancet 2014; 383: 83-93
    CrossrefPubMedSearch in Google Scholar
  • 4 Oude Nijhuis R, Zaninotto G, Roman S. et al. European Guideline on Achalasia – UEG and ESNM recommendations. United European Gastroenterol J 2020; 8: 13-34
    CrossrefPubMedSearch in Google Scholar
  • 5 Weusten BLAM, Barret M, Bredenoord AJ. et al. Endoscopic management of gastrointestinal motility disorders – part 1: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 498-515
    Thieme ConnectPubMedSearch in Google Scholar
  • 6 Bisschops R, Dekker E, East JE. et al. European Society of Gastrointestinal Endoscopy (ESGE) curricula development for postgraduate training in advanced endoscopic procedures: rationale and methodology. Endoscopy 2019; 51: 976-979
    Thieme ConnectPubMedSearch in Google Scholar
  • 7 Hassan C, Ponchon T, Bisschops R. et al. European Society of Gastrointestinal Endoscopy (ESGE) Publications Policy – Update 2020. Endoscopy 2020; 52: 123-126
    Thieme ConnectPubMedSearch in Google Scholar
  • 8 Dewidar O, Lotfi T, Langendam MW. et al. Good or best practice statements: proposal for the operationalisation and implementation of GRADE guidance. BMJ Evid Based Med 2023; 28: 189-196
    CrossrefPubMedSearch in Google Scholar
  • 9 Weusten BLAM, Barret M, Bredenoord AJ. et al. Endoscopic management of gastrointestinal motility disorders – part 2: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 600-614
    Thieme ConnectPubMedSearch in Google Scholar
  • 10 Khashab MA. Thoughts on starting a peroral endoscopic myotomy program. Gastrointest Endosc 2013; 77: 109-110
    CrossrefPubMedSearch in Google Scholar
  • 11 Kishiki T, Lapin B, Wang C. et al. Teaching peroral endoscopic myotomy (POEM) to surgeons in practice: an “into the fire” pre/post-test curriculum. Surg Endosc 2018; 32: 1414-1421
    CrossrefPubMedSearch in Google Scholar
  • 12 Saxena P, Khashab MA. New NOTES clinical training and program development. Gastrointest Endosc Clin N Am 2016; 26: 385-400
    CrossrefPubMedSearch in Google Scholar
  • 13 Schlachterman A, Aziz A, Alajlan B. et al. Per-oral endoscopic myotomy (POEM) training and skills evaluation tool: a pilot study. Endosc Int Open 2020; 8: E1826-E1831
    Thieme ConnectPubMedSearch in Google Scholar
  • 14 Varma P, Saxena P. Establishing a submucosal endoscopy program in a gastrointestinal unit. raining for peroral endoscopic myotomy. Int J Gastrointest Interv 2020; 9: 36-41
    CrossrefPubMedSearch in Google Scholar
  • 15 Waschke KA, Coyle W. Advances and challenges in endoscopic training. Gastroenterology 2018; 154: 1985-1992
    CrossrefPubMedSearch in Google Scholar
  • 16 Wong HJ, Su B, Attaar M. et al. Teaching peroral endoscopic pyloromyotomy (POP) to practicing endoscopists: An “into-the-fire” approach to simulation. Surgery 2021; 169: 502-507
    CrossrefPubMedSearch in Google Scholar
  • 17 von Renteln D, Vassiliou MC, Rösch T. Training for peroral endoscopic myotomy. Techniques in Gastrointestinal Endoscopy 2013; 15: 153-156
    CrossrefPubMedSearch in Google Scholar
  • 18 Dacha S, Aihara H, Anand GS. et al. Core curriculum for peroral endoscopic myotomy (POEM). Gastrointest Endosc 2021; 93: 539-543
    CrossrefPubMedSearch in Google Scholar
  • 19 Matharoo M, Haycock A, Sevdalis N. et al. Endoscopic non-technical skills team training: the next step in quality assurance of endoscopy training. World J Gastroenterol 2014; 20: 17507-17515
    CrossrefPubMedSearch in Google Scholar
  • 20 Hitchins CR, Metzner M, Edworthy J. et al. Non-technical skills and gastrointestinal endoscopy: a review of the literature. Frontline Gastroenterol 2018; 9: 129-134
    CrossrefPubMedSearch in Google Scholar
  • 21 Ravindran S, Bassett P, Shaw T. et al. Improving safety and reducing error in endoscopy (ISREE): a survey of UK services. Frontline Gastroenterol 2021; 12: 593-600
    CrossrefPubMedSearch in Google Scholar
  • 22 Siau K, Crossley J, Dunckley P. et al. Colonoscopy Direct Observation of Procedural Skills assessment tool for evaluating competency development during training. Am J Gastroenterol 2020; 115: 234-243
    CrossrefPubMedSearch in Google Scholar
  • 23 Hernandez LV, Klyve D, Feld L. et al. Do nontechnical skills affect legal outcomes after endoscopic perforations?. Am J Gastroenterol 2020; 115: 1460-1465
    CrossrefPubMedSearch in Google Scholar
  • 24 Bourikas LA, Tsiamoulos ZP, Haycock A. et al. How we can measure quality in colonoscopy?. World J Gastrointest Endosc 2013; 5: 468-475
    CrossrefPubMedSearch in Google Scholar
  • 25 Walsh CM, Scaffidi MA, Khan R. et al. Non-technical skills curriculum incorporating simulation-based training improves performance in colonoscopy among novice endoscopists: Randomized controlled trial. Dig Endosc 2020; 32: 940-948
    CrossrefPubMedSearch in Google Scholar
  • 26 Patel K, Pinto A, Faiz O. et al. Factors defining expertise in screening colonoscopy. Endosc Int Open 2017; 5: E931-E938
    Thieme ConnectPubMedSearch in Google Scholar
  • 27 Grover SC, Garg A, Scaffidi MA. et al. Impact of a simulation training curriculum on technical and nontechnical skills in colonoscopy: a randomized trial. Gastrointest Endosc 2015; 82: 1072-1079
    CrossrefPubMedSearch in Google Scholar
  • 28 Ravindran S, Haycock A, Woolf K. et al. Development and impact of an endoscopic non-technical skills (ENTS) behavioural marker system. BMJ Simul Technol Enhanc Learn 2020; 7: 17-25
    CrossrefPubMedSearch in Google Scholar
  • 29 Ching H-L, Lau MS, Azmy IA. et al. Performance measures for the SACRED team-centered approach to advanced gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2022; 54: 712-722
    Thieme ConnectPubMedSearch in Google Scholar
  • 30 Tate DJ, Argenziano ME, Anderson J. et al. Curriculum for training in endoscopic mucosal resection in the colon: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2023; 55: 645-679
    Thieme ConnectPubMedSearch in Google Scholar
  • 31 Siau K, Dunckley P, Feeney M. et al. ERCP assessment tool: evidence of validity and competency development during training. Endoscopy 2019; 51: 1017-1026
    Thieme ConnectPubMedSearch in Google Scholar
  • 32 Campos S, Devière J, Arvanitakis M. Who will excel in advanced endoscopy? A study assessing the criteria and perceptions of experts with regard to selection of ERCP and EUS trainees. Endosc Int Open 2023; 11: E268-E275
    Thieme ConnectPubMedSearch in Google Scholar
  • 33 Jawaid S, Draganov PV, Aihara H. et al. Pilot prospective study on formal training in per-oral endoscopic myotomy (POEM) during advanced endoscopy fellowship. Endosc Int Open 2021; 9: E1890-E1899
    Thieme ConnectPubMedSearch in Google Scholar
  • 34 Kurian AA, Dunst CM, Sharata A. et al. Peroral endoscopic esophageal myotomy: defining the learning curve. Gastrointest Endosc 2013; 77: 719-725
    CrossrefPubMedSearch in Google Scholar
  • 35 Yang D, Draganov PV, Pohl H. et al. Development and initial validation of a video-based peroral endoscopic myotomy assessment tool. Gastrointest Endosc 2024; 99: 177-118
    CrossrefPubMedSearch in Google Scholar
  • 36 Puli SR, Wagh MS, Forcione D. et al. Learning curve for esophageal peroral endoscopic myotomy: a systematic review and meta-analysis. Endoscopy 2023; 55: 355-360
    Thieme ConnectPubMedSearch in Google Scholar
  • 37 Fujiyoshi Y, Inoue H, Fujiyoshi MRA. et al. Learning curve for peroral endoscopic myotomy in therapeutic endoscopy experts and nonexperts: Large single-center experience. Dig Endosc 2023; 35: 323-331
    CrossrefPubMedSearch in Google Scholar
  • 38 Maulahela H, Annisa NG, Konstantin T. et al. Simulation-based mastery learning in gastrointestinal endoscopy training. World J Gastrointest Endosc 2022; 14: 512-523
    CrossrefPubMedSearch in Google Scholar
  • 39 Mittal C, Wagh MS. Training pathways and competency assessment in peroral endoscopic myotomy (POEM). Tech Gastrointest Endosc 2017; 19: 170-174
    CrossrefPubMedSearch in Google Scholar
  • 40 Kim Y, Lee JH, Lee GH. et al. Simulator-based training method in gastrointestinal endoscopy training and currently available simulators. Clin Endosc 2023; 56: 1-13
    CrossrefPubMedSearch in Google Scholar
  • 41 Goodman AJ, Melson J. , ASGE Technology Committee. et al. Endoscopic simulators. Gastrointest Endosc 2019; 90: 1-12
    CrossrefPubMedSearch in Google Scholar
  • 42 Mahmood T, Darzi A. The learning curve for a colonoscopy simulator in the absence of any feedback: no feedback, no learning. Surg Endosc 2004; 18: 1224-1230
    CrossrefPubMedSearch in Google Scholar
  • 43 Gulati S, Emmanuel A, Inoue H. et al. Feasibility of EndogelTM simulation training for per-oral endoscopic myotomy (POEM): First United Kingdom experience. Gastrointest Endosc 2017; 85: AB152-AB153
    CrossrefPubMedSearch in Google Scholar
  • 44 Gromski MA, Ahn W, Matthes K. et al. Pre-clinical training for new notes procedures: from ex-vivo models to virtual reality simulators. Gastrointest Endosc Clin N Am 2016; 26: 401-412
    CrossrefPubMedSearch in Google Scholar
  • 45 Eleftheriadis N, Inoue H, Ikeda H. et al. Training in peroral endoscopic myotomy (POEM) for esophageal achalasia. Ther Clin Risk Manag 2012; 8: 329-342
    CrossrefPubMedSearch in Google Scholar
  • 46 Parra-Blanco A, González N, González R. et al. Animal models for endoscopic training: do we really need them?. Endoscopy 2013; 45: 478-484
    Thieme ConnectPubMedSearch in Google Scholar
  • 47 Ren Y, Tang X, Zhi F. et al. A stepwise approach for peroral endoscopic myotomy for treating achalasia: from animal models to patients. Scand J Gastroenterol 2015; 50: 952-958
    CrossrefPubMedSearch in Google Scholar
  • 48 Chiu PWY, Wu JCY, Teoh AYB. et al. Peroral endoscopic myotomy for treatment of achalasia: from bench to bedside (with video). Gastrointest Endosc 2013; 77: 29-38
    CrossrefPubMedSearch in Google Scholar
  • 49 Miranda-García P, Muñoz González R, Marín Gabriel JC. et al. Implementation of a peroral endoscopic myotomy program. Rev Esp Enferm Dig 2021; 113: 339-344
    CrossrefPubMedSearch in Google Scholar
  • 50 Gonzalez J-M, Meunier E, Debourdeau A. et al. Training in esophageal peroral endoscopic myotomy (POEM) on an ex vivo porcine model: learning curve study and training strategy. Surg Endosc 2023; 37: 2062-2069
    CrossrefPubMedSearch in Google Scholar
  • 51 Peñaloza-Ramírez A, Suárez-Correa J, Báez-Blanco J. et al. In vivo experience with peroral endoscopic myotomy: An essential activity for developing the technique in humans. Rev Gastroenterol Mex (Engl Ed) 2018; 83: 86-90
    CrossrefPubMedSearch in Google Scholar
  • 52 Hernández Mondragón OV, Rascón Martínez DM, Muñoz Bautista A. et al. The per oral endoscopic myotomy (POEM) technique: how many preclinical procedures are needed to master it?. Endosc Int Open 2015; 3: E559-E565
    Thieme ConnectPubMedSearch in Google Scholar
  • 53 Küttner-Magalhães R, Dinis-Ribeiro M, Bruno MJ. et al. Training in endoscopic mucosal resection and endoscopic submucosal dissection: Face, content and expert validity of the live porcine model. United European Gastroenterol J 2018; 6: 547-557
    CrossrefPubMedSearch in Google Scholar
  • 54 Parra-Blanco A, Arnau MR, Nicolás-Pérez D. et al. Endoscopic submucosal dissection training with pig models in a Western country. World J Gastroenterol 2010; 16: 2895-2900
    CrossrefPubMedSearch in Google Scholar
  • 55 Vázquez-Sequeiros E, de Miquel DB, Olcina JRF. et al. Training model for teaching endoscopic submucosal dissection of gastric tumors. Rev Esp Enferm Dig 2009; 101: 546-552
    CrossrefPubMedSearch in Google Scholar
  • 56 Chapelle N, Musquer N, Métivier-Cesbron E. et al. Efficacy of a three-day training course in endoscopic submucosal dissection using a live porcine model: a prospective evaluation. United European Gastroenterol J 2018; 6: 1410-1416
    CrossrefPubMedSearch in Google Scholar
  • 57 Huang J, Du B-R, Qiao W-G. et al. Endoscopic submucosal dissection training: evaluation of an ex vivo training model with continuous perfusion (ETM-CP) for hands-on teaching and training in China. Surg Endosc 2023; 37: 4774-4783
    CrossrefPubMedSearch in Google Scholar
  • 58 Leung LJ, Ma GK, Lee JK. et al. Successful design and implementation of a POEM program for achalasia in an integrated healthcare system. Dig Dis Sci 2023; 68: 2276-2284
    CrossrefPubMedSearch in Google Scholar
  • 59 Patel KS, Calixte R, Modayil RJ. et al. The light at the end of the tunnel: a single-operator learning curve analysis for per oral endoscopic myotomy. Gastrointest Endosc 2015; 81: 1181-1187
    CrossrefPubMedSearch in Google Scholar
  • 60 Liu Z, Zhang X, Zhang W. et al. Comprehensive evaluation of the learning curve for peroral endoscopic myotomy. Clin Gastroenterol Hepatol 2018; 16: 1420-1426.e2
    CrossrefPubMedSearch in Google Scholar
  • 61 El Zein M, Kumbhari V, Ngamruengphong S. et al. Learning curve for peroral endoscopic myotomy. Endosc Int Open 2016; 4: E577-E582
    Thieme ConnectPubMedSearch in Google Scholar
  • 62 Lv H, Zhao N, Zheng Z. et al. Analysis of the learning curve for peroral endoscopic myotomy for esophageal achalasia: Single-center, two-operator experience. Dig Endosc 2017; 29: 299-306
    CrossrefPubMedSearch in Google Scholar
  • 63 Teitelbaum EN, Soper NJ, Arafat FO. et al. Analysis of a learning curve and predictors of intraoperative difficulty for peroral esophageal myotomy (POEM). J Gastrointest Surg 2014; 18: 92-98 discussion 98–99
    CrossrefPubMedSearch in Google Scholar
  • 64 Dacha S, Wang L, Li X. et al. Outcomes and quality of life assessment after per oral endoscopic myotomy (POEM) performed in the endoscopy unit with trainees. Surg Endosc 2018; 32: 3046-3054
    CrossrefPubMedSearch in Google Scholar
  • 65 Abdelfatah MM, Calderon LF, Koldhekar A. et al. Long-term outcome of per-oral endoscopic myotomy performed in the endoscopy unit with trainees. Surg Laparosc Endosc Percutan Tech 2021; 32: 114-118
    CrossrefPubMedSearch in Google Scholar
  • 66 Shiwaku H, Inoue H. Issues to be considered for learning curve for peroral endoscopic myotomy. Clin Endosc 2021; 54: 625-626
    CrossrefPubMedSearch in Google Scholar
  • 67 Bechara R, Woo M, Hookey L. et al. Peroral endoscopic myotomy (POEM) for complex achalasia and the POEM difficulty score. Dig Endosc 2019; 31: 148-155
    CrossrefPubMedSearch in Google Scholar
  • 68 Liu X-Y, Geng Z-H, Chen W-F. et al. A prediction model and nomogram for technical difficulty of peroral endoscopic myotomy. Surg Endosc 2023; 37: 2781-2788
    CrossrefPubMedSearch in Google Scholar
  • 69 Nakai T, Abe H, Tanaka S. et al. Risk-scoring system for predicting challenging cases of peroral endoscopic myotomy. Dig Endosc 2023; 35: 729-735
    CrossrefPubMedSearch in Google Scholar
  • 70 Inoue H, Shiwaku H, Iwakiri K. et al. Clinical practice guidelines for peroral endoscopic myotomy. Dig Endosc 2018; 30: 563-579
    CrossrefPubMedSearch in Google Scholar
  • 71 Kahaleh M, Tyberg A, Suresh S. et al. The learning curve for peroral endoscopic myotomy in Latin America: a slide to the right?. Clin Endosc 2021; 54: 701-705
    CrossrefPubMedSearch in Google Scholar
  • 72 Tefas C, Boroș C, Ciobanu L. et al. POEM: Five years of experience in a single East European center. J Gastrointest Liver Dis 2020; 29: 323-328
    CrossrefPubMedSearch in Google Scholar
  • 73 Sweet LR, Palazzi DL. Application of Kern’s Six-step approach to curriculum development by global health residents. Educ Health (Abingdon) 2015; 28: 138-141
    CrossrefPubMedSearch in Google Scholar
  • 74 Dumonceau JM, Hassan C, Riphaus A. et al. European Society of Gastrointestinal Endoscopy (ESGE) Guideline Development Policy. Endoscopy 2012; 44: 626-629
    Thieme ConnectPubMedSearch in Google Scholar