POEM training in Europe- ESGE Statement

The European Society of Gastrointestinal Endoscopy (ESGE) has issued a comprehensive Position Statement regarding the training curriculum for performing peroral endoscopic myotomy (POEM) in Europe. POEM is an advanced endoscopic procedure that is now recognized as a first-line treatment for achalasia and other spastic esophageal motility disorders. Given the high level of technical expertise required and the potential risks of significant adverse events, ESGE stresses the importance of a structured, standardized training program to ensure safe and effective practice.

### Key Highlights of the ESGE POEM Training Curriculum:

#### 1. **Training Foundations**

• Trainees must develop a strong theoretical foundation before performing POEM. This includes:
• Understanding the pathophysiology of achalasia and other spastic esophageal motility disorders.
• Being proficient in diagnostic techniques, such as high-resolution manometry, which is critical for diagnosing and managing these conditions.
• Familiarity with expected treatment outcomes and strategies for managing complications.

#### 2. **Prerequisites for Training**

• Trainees should already have advanced endoscopic skills, particularly in techniques such as Endoscopic Mucosal Resection (EMR) or Endoscopic Submucosal Dissection (ESD). These skills are directly transferable to the submucosal dissection required for POEM.
• For those without prior ESD experience, training should include at least **20 simulated POEM procedures** on ex vivo or animal models before progressing to human cases.

#### 3. **Observational Training**

• Trainees are advised to observe at least **20 live POEM procedures** at expert centers. This allows them to gain insight into the technical nuances, procedural steps, and decision-making processes involved in POEM.

#### 4. **Hands-On Clinical Training**

• Trainees should perform a minimum of **10 supervised human POEM cases** under the guidance of experienced mentors.
• It is recommended to begin with straightforward cases, avoiding complex or high-risk cases during the early stages of training.
• The goal is for trainees to be able to independently complete all steps of the POEM procedure by the end of their training.

#### 5. **Competency Evaluation**

• Competency is assessed based on:
• Procedural success.
• Clinical outcomes (e.g., improvement in symptoms and quality of life).
• Low rates of adverse events.
• The evaluation should ensure that the trainee can perform the procedure safely and effectively.

#### 6. **Quality Assurance and Continuous Improvement**

• Centers offering POEM training are encouraged to maintain prospective registries of their procedures. These registries will help monitor the quality of training, track clinical outcomes, and ensure continuous improvement in the field.

#### 7. **Consensus-Based Development**

• The recommendations in the ESGE Position Statement were developed through a systematic review of the literature and a Delphi consensus process. This involved collaboration with expert POEM endoscopists from across Europe to ensure the curriculum is both evidence-based and practical.

### Conclusion:

The ESGE emphasizes that the structured training program outlined in this Position Statement is crucial for maintaining high standards of care and patient safety in the practice of POEM. By adhering to these recommendations, trainees can develop the necessary skills and knowledge to perform POEM with precision and confidence, ultimately improving patient outcomes.