Communication

from the ASGE

Training CORE CURRICULUM
Committee

Core curriculum for peroral endoscopic myotomy (POEM)

Sunil Dacha, MD,1,* Hiroyuki Aihara, MD, PhD,2,* Gobind S. Anand, MD,3 Kathryn R. Byrne, MD,4
Prabhleen Chahal, MD,5 Theodore James, MD,6 Thomas E. Kowalski, MD,7 Emad Qayed, MD, MPH,8
Aparna Repaka, MD,9 Mohammed Saadi, MD,10 Sunil G. Sheth, MD,11 Jason R. Taylor, MD,12
Catharine M. Walsh, MD, MEd, PhD,13 Renee L. Williams, MD, MHPE,14
Mihir S. Wagh, MD, FACG, FASGE (ASGE Training Committee Chair)15

This document was reviewed and approved by the Governing Board of the American Society for Gastrointestinal
Endoscopy.

This document is one of a series of documents pre-
pared by the American Society for Gastrointestinal Endos-
copy Training Committee. This document contains
recommendations for a training curriculum intended
for use by endoscopy training directors, endoscopists
involved in peroral endoscopic myotomy training, and
trainees learning this procedure. This document was
developed as an overview of techniques currently favored
for the performance and training of peroral endoscopic
myotomy and to serve as a guide to published references,
videos, and other resources available to the trainer.
Peroral endoscopic myotomy (POEM) has emerged as a
minimally invasive, flexible endoscopic option for the treat-
ment of achalasia and other spastic esophageal motility disor-
ders.1-4 POEM is currently performed by interventional
gastroenterologists, minimally invasive foregut surgeons,
and cardiothoracic surgeons. However, no standard training
curriculum is presently available for providing comprehensive
information on the training process for POEM, and hands-on
training for POEM in North America is limited. The perfor-
mance of POEM requires advanced flexible endoscopic skills
and a thorough understanding of mediastinal and upper
abdominal anatomy. The aim of this document is to highlight
core concepts and skills required for the performance of safe
and effective POEM with emphasis on technical, nontech-
nical, and cognitive aspects of training. Additional information
can be accessed at the American Society for Gastrointestinal
Endoscopy (ASGE) guidelines for achalasia.5
TRAINING ENVIRONMENT
the standard 3-year gastroenterology fellowship, they can
learn the performance of POEM during a dedicated
advanced endoscopy fellowship or in special Third Space
Endoscopy programs, as available.
Faculty
Programs dedicated to POEM training should have at
least one faculty member experienced in POEM and sub-
mucosal endoscopic procedures. The training faculty
should be committed to providing a comprehensive
training experience that includes didactic teaching, super-
vised ex vivo model and simulator training, clinical
hands-on training, and continuous assessment of technical,
nontechnical, and cognitive skills. The training faculty
should ensure hands-on participation in an adequate num-
ber of cases and quality teaching during training.
Facilities
POEM can be performed in the interventional endoscopy
suite or in an operating room. An upper endoscope with a distal
attachment cap, electrosurgical generator, low-flow CO2 insuf-
flator, endoscopic knives, and hemostatic forceps are essential
for performing POEM procedures. Programs should consider
setting up a “POEM cart” with the necessary equipment needed
for the performance of the procedure and management of
adverse events (eg, Veress needle for abdominal decompres-
sion). In addition, the facility should have endoscopy nurses
and technicians familiar with POEM assisting during the proced-
ure. The availability of appropriate surgical backup is recommen-
ded in case of unforeseen adverse events.

Trainee
Before initiation of POEM training, trainees should be
proficient in all aspects of general endoscopy. Once
trainees acquire adequate general endoscopic skills during
Copyright ª 2021 by the American Society for Gastrointestinal Endoscopy
0016-5107/$36.00
https://doi.org/10.1016/j.gie.2020.10.026
TRAINING PROCESS
Although there are no published guidelines for training
in POEM, experts suggest starting with observation of live
cases,6,7 attending POEM-related didactic courses, and
engaging in self-learning using online contents (eg, ASGE
GI Leap).8 A hands-on experience on ex vivo models and
progressing to live animal models is preferred before the

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Core curriculum for POEM Dacha et al

TABLE 1. Core technical, nontechnical and cognitive skills for training in POEM

Technical Nontechnical Cognitive

 Appropriately apply the distal
attachment cap to the endoscope
 Create a submucosal bleb and
perform mucosal incision
 Safely navigate the endoscope
into the submucosal space
 Perform submucosal tunneling
 Minimize CO2 insufflation in the
submucosal tunnel
 Appropriately perform hemostasis
using the dissection knife and
electrosurgical coagulation graspers
 Perform selective circular muscle
myotomy and/or full thickness
myotomy
 Avoid excessive myotomy in
gastric cardia to minimize
esophageal reflux
 Identify and manage adverse
events during POEM
 Work effectively as a member of a multidisciplinary
team to ensure that knowledge is shared and
understanding is reached to provide effective
patient-centered care
 Demonstrate situational awareness including
continuous assessment of the situation and
problem recognition
 Demonstrate leadership by supporting team
members, maintaining standards, and directing
problem management
 Demonstrate judgement and decision-making
skills to choose appropriate course of action
 Evaluate patient suitability and cardiopulmonary
fitness for the POEM procedure, in consultation with
anesthesia specialist as needed in selected cases
 Obtain informed consent by explaining the risks,
benefits, and alternatives for POEM and expected
outcomes
 Understand the risk of aspiration and communicate
with the anesthesia team
 Effectively communicate endoscopic plan and
procedure goals with endoscopy team
 Document a detailed procedure report with an
accurate description of procedure details, types
of devices used, and intraprocedural adverse
events, if any
 Understand the indications, contraindications,
and alternatives for POEM
 Formulate an endoscopic plan for the POEM
procedure based on prior surgical and
endoscopic treatments
 Interpret high-resolution esophageal
manometry and esophagrams to identify
type of motility disorder amenable for POEM
 Recognize the emerging role of impedance
planimetry (endoluminal functional lumen
imaging probe) as a potential adjunctive
diagnostic tool
 Understand periprocedure antiplatelet and
anticoagulation management
 Understand the importance of using
low-flow CO2
 Know the different types of endoscopic
knives, coagulation graspers, and
electrosurgical generators
 Understand mediastinal anatomy
 Recognize anatomic landmarks to identify
anterior and posterior walls of the
esophagus and landmarks at the
gastroesophageal junction
 Consistently identify the orientation
of mucosa and muscle layers in the
submucosal tunnel

POEM, Peroral endoscopic myotomy.

trainee can transition to participation in live human POEM
cases with an experienced trainer.6,7 The training program
should provide adequate POEM cases for obtaining
proficiency in POEM for independent practice. The
number of cases required to achieve proficiency
in POEM is highly variable (ranging from 13 to 100
cases),9-13 with most reports based on the personal
learning curves of experienced endoscopists rather than
on training data.6,14
GOALS OF TRAINING
history, including prior endoscopic and surgical treatment, is
essential to plan the POEM procedure (eg, prior history of
Heller myotomy). Based on these factors and the type of
achalasia (types I/II vs III) and esophageal anatomy (eg, sig-
moid esophagus), trainees should be able to formulate an
appropriate endoscopic plan regarding perioperative use of
antibiotics, location and length of myotomy, and preoperative
and postoperative diet restrictions. Trainees should also learn
to obtain informed consent by explaining the risks and bene-
fits of and alternatives to the POEM procedure, and expected
outcomes to the patients.

The core technical, nontechnical, and cognitive skills for Equipment

training in POEM are listed in Table 1 and further discussed
below.
Preprocedure assessment
Trainees should understand the indications for perform-
ing POEM and be able to appropriately recommend POEM
as indicated by the findings of endoscopic, manometric,
and radiographic evaluations. Trainees should recognize
the emerging role of the endoluminal functional lumen
imaging probe as a potential adjunctive diagnostic tool.
Trainees should understand contraindications and alternatives
to POEM, including pneumatic balloon dilation, endoscopic
botulinum toxin injection, and Heller myotomy, and be able
to appropriately select patients for POEM. A detailed medical
As with any endoscopic procedure, trainees should un-
derstand the functioning of all equipment used in the
POEM procedure. Trainees should understand the impor-
tance of using a distal attachment cap and low-flow CO2
insufflation for the POEM procedure. Trainees should
know the appropriate concentration of blue dye in the in-
jection solution (indigo carmine or methylene blue) to
facilitate recognition of the submucosal layer during sub-
mucosal tunneling. Trainees should be well versed with
electrosurgical generator settings used during POEM
because the various steps in POEM require appropriate
adjustment of electrosurgical parameters for mucosal inci-
sion, submucosal dissection, hemostasis, and performing
myotomy. Trainees need to understand the types of

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Dacha et al
endoscopic knives with or without fluid injection function
and their dissection, cutting, and coagulation capabilities
based on the shape of the knives and current density.
Sedation management
Trainees should communicate the plan and expecta-
tions with their endoscopy team including anesthesia pro-
viders before all POEM procedures. Because all POEM
procedures are performed with the patient under general
anesthesia with endotracheal intubation, trainees should
discuss the risk of aspiration because of esophageal stasis
with their anesthesiology providers. Rapid sequence intu-
bation followed by aggressive oral suctioning and endotra-
cheal suction may need to be performed to prevent
aspiration. Trainees should work with their anesthesia pro-
viders to develop an anesthesia-related protocol for POEM,
including administration of antibiotics, maintaining paraly-
sis during the entire procedure, and intraprocedure moni-
toring of peak airway pressures.
POEM hands-on training
POEM is an advanced endoscopic procedure requiring
skills in submucosal dissection and hemostasis. Based on
their skill level, trainees may initially only participate partially
in each step of the procedure, whereas critical steps may be
performed by the experienced trainer. These critical steps
include submucosal entry, preemptive coagulation of sub-
mucosal vessels and perforating arteries, and mucosotomy
closure.14-16 Subsequently, after gaining more experience,
trainees should be able to independently perform all the
steps of the POEM procedure as described below.
Submucosal injection and mucosal incision.
Trainees should be able to select the site for mucosal inci-
sion and perform an appropriate submucosal injection.
Mucosal incision is a crucial early step in the POEM proced-
ure. Trainees should understand the importance of avoid-
ing muscle incision and perforation at this stage, because a
perforation may preclude completion of the POEM proced-
ure. Trainees should learn the appropriate depth of inser-
tion of the endoscopic knife to cut both the mucosal layer
and muscularis mucosae to expose the submucosal tissue.
Submucosal entry. After performing a mucosal inci-
sion, trainees should learn the technique to advance the
endoscope into the submucosal layer. To facilitate submu-
cosal entry, the submucosa under the mucosotomy site
should be dissected toward the distal and lateral sides.
This step remains a significant challenge for most trainees
during early POEM procedures, and correct principles of
submucosal dissection should be emphasized.
Visualization within the submucosal tunnel and
submucosal dissection. Trainees should be able to
consistently identify the orientation of the mucosa, submu-
cosal layer, and proper muscle layer to prevent inadvertent
mucosal injury while creating a submucosal tunnel.
Trainees should understand the importance of performing
submucosal dissection closer to the muscle layer to pre-
www.giejournal.org
Core curriculum for POEM
vent unintentional mucosal injury. Trainees should learn
to minimize CO2 insufflation in the submucosal tunnel to
minimize capnomediastinum and capnoperitoneum.
Trainees should be able to identify perforating vessels to
perform appropriate prophylactic hemostasis. A very
crucial step in the POEM procedure is the identification
of the gastroesophageal junction while performing submu-
cosal dissection to determine the length of the tunnel in
the esophagus and gastric cardia. Trainees should be
able to identify the gastroesophageal junction by the nar-
row submucosal space, change in vascularity, and orienta-
tion of muscle layers. Trainees should also be able to
identify the sling muscle fibers in the gastric cardia and
take precautions to avoid injury.
Performing myotomy. Trainees should be able to
determine the appropriate location to begin the myotomy
(typically at 1-2 cm distal to the mucosotomy site).
Trainees should be able to identify circular and longitudi-
nal muscle layers when performing the myotomy. Trainees
should be able to extend the myotomy up to 2 to 3 cm into
the stomach beyond the gastroesophageal junction.
Trainees should understand the importance of avoiding
extensive myotomy in the cardia to minimize gastroesoph-
ageal reflux.
Mucosotomy closure. Trainees should be able to
perform a secure mucosotomy closure with endoscopic
clips or endoscopic suturing under direct vision because
this is a critical step to prevent post-POEM leak.
Recognition, prevention, and management of
adverse events
POEM is a technically challenging and complex endo-
scopic procedure with the potential for severe adverse
events. Many published articles have reported low adverse
event rates.17 However, it is crucial to understand that
most of those cases were performed by experts, and the
potential for severe adverse events in the hands of
novice endoscopists should be appreciated by trainees.
Trainees should learn to identify adverse events in a
timely manner and manage them appropriately, as
outlined below.
Bleeding. Bleeding can be encountered during any
step of the POEM procedure but can be more severe
from large perforating vessels near the esophagogastric
junction and on the gastric side of the submucosal tunnel.
Trainees should learn to identify these vessels and coagu-
late them preemptively. Once acute bleeding is encoun-
tered, trainees should learn to treat small vessels by
coagulation with the dissecting knife and also be profi-
cient in using an electrosurgical coagulation grasper to
manage larger blood vessels. Trainees should understand
the role of tamponade with the distal cap or balloon when
endoscopic visualization is not feasible because of signif-
icant bleeding. Trainees should understand the impor-
tance of preemptive coagulation of visible vessels to
prevent delayed bleeding within the tunnel.
Volume 93, No. 3 : 2021 GASTROINTESTINAL ENDOSCOPY 541
Core curriculum for POEM
Perforation. Inadvertent perforation can occur during
initial mucosal incision. This is typically caused by insuffi-
cient submucosal injection, submucosal fibrosis, misrecog-
nition of the depth of insertion of the endoscopic knife,
and insufficient submucosal dissection at the time of sub-
mucosal entry. Trainees should learn to perform a secure
closure if a full-thickness perforation is encountered at or
in close proximity to the mucosotomy site.
Trainees should also understand the importance of
maintaining mucosal integrity during the POEM procedure.
Mucosal injury may occur in the tunnel because of thermal
injury when dissection, myotomy, or hemostasis is per-
formed close to the mucosa. Trainees should carefully
check the mucosal layer to identify mucosal injuries during
submucosal dissection or myotomy and promptly close the
defect.
Capnomediastinum and capnoperitoneum.
Trainees should learn that POEM should only be per-
formed with CO2 insufflation and never using air. CO2
can escape into the mediastinum and peritoneal cavity dur-
ing the POEM procedure. Trainees should recognize the
signs and symptoms of capnoperitoneum (abdominal
distention, pain) and be able to perform needle decom-
pression of the abdomen if hemodynamic instability is
encountered. Trainees should recognize the benign nature
of subcutaneous emphysema during POEM and communi-
cate with the anesthesia team and nurses regarding post-
procedure expectations and recognition of triggers for
higher levels of care.
Esophageal stent placement for leaks or perfora-
tion. It is unusual to encounter a large perforation during
a meticulously performed POEM procedure. However,
trainees should be able to perform esophageal stent place-
ment for leaks and/or large full-thickness perforations not
amenable to primary endoscopic closure.
Infections. Prophylactic antibiotics are typically
administered perioperatively for POEM. Trainees should
be aware of the possibility of mediastinitis, one of the
most feared, albeit uncommon, adverse events related to
POEM, resulting from esophageal leaks or infection within
the submucosal tunnel.
Postoperative care and follow-up
Trainee should be able to document a detailed proced-
ure report with an accurate description of procedure de-
tails, types of devices used, and intraprocedural adverse
events, if any. Patients are usually admitted for overnight
observation after POEM, although some centers have
shown that same-day discharge is feasible and safe in
selected cases.18 Trainees should be actively involved in
the patient’s care after POEM. Trainees should learn the
role of performing routine contrast esophagram after
POEM, identify any potential leaks, and devise further
management based on radiologic and clinical findings.
Trainees should recognize the benign nature of
pneumoperitoneum, pneumomediastinum and subcutane-
542 GASTROINTESTINAL ENDOSCOPY Volume 93, No. 3 : 2021
Dacha et al
ous emphysema, often seen on radiologic imaging after
POEM, in asymptomatic patients. Trainees should recognize
that false-negative findings on an esophagogram can occur
in some patients.19 Trainees should understand the
importance of postprocedure follow-up to document
improvement in symptoms (Eckardt score)20 and additional
tests such as esophageal manometry, upper endoscopy, and
esophageal pH testing as needed.
SUMMARY
This POEM training curriculum is meant to serve as a
platform for education, training, and practice. By providing
information to endoscopy trainers about the common
practices used by experts in these techniques, the ASGE
hopes to improve the teaching and performance of POEM.
DISCLOSURES
The following authors disclosed financial relationships:
H. Aihara: Consultant for Boston Scientific Corporation, Fu-
jifilm Medical Systems USA, Inc, and Olympus America, Inc.
K. R. Byrne: Royalties from UpToDate, Inc. T. E. Kowalski:
Consultant for Boston Scientific Corporation and Medtronic
USA, Inc. J. R. Taylor: Consultant for AbbVie. R. L. Williams:
Stockholder in Boston Scientific Corporation. M. S. Wagh:
Consultant for Boston Scientific Corporation, Incyte Corpo-
ration, Medtronic, and Olympus America Inc.
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AbbreviationsASGE, American Society for Gastrointestinal
EndoscopyPOEM, peroral endoscopic myotomy
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Core curriculum for POEM
Received October 26, 2020. Accepted October 26, 2020.
Current affiliations: Division of Gastroenterology, Underwood Center for
Digestive Disorders, Houston Methodist Hospital, Houston, Texas, USA
(1), Division of Gastroenterology, Hepatology and Endoscopy, Brigham
and Women’s Hospital, Harvard Medical School, Boston, Massachusetts,
USA (2), Division of Gastroenterology, University of California San Diego,
San Diego, California, USA (3), Division of Gastroenterology, University
of Utah, Salt Lake City, Utah, USA (4), Digestive Disease and Surgery
Institute, Cleveland Clinic, Cleveland, Ohio, USA (5), Division of Gastro-
enterology and Hepatology, University of North Carolina, Chapel Hill,
North Carolina, USA (6), Division of Gastroenterology and Hepatology,
Thomas Jefferson University, Philadelphia, Pennsylvania, USA (7),
Department of Medicine, Division of Digestive Diseases, Emory Univer-
sity School of Medicine, Atlanta, Georgia, USA (8), Division of Gastroen-
terology, VA Boston Healthcare system. Department of Medicine,
Boston University School of Medicine, Boston, Massachusetts (9), Divi-
sion of Gastroenterology, Mayo Clinic Arizona, Scottsdale, Arizona,
USA (10), Division of Gastroenterology, Beth Israel Deaconess Medical
Center and Harvard Medical School, Boston, Massachusetts, USA (11),
Division of Gastroenterology and Hepatology, St Louis University, St
Louis, Missouri, USA (12), Division of Gastroenterology, Hepatology
and Nutrition and the Research and Learning Institutes, Hospital for
Sick Children, Department of Paediatrics and the Wilson Centre, Univer-
sity of Toronto, Toronto, Ontario, Canada (13), Division of Gastroenter-
ology and Hepatology, NYU Langone Health, New York, New York, USA
(14), Division of Gastroenterology, University of Colorado-Denver
School of Medicine, Aurora, Colorado, USA (15).
Reprint requests: Mihir S. Wagh, MD, FACG, FASGE, Division of Gastroenter-
ology, University of Colorado-Denver, 1635 Aurora Ct, F735, Aurora,
CO 80045, USA.
Volume 93, No. 3 : 2021 GASTROINTESTINAL ENDOSCOPY 543