American Society for Gastrointestinal Endoscopy standards for fellowship training in peroral endoscopic myotomy

Background and Aims Peroral endoscopic myotomy (POEM) is a complex, technically demanding endoscopic procedure that requires focused, structured training. While increasingly adopted in both gastroenterology and surgical practice, there has been no consensus-based guidance to establish adequate training standards in POEM. Using a validated consensus methodology, we aimed to define minimum standards for POEM training programs to ensure competence in technical, cognitive, and integrative skills necessary for safe and effective practice. Methods A multidisciplinary expert panel was convened by the American Society for Gastrointestinal Endoscopy. The Research and Development (RAND)/University of California, Los Angeles appropriateness method (RAM) was used to evaluate candidate statements across 5 domains: pretraining activities, structure of training programs, POEM-specific cognitive training, POEM-specific technical training, and assessment of competence. Experts participated in 2 rounds of voting, rating each statement on a 9-point scale from highly inappropriate (1) to highly appropriate (9). For each statement, the median score and mean absolute deviation from the median were calculated. A statement was considered appropriate if it received a median score ≥7 and met the criteria for appropriateness based on the BIOMED, Interpercentile Range Adjusted for Symmetry, and P value methods. Results Of the 40 proposed statements, 34 met the criteria as appropriate. Key recommendations included that trainees should undergo POEM training within programs performing at least 40 procedures annually, be mentored by at least 1 trainer with ≥100 prior POEMs, and complete a minimum of 15 POEMs before undergoing milestone assessments with a validated assessment tool. Cognitive requirements included mastery of mediastinal anatomy, GERD management, electrosurgical tools, and interpretation of motility and imaging studies. Simulation model training and exposure to esophageal POEM, gastric POEM, and Zenker’s POEM were also recommended. Conclusions This consensus effort provides evidence-based minimum standards for POEM training, applicable to both GI and surgical trainees. These recommendations are intended to guide the structure of training programs, ensure safe dissemination of POEM, and support the evolution of competency-based education in third-space endoscopy.