Some technical differences do exist between the POP and the POEM techniques. Unlike in a POEM, we prefer to keep a fairly short submucosal tunnel with the mucosal incision that is performed only about 2–3 cm proximal to the pylorus. Also, the myotomy itself is fairly restricted to the pylorus and only extends proximally by about 1 cm. During the pyloromyotomy, no specific attempt is made to selectively divide only the circular muscular layer, and it is typically divided in a full-thickness fashion down to the serosal layer. Special attention must be paid when performing the distal portion of the pyloromyotomy since the duodenal mucosa will drape over it in a perpendicular direction and could easily be perforated during this portion of the dissection. Finally, there is still some disagreement as to the optimal location to perform the myotomy. We prefer to perform the pyloromyotomy on the posterior aspect of the greater curvature to benefit from the natural positioning of the endoscope. An argument, however, can be made to perform the myotomy along the anterior aspect so that the procedure can more easily be converted to a laparoscopic pyloroplasty in case of an endoscopic full-thickness perforation.

The success of POEM expanded the indications and the acceptance of endoscopic submucosal dissection techniques. This is evident by the increasing numbers of gastroenterologists and surgeons in the Western world performing advanced endoscopic techniques such as endoscopic pyloromyotomies. Further studies with larger number of patients are of course required to determine the long-term outcomes, indications, and optimal patient selection for per-oral pyloromyotomy.

An important limitation to widespread acceptance is that significant challenges remain with respect to adequate physician training to perform these advanced procedures. Only a few centers have evaluated the learning curve for POEM. Estimated numbers of procedures required to reach mastery of the POEM procedure vary between 20 and 60 cases [33, 34]. Per-oral pyloromyotomy may in fact be even more challenging than a myotomy of the lower esophageal sphincter. Obtaining this required level of experience can be quite challenging, especially in the setting of these relatively rare disorders. Future research must therefore also focus on the improvement in the training and simulation of these procedures. With time, the available endoscopic surgical platforms will continue to improve and evolve, perhaps making these techniques accessible to an increasing group of practitioners.