GERD-HRQL. Scale: 0 = no symptoms. 1 = dymptoms noticeable, but not bothersome. 2 = symptoms noticeable and bothersome, but not every day. 3 = symptoms bothersome every day. 4 = symptoms affect daily activities. 5 = symptoms are incapacitating, unable to do daily activities
Compared to other initial series, these results are similar (Table 14.1). However, there are some subtle differences suggesting that structure training is helpful. During the initial six cases, two attending surgeons were used similar to Teitelbaum et al., but there was enough comfort with the procedure to allow for appropriate fellow involvement sooner. Comparatively, Dr. Lee Swanström as an early innovator and who did not have the benefit of course training involved fellows at case 16. Similarly, comfort with the procedure allows for an early transition to more complex cases such as those that had prior esophageal surgery or sigmoidal esophagi while maintaining low complication rates. Nevertheless, these differences are minor.
Comparison of outcomes using a structured training program
Number of endoscopists
Prior intervention (N, %)
Prior myotomy (N, %)
Sigmoidal esophagus (N, %)
Inadvertent mucosotomy (N, %)
Mean operative time
Swedish Series (2015)
1 attending with fellow at case 6
None related to achalasia
141.1 min ± 43.3 (sigmoid esophagus/redo’s excluded)
Kurian et al. (2013)
1 attending with fellow at case 16
Previous esophageal surgery, BMI > 40
133 min ± 41
Teitelbaum et al. (2014)
No prior interventions for the first ten cases
112 min ± 36
Patel et al. (2015)
“Contraindications to POEM”
149.7 min ± 36.7 (estimated time first 30 cases)
Why Use a Structured Training Program?
Many physicians will wonder if all of this is absolutely necessary since the physicians who pioneered the procedure didn’t rely on any sort of training. They simply “made it up” or “learned as they went.” As we move away from the innovators such as Pasricha and Inoue and the early adopters such as Stavropoulos and Swanström, a lot has been learned by these physicians. A structured training program allows the experiences and knowledge of many early adopters to be passed along for the betterment of patient experience. It’s ultimately about safety and achieving good outcomes from the very beginning. In addition, we have found that the time and effort invested in preparation for surgeons, team, and institution have yielded big dividends in performance satisfaction, decreased stress for the entire team, and enhanced credibility with colleagues and administrators, paving the way for a systematic approach to the introduction of new technology in the future.
Aside from the above, national organization and governing bodies are establishing best practice guidelines to guide technology adoption. The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) has already outlined key components required to introduce new technology into practice, and they specifically identified the POEM procedure as one where this type of structure program should be utilized . These guidelines are listed in Table 14.2. Use of a structured training program allows the physician to meet each of these criteria.
Technology adoption guidelines from SAGES
Familiarization with the device or procedure before introduction
Cognitive training in new device or procedure (e.g., indications, patient selection, etc.)
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