424 POEM Training and Skills Evaluation Tool: A Pilot Study

Abstract

INTRODUCTION: Hands-on training for Per-Oral Endoscopic Myotomy (POEM) in the United States is limited and without a structured curriculum and assessment tool. Training to competency in POEM is critical and POEM trainees must acquire multiple cognitive and technical skills to achieve proficiency. METHODS/METHODS AND AIM: The aim of this study was to develop a POEM training and skills evaluation tool. This pilot study was performed at a tertiary academic medical center in the US from 5/2018 – 11/2018. The training protocol included initial swine explant models followed by live human cases, proctored by a single endoscopist experienced in POEM who graded trainees for each task on a 5-point scale (1 = trainer had to take over, 2 = trainer provided technical assistance, 3 =trainer provided substantial verbal guidance, 4 =trainer provided minimal verbal guidance, and 5 =trainee performed completely independently). Three trainees were prospectively graded on specific cognitive (identification of GE junction, incision site selection, identification of esophageal wall layers, recognition of planes during tunneling, identifying structures at GEJ and cardia in the tunnel, and identification of circular and longitudinal muscles) and technical skills (entry into the submucosal space, submucosal tunneling, myotomy and hemostasis) essential for successful POEM completion. Competency was considered at skill level ≥ 4 for each skill. RESULTS: Three trainees (interventional endoscopy fellows) completed a total of 18 cases (8 cases on animal explant models and 10 human cases) and were evaluated by one expert supervisor. Cognitive skills were acquired early in training with trainee scores of ≥ 4 by the 3rd swine explant case and 3rd human case. Technical skills required more cases and direction. Level ≥ 4 in technical skills was achieved by the 8th human case. Entry of the endoscope into the submucosal space was the most difficult step. No adverse events occurred in the human cases. CONCLUSION: This pilot study introduces a POEM training and skills evaluation tool for training to competency. Submucosal entry, tunneling and myotomy were the most challenging to learn while cognitive skills were learned early in training. The main limitations of this study include single site study with small number of trainees and procedures, and a single instructor. Evaluation of POEM procedures performed by more trainees at multiple sites will be necessary to further validate the utility of this tool.