Impact of Focused Hands-on Training Course on Practice Adoption of Advanced Endoscopic Techniques and Per-Oral Endoscopic Myotomy

Introduction

The technique of per-oral endoscopic myotomy (POEM) has become an increasingly popular and undoubtedly valuable tool for the treatment of foregut motility disorders. ¹ However, as with the widespread implementation of any new surgical technique, effective teaching methods and strategies for overcoming the learning curve can be challenging barriers, particularly when the disease of interest is rare and the procedure technically challenging, as is the case with achalasia and POEM. ² This is particularly true in the area of advanced surgical endoscopy as this sort of curriculum is not currently standard in general surgery residency training. As a result, many general surgeons entering practice may not possess the advanced therapeutic endoscopy skills that are the base of the POEM procedure. Even for some gastroenterologists with significant endoscopic background, the transition to POEM can be somewhat daunting, and fellowships providing significant exposure to POEM are somewhat limited throughout the country.

Ultimately, those practitioners who are interested in learning this technique and launching a POEM practice at their home institution must seek individual training. To meet this need, there are several focused, hands-on courses offered throughout the country. However, whether such rapid training is sufficient to allow individuals to take this knowledge and skill back home and successfully launch a practice in POEM or advanced therapeutic endoscopy is unknown. The purpose of this study was to evaluate the successes of and barriers to implementation of a POEM practice after attending a hands-on course and to identify future areas of concentration to allow for effective and meaningful training in this important procedure.

Methods

Similar to various other POEM courses around the nation, our Foundation for Surgical Innovation and Education regularly offers a hands-on, 2-day training in POEM that involves a combination of didactic lectures, explant simulations, a porcine laboratory, and live case demonstrations taught by experts in the field to teach the technique of POEM to interested individuals. All participants of our course since its inception were sent a simple 20 question survey (survey monkey) by email to assess their endoscopic practice before and after the course, concentrating on their ability to implement POEM after returning to their home institution and what barriers, if any, they encountered while attempting to do so. We additionally collected information on their overall experience with the course and aspects of the training that were particularly useful or not. Results were recorded and descriptive statistics utilized to quantify outcomes of training.

Results

From the start of our course in 2012 through the end of 2017, 11 separate POEM courses were held, training a total of 102 individuals ranging from 5 to 12 participants per course. A total of 55 individuals responded to our survey (53.9%) with full demographic information listed in Table 1. Our respondents consisted mostly of general surgeons (49.1%) with additional participation from thoracic surgeons (23.6%) and gastroenterologists (23.6%) as well as a few pediatric surgeons (3.6%). There was perhaps a slight predominance of academic physicians compared with those from private institutions, but a fairly even distribution of both newer graduates and well-established physicians attending training. Most participants in the course (76.4%) already had some previous advanced endoscopic experience before attending the course (endoscopic submucosal dissection, endoscopic mucosal resection < radio frequency ablation, dilation, etc.) with 40.7% doing advanced therapeutic endoscopy regularly, whereas 12 (21.8%) had no previous therapeutic endoscopy experience. Most (83.6%) had never performed a POEM before attending the course with no participants having done more than five POEMs before training.

Following completion of the course, the majority of participants felt either somewhat (47.3%) or very (30.9%) confident in their new skill set. While 23 (41.8%) have not gone on to perform POEMs in their practice, many of our trainees (58.2%) have become independent practitioners in POEM with case numbers ranging from 1 to greater than 50. This has proven to be sustainable with 90.6% of those who started doing POEM continuing to perform the procedure regularly. This was likely assisted by the fact that 65.6% of the individuals who successfully began doing POEM received in-person proctoring after returning to their home institution, most commonly for two to five cases. In addition, nearly half of all participants did additional explant laboratories after their hands-on POEM course for additional training (43.6%). Many of our participants, even those who are not currently performing POEM, are still performing other advanced endoscopic procedures since their training (Table 2).

Looking specifically at the individuals who were, in fact, successful in implementing POEM at their home institutions after attending training, it was notable that these practitioners had a higher rate of previous therapeutic endoscopy experience (90.3%) compared with those individuals who did not go on to practice POEM (65.0%). Of patients with no previous therapeutic endoscopy experience only 4 (33.3%) were able to start performing POEM. In addition, of the participants who were not confident in their ability to perform POEM after completing the course (which interestingly included many individuals with previous endoscopic experience), 36.4% (4/11) did go on to implement a POEM practice with three of these 4 individuals getting proctoring and the last individual doing additional explant laboratories to supplement their training. In all, 71.4% of those individuals who were successful in implementing POEM having received postcourse proctoring and 54.8% did additional explant laboratories. Only 1 individual who received postcourse proctoring did not go on to launch a POEM practice.

In general, course participants felt that the hands-on POEM course was helpful in their current practice, regardless of whether they are performing POEM or not, and would recommend a hands-on course for any individual interested in starting to do POEM (Table 3).

In evaluating those patients who identified barriers to performing POEM at their own institution after the course, more than 40% of all trainees who could not successfully implement a POEM program cited a lack of institutional support as the main reason for not performing the procedure (Table 4). When queried further, these responders cited that they did not have appropriate equipment, there were barriers in credentialing, or it was not in the priorities of the department to support surgical endoscopy. Lack of referral volume and insurance denials were cited as the next most common limitations to maintain a POEM program. Very few felt that the technical aspects of the procedure, their inability to get proctoring, or concerns over potential complications played a role in their inability to establish a POEM practice.

Of the 47 individuals who took the POEM course but did not respond to the survey, we know anecdotally that 13 individuals have performed POEM since the course and 7 have not. The other 27 individuals' implementation remains unknown (Table 5).

Discussion

In this work, we have shown that even a relatively short and focused hands-on training course in POEM can lead to successful implementation into practice with relatively high rates of POEM adoption among participants of the course, despite their relatively novice starting positions with respect to the procedure itself and the rather short duration of the course at only 2 days.

The findings of this study are particularly reassuring against concerns over the ability to adequately train in POEM. Initial studies evaluating the learning curve in POEM suggest that between 70 and 100 cases are required to decrease the risk of technical failures, adverse events, and clinical failure.^3,4 Given the rarity of the disease and the relatively few number of training programs available, achieving such numbers may be all but impossible for a new practitioner looking to incorporate POEM into their armamentarium. ² It is estimated that in patients with previous advanced endoscopic experience, the learning curve may be as low as 25 cases, ⁵ and in an expert endoscopist, as few as 13. ⁶ Adoption may be further improved by performing preclinical procedures in animal models (such as a during a hands-on course) before attempting POEM in live human subjects. ⁷ In all, a multimodal curriculum with procedural practice has been shown to be an effective design for teaching the procedure. ⁸

As the need for POEM continues to grow, expanding the pool of well-trained surgical endoscopists will be paramount to ensure the longevity of the procedure. A successful comprehensive training strategy for POEM must then look at all predictors of success and failure to design the best possible focused experience to optimize successful implementation and must consider both the trainee as well as the institution that they are returning to.

It is notable that despite the previously held belief that a high number of cases are needed to achieve proficiency, many practitioners were confident in performing POEM after their short training. While a lack of advanced therapeutic endoscopy curriculum in general surgery training may limit the number of surgeons with the base technical skills that set them up for a highest likelihood of success in POEM, with the addition of just a few cases of in-person expert proctoring (average 2–5) and additional explant laboratories, even some individuals with no previous therapeutic endoscopic experience were able to begin a POEM practice. It is clear that additional training after a hands-on course with additional explant laboratories or in-person expert proctoring are very beneficial implementing a POEM practice as 71.4% of those individuals who were successful in implementing POEM had received postcourse proctoring. Only 1 individual who received postcourse proctoring failed to institute a POEM practice, due to lack of institutional support.

The higher rate of POEM adoption in practitioners with previous therapeutic endoscopy experience is perhaps not surprising and should be considered in setting expectations for adoption. It does confirm that given the technical challenges of the POEM procedure, it may be easier for those with past endoscopic experience to learn POEM, as they have the base skills already in place and they are comfortable in the endoluminal space. However, it may equally have to do with the fact that such individuals likely come from practices that already own the necessary advanced endoscopic tools needed to perform POEM and their institutions are comfortable with the practice of advanced therapeutic endoscopy and supportive of the arrival of POEM. These individuals are likely to be the most successful after POEM training.

In all, it does not seem to be challenges in learning the technical aspects of the procedure that are keeping people from adopting POEM. In fact, the majority of barriers cited for not performing POEM did not relate to the course itself, but instead were outside influences, such as lack of institutional support, missing equipment, and insurance denial, issues that stem from the lack of societal and cultural support for the procedure. Many of our participants felt eager to perform POEM and confident in their skills after training, but were simply unable to overcome their institutional barriers and thus abandoned the procedure.

This study certainly has its limitations, including the relatively low survey response rate at just above 50%. It is possible that this low response rate falsely elevated the percent of trainees who have successfully implemented a POEM program, as they may have been more motivated or likely to respond to the survey request. It is also representative of the outcomes of only one, institution-specific training program and may not be reflective of the outcomes of different educational approaches at courses across the country.

Conclusion

Hands-on POEM training is an effective tool for teaching this complex technique and is associated with a high rate of implementation of an independent POEM practice, particularly in practitioners with previous advanced therapeutic endoscopy experience, readily available equipment and institutional support. The largest barriers to successful adoption of POEM are not technical factors or the ability to learn the procedure, but rather are related to poor institutional support and lack of insurance approval. POEM training will only be effective in increasing the number of POEM practitioners across the country if these nonprocedural barriers can be addressed through societal and cultural support.