Anesthetic management of peroral endoscopic myotomy for esophageal achalasia: a retrospective case series. J Anesth. 2014;28:456-459. [PMID: 24185834 DOI: 10.1007/s00540-013-1735-0]

Invasive CO 2 monitoring with arterial line compared to end tidal CO 2 during peroral endoscopic myotomy

Background and study aims  Peroral endoscopic myotomy (POEM) has become a recognized treatment for achalasia. The technique requires CO 2 insufflation. It is estimated that the partial pressure of CO 2 (PaCO 2 ) is 2 to 5 mm Hg higher than the end tidal CO 2 (etCO 2 ), and etCO 2 is used as a surrogate for PaCO 2 because PaCO 2 requires an arterial line. However, no study has compared invasive and noninvasive CO 2 monitoring during POEM. Patients and methods  Seventy-one patients who underwent POEM were included in a prospective comparative study. PaCO 2 plus etCO 2 was measured in 32 patients (invasive group) and etCO 2 only in 39 matched patients (noninvasive group). Pearson correlation coefficient (PCC) and Spearman's Rho were used to calculate the correlation between PaCO 2 and ETCO 2 . Results  PaCO 2 and ETCO 2 were strongly correlated: PCC R value: 0.8787 P  ≤ 0.00001, Spearman's Rho R value: 0.8775, P  ≤ 0.00001. Within the invasive group, the average difference between PaCO 2 and ETCO 2 was 3.39 mm Hg (median 3, standard deviation 3.5), within the 2- to 5-mm Hg range. The average procedure time (scope in to scope out) was increased 17.7 minutes ( P  = 0.044) and anesthesia duration was 46.3 minutes. Adverse events (AEs) included three hematomas and one nerve injury in the invasive group and one pneumothorax in the noninvasive group. There were no differences in AE rates between the groups (13 % vs 3 % P  = 0.24). Conclusions  Universal PaCO 2 monitoring contributes to increased procedure and anesthesia times without any decrease in AEs in patients undergoing POEM. CO 2 monitoring with an arterial line should only be performed in patients with major cardiovascular comorbidities; in all other patients, ETCO 2 is an appropriate tool.

High Eckardt score and previous treatment were associated with poor postperoral endoscopic myotomy pain control: A retrospective study

BACKGROUND

Peroral endoscopic myotomy (POEM) is a safe and effective endoscopic treatment for achalasia. However, postoperative pain management for these patients is often neglected by anesthesiologists because of the short operative time, short hospital stay and the minimally invasive nature of the procedure.

AIM

To assess the pain and sleep quality of achalasia patients receiving the POEM procedure and investigate factors that affect postoperative pain.

METHODS

This observational study included patients with achalasia who underwent POEM at Zhongshan Hospital from December 2017 to March 2018. General anesthesia was performed with endotracheal intubation. The postoperative visual analog scale (VAS), postoperative sleep quality, basic patient information, and surgical parameters were collected. Depending on whether the 12-h post-POEM VAS score was less than 4, patients were divided into two groups, a well-controlled pain group and a poorly controlled pain group. Univariate, multivariate, and stepwise logistic regression analyses were used to investigate risk factors for poor pain control. A prediction model of post-POEM pain risk was established in the form of a nomogram. The calibration curve and receiver operating characteristic curve were used to evaluate the clinical usage of the prediction model. Repeated measures analysis of variance and simple effect analysis were used to verify whether differences in the VAS and sleep scores of the high- and low-risk groups, divided by the model from the raw data, were statistically significant.

RESULTS

A total of 45 eligible patients were included. Multivariate logistic regression and further stepwise logistic regression analysis found that the preoperative Eckardt score [odds ratio (OR): 1.82, 95% confidence interval (CI): 1.17-2.84, P < 0.001], previous treatment (OR: 7.59, 95%CI: 1.12-51.23, P = 0.037) and the distance between the end of the muscle incision and the cardia (OR: 1.52, 95%CI: 0.79-293.93, P = 0.072) were risk factors for post-POEM pain. Repeated measures analysis of variance demonstrated that VAS (P = 0.0097) and sleep scores (P = 0.043) were higher in the high-risk group, and the interactions between the two main effects were obvious (VAS score: P = 0.019, sleep score: P = 0.035). Further simple effect analysis found that VAS scores were higher in the high-risk group at 2 h, 6 h and 12 h (P = 0.005, P = 0.019, P < 0.001), and sleep scores were higher in the high-risk group at day 1 (P = 0.006).

CONCLUSION

Achalasia patients who underwent POEM experienced serious postoperative pain, which may affect sleep quality. A higher Eckardt score, previous treatment, and a longer distance between the muscle incision ending and the cardia were risk factors for poor post-POEM pain control.

Pediatric anesthesia and achalasia: 10 years' experience in peroral endoscopy myotomy management

BACKGROUND

Endoscopic treatment for achalasia (POEM) is a recently introduced technique that incorporates the concepts of natural orifice transluminal surgery. Although pediatric achalasia is rare, POEM has been episodically used in children since 2012. Despite this procedure entails many implications for airway management and mechanical ventilation, evidences about anesthesiologic management are very poor. We conducted this retrospective study to pay attention on the clinical challenge for pediatric anesthesiologists. We put special emphasis on the risk in intubation maneuvers and in ventilation settings.

RESULTS

We retrieved data on children 18 years old and younger who underwent POEM in a single tertiary referral endoscopic center between 2012 and 2021. Demographics, clinical history, fasting status, anesthesia induction, airway management, anesthesia maintenance, timing of anesthesia and procedure, PONV, and pain treatment and adverse events were retrieved from the original database. Thirty-one patients (3-18 years) undergoing POEM for achalasia were analyzed. In 30 of the 31 patients, rapid sequence induction was performed. All patients manifested consequences of endoscopic CO₂ insufflation and most of them required a new ventilator approach. No life-threatening adverse events have been detected.

CONCLUSIONS

POEM procedure seems to be characterized by a low-risk profile, but specials precaution must be taken. The inhalation risk is actually due to the high rate of full esophagus patients, even if the Rapid Sequence Induction was effective in preventing ab ingestis pneumonia. Mechanical ventilation may be difficult during the tunnelization step. Future prospective trials will be necessary to individuate the better choices in such a special setting.

Effect of Drinking Warm Water on Esophageal Preparation Before Peroral Endoscopic Myotomy in Patients With Achalasia

Background/Aims

Food retention, which is a characteristic observed in patients with achalasia, can interfere with peroral endoscopic myotomy (POEM). However, there is no established guideline for esophageal preparation for POEM. A previous study has shown that drinking warm water may reduce the lower esophageal sphincter pressure in patients with achalasia. This study aims to evaluate the possibility of proper preparation of POEM by instructing the patient to drink warm water.

Methods

The warm water preparation was performed in 29 patients with achalasia who underwent POEM. The patients drank 1 L of warm water (60oC) the night before POEM. We evaluated the esophageal clearness and determined the preparation quality. Twentynine patients were prospectively recruited and compared to control group. The control cohort comprised achalasia patients whose endoscopic image was available from the achalasia database of our institution. A 1:2 propensity score-matched control cohort was established from the database of achalasia subjects (n = 155) to compare the outcome of the preparation.

Results

In the warm water preparation group, only 1 patient (3.4%) had some solid retention, but it did not interfere with the POEM procedure. The grade of clearness (P = 0.016) and quality of preparation (P < 0.001) were significantly better in the warm water preparation group than in the matched control group. There was no any adverse event at all related to warm water preparation protocol.

Conclusions

Drinking warm water dramatically reduces esophageal food retention and significantly improves the quality of esophageal preparation. This simple protocol is quite useful, safe, and cost-effective in the preparation of achalasia patients for POEM.

A New Preparation Method for Peroral Endoscopic Myotomy in Patients with Achalasia Can Effectively Reduce the Esophageal Residual Contents: A Comparative Retrospective Study

Methods

This retrospective study enrolled 65 achalasia patients who underwent POEM from June 2017 to October 2021. Based on the preoperative diet strategies, patients were divided into carbonated beverage group (n = 48) and control group (n = 17). Demographic and clinical data, duration of preoperative endoscopy, quality of esophagus cleansing, and patient satisfaction on preoperative procedure were collected and compared. In the current study, we established the quality of esophagus cleansing: Grade A, no remnants or only liquid or frothy discharge; Grade B, a little amount of solid content remained; and Grade C, a large amount of solid content remained.

Results

There were 41 Grade A, 6 Grade B, and 1 Grade C patients in the carbonated beverage group, while there were 8 Grade A, 6 Grade B, and 3 Grade C patients in the control group (p value = 0.001). The esophagus cleansing degrees were significantly ameliorated after drinking carbonated beverages in all the three subtypes of achalasia according to the degree of dilatation. The mean duration of preoperative endoscopy was 6.54 ± 2.250 minutes in the carbonated beverage group and 10.27 ± 4.788 minutes in the control group (p value = 0.010). The score of patient satisfaction concerning the procedure before the POEM in the carbonated beverage group was 4.5 ± 0.652, while the score in the control group was 4.35 ± 0.702 (p value = 0.436). In the multivariate analysis, patient satisfaction was significantly associated with male (odds ratio 0.296, 95% CI: 0.097-0.905, p value = 0.033).

Conclusions

Drinking carbonated beverages reduce the duration of preoperative endoscopy and ameliorate the esophagus cleansing degrees without impairing patient satisfaction.

Anesthesia for Per-oral endoscopic myotomy (POEM) – not so poetic!

Peroral endoscopic myotomy (POEM) is a promising natural orifice transluminal endoscopic procedure for the treatment of esophageal motility disorders, with similar effectiveness as of Heller myotomy. It is performed under general anesthesia in endoscopy suite. Creation of submucosal tunnel in the esophageal wall is a key component. The continuous insufflation of CO₂ inadvertently tracks into surrounding tissues and leads to capno mediastinum, capno thorax, capno peritoneum, and subcutaneous emphysema. Thus, the challenges, for an anesthesiologist are not only providing remote location anesthesia, increased risk of aspiration during induction, but also early detection of these complications and specific emergency management. Though a therapeutic innovation, POEM remains an interdisciplinary challenge with no specific anesthesia care algorithms and evidence-based recommendations. The purpose of this review is to outline the anesthesia and periprocedural practices based on existing evidence.

Esophageal achalasia detected by vomiting during induction of general anesthesia: a case report

Background

Esophageal achalasia is a rare disease with a high risk of aspiration during anesthesia induction. Here, we describe our experience involving a case of undiagnosed esophageal achalasia with profuse vomiting during anesthesia induction.

Case presentation

A 58-year-old woman was scheduled for orthopedic surgery under general anesthesia. She vomited a large amount of watery contents during anesthesia induction, and planned surgery was postponed. After recovery from anesthesia, she informed us that she usually had to drink a large amount of water to get food into her stomach and purged watery vomit every night before sleep. However, she attributed it to her constitutional problem, not to a specific disease. She was subsequently diagnosed with esophageal achalasia and underwent Heller myotomy with Dor fundoplication before her re-scheduled orthopedic surgery.

Conclusions

A detailed history of dysphagia and regurgitation should be taken in preoperative examinations to prevent unexpected aspiration due to undiagnosed achalasia.

Challenges in Anesthesia Management for Peroral Endoscopic Myotomy: A Retrospective Analysis

BACKGROUND

Peroral endoscopic myotomy (POEM) is used to treat achalasia with efficacy and reliability. However, during the procedure potential complications require attention in terms of anesthesia. This study aimed to investigate complications of the POEM procedure and its effects on arterial blood gas (ABG) parameters, peak airway pressures (PIP), hemodynamics, and postoperative analgesia requirements.

METHODS

Data from 220 patients who underwent POEM between 2014 and 2017 were retrospectively assessed. During the procedure, ABG samples, PIP, mean arterial pressure, and heart rate were recorded. The effects of the procedure and paracentesis on ABG, PIP, mean arterial pressure, heart rate, perioperative complications, and postoperative analgesia requirements were assessed.

RESULTS

Data from 220 POEM patients were analyzed. During the procedure, the mean PaCO2 was 48.27±6.34 mm Hg, which was significantly higher than the PaCO2 values before and after the procedure. The mean increase in maximum PIP was 5.90±3.49 cmH2O during the procedure. However, there was a significant decrease in PaCO2 and PIP values in cases with paracentesis compared with those without paracentesis. With regards to complications, subcutaneous emphysema (48, 21.8%), pneumoperitoneum requiring decompression (66, 30%), pneumothorax (1, 0.5%), aspiration pneumonia (1, 0.5%), and bronchospasm (5, 2.2%) were observed during the procedure. In the postoperative period, 58 patients (26%) had additional analgesia requirements because of visual analog scale values >3.

CONCLUSION

Periprocedural abdominal decompression with veress needle led to a reduction in arterial PaCO2 and PIP, and improved postoperative analgesia. Serious complications because of perioperative aspiration and CO2 insufflation were observed during the POEM procedure.

Acquiring new complex endoscopic skills: Experience from the development of peroral endoscopic myotomy (POEM) in Malaysia

Peroral endoscopic myotomy (POEM) has rapidly gained popularity as an effective treatment modality for achalasia. However, POEM services in the South East Asian region are not widely available due to either a lack of expertise or interest. In this article, we describe how a POEM service can be developed through a combination of networking with regional experts, having prior experience of endoscopic submucosal dissection (ESD), attending animal model workshops, collaborating with upper gastrointestinal surgeons, and working together in a multidisciplinary team. A total of 68 POEM procedures have been performed since 2015, with a 94.1% technical and 93.4% clinical success rate, and a 21.5% minor complication rate. We believe that our model may be useful for other Endoscopy Units in the region, which are performing advanced therapeutic endoscopy, to develop a POEM service too.

[Anesthesia in gastrointestinal endoscopy: peroral endoscopic myotomy]

Idiopathic achalasia is a motility disorder of the esophagus characterized by a dysfunction of the lower esophageal sphincter, which typically manifests as dysphagia. Peroral endoscopic myotomy (POEM) is an interventional endoscopic procedure for achalasia, which was introduced in 2010. Although results from randomized studies comparing short-term and long-term safety and efficacy are yet to be published, POEM is regarded to be less invasive than the standard treatment of achalasia (laparoscopic Heller myotomy). POEM is the first endoscopic procedure routinely performed with the patient under general anesthesia. During the preoperative assessment particular attention must be paid to the specific fasting intervals and the risk of aspiration during induction of anesthesia. For the purpose of temporary surgical access, the integrity of the esophageal wall is deliberately interrupted to create a long submucosal tunnel. As a result, unwanted fistulas can arise between the esophageal lumen, the mediastinum, the pleura or the intraperitoneal cavity. Endoscopically insufflated CO₂ may escape into these surrounding compartments with subsequent systemic CO₂ accumulation, capnomediastinum, tension capnoperitoneum or pneumothorax. As a result substantial cardiorespiratory instability can arise. Thus, the attending anesthesiologist must be familiar with these typical complications and with specific emergency measures, such as compensatory hyperventilation, percutaneous needle decompression and thoracic drainage. The POEM procedure is a therapeutic innovation and interdisciplinary challenge. However, anesthesia standards of care have not yet been specified. The aim of this review is therefore to outline some clinical recommendations for the daily clinical practice based on existing evidence.

LMA Gastro™ airway is feasible during upper gastrointestinal interventional endoscopic procedures in high risk patients: a single-center observational study

Background

Nonoperating room anesthesia during gastroenterological procedures is a growing field in anesthetic practice. While the numbers of patients with severe comorbidities are rising constantly, gastrointestinal endoscopic interventions are moving closer to minimally invasive endoscopic surgery. The LMA Gastro™ is a new supraglottic airway device, developed specifically for upper gastrointestinal endoscopy and interventions. The aim of this study was to evaluate the feasibility of LMA Gastro™ in patients with ASA physical status ≥3 undergoing advanced endoscopic procedures.

Methods

We analyzed data from 214 patients retrospectively who received anesthesia for gastroenterological interventions. Inclusion criteria were upper gastrointestinal endoscopic interventions, airway management with LMA Gastro™ and ASA status ≥3. The primary outcome measure was successful use of LMA Gastro™ for airway management and endoscopic intervention.

Results

Thirtyone patients with ASA physical status ≥3, undergoing complex and prolonged upper gastrointestinal endoscopic procedures were included. There were 7 endoscopic retrograde cholangiopancreatographies, 7 peroral endoscopic myotomies, 5 percutaneous endoscopic gastrostomies and 12 other complex procedures (e.g. endoscopic submucosal dissection, esophageal stent placement etc.). Of these, 27 patients were managed successfully using the LMA Gastro™. Placement of the LMA Gastro™ was reported as easy. Positive pressure ventilation was performed without difficulty. The feasibility of the LMA Gastro™ for endoscopic intervention was rated excellent by the endoscopists. In four patients, placement or ventilation with LMA Gastro™ was not possible.

Conclusions

We demonstrated the feasibility of the LMA Gastro™ during general anesthesia for advanced endoscopic procedures in high-risk patients.

Trial registration

German Clinical Trials Register (DRKS00017396) Date of registration: 23rd May 2019, retrospectively registered.

Anesthetic Consideration for Peroral Endoscopic Myotomy

A recent achalasia guideline suggests that peroral endoscopic myotomy (POEM) is a safe option for achalasia that is as effective as Heller myotomy. It is recommended that POEM should be performed under general anesthesia. The incidence of adverse events such as bleeding, perforation, and carbon dioxide insufflation-related complications was lower in POEM under endotracheal general anesthesia than in POEM under sedation. Subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, and accompanying hemodynamic instability can be caused by carbon dioxide insufflation. Treatment of possible physiological changes and adverse events during the POEM procedure from the point of view of anesthesiologists may give endoscopists a new perspective on improving patient safety. The territory of therapeutic endoscopy can be expanded through cooperation with other departments, including anesthesia services. Efforts to understand different perspectives will certainly help not only secure patient safety but also expand the area of treatment.

Anesthesia for peroral endoscopic myotomy in Japan

PURPOSE OF REVIEW

Peroral endoscopic myotomy (POEM) was developed in Japan as a less invasive treatment for esophageal achalasia requiring general anesthesia under positive pressure ventilation. In 2018, the Japan Gastroenterological Endoscopy Society published the first guidelines describing the standard care for POEM. Based on these guidelines, we discuss the typical approach to anesthesia during POEM for the management of esophageal achalasia in Japan.

RECENT FINDINGS

Prior cleansing of the esophagus is essential to prevent both aspiration during induction of anesthesia and contamination of the mediastinum and thoracic/abdominal cavity by esophageal remnants after endoscopic resection of the esophageal mucosa. Although rare, adverse events related to intraoperative carbon dioxide insufflation occur. These are treated through percutaneous needle decompression and insertion of a chest drainage tube for pneumoperitoneum and pneumothorax, respectively. Caution should be exercised regarding the development of subcutaneous emphysema and its involvement in airway obstruction.

SUMMARY

Prevention of aspiration pneumonia and adverse events related to the insufflation of carbon dioxide is essential in the management of esophageal achalasia through POEM. Close cooperation between gastrointestinal endoscopic surgeons and anesthesiologists is indispensable in POEM.

Anesthetic management and associated complications of peroral endoscopic myotomy: A case series

AIM

To investigate the anesthetic management of peroral endoscopic myotomy (POEM) and its associated complications.

METHODS

This study was a single-center, retrospective, observational study comprising a case series of all patients who underwent POEM in our hospital from April 2015 to November 2016. We collected data regarding patient characteristics, anesthetic methods, surgical factors, and complications using an electronic chart.

RESULTS

There were 86 patients who underwent POEM in our hospital during the study period. Preoperatively, patients were maintained on a low residue diet for 48 h prior to the procedure. They were fasted of solids for 24 h before surgery. There was one case of aspiration (1.2%). During POEM, patients were positioned supine with the upper abdomen covered by a clear drape so that pneumoperitoneum could be timeously identified. In three cases, the peak airway pressure exceeded 35 cmH2O during volume controlled ventilation with tidal volumes of 6-8 mL/kg and subsequent impairment of ventilation. These cases had been diagnosed with spastic esophageal disorders (SEDs) and the length of the muscular incision on the esophageal side was longer than normal.

CONCLUSION

In the anesthetic management of POEM, it is important to prevent aspiration during induction of anesthesia and to identify and treat complications associated with CO2 insufflation.

Clinical practice guidelines for peroral endoscopic myotomy

Peroral endoscopic myotomy (POEM) is a novel clinical technique developed in Japan used to treat esophageal achalasia and esophageal motility disorders. This technique has been rapidly accepted and widely disseminated throughout our clinical practice because of its low invasiveness, technical novelty, and high efficacy. Since the advent of POEM, there have been no clinical guidelines that clearly indicated its standard of care, and these guidelines have been anticipated both nationally and internationally by clinicians who engage in POEM practice. In 2017, to meet these needs, the Japan Gastroenterological Endoscopy Society (JGES) launched the guideline committee for POEM. Based on the guideline development process proposed by the Medical Information Network Distribution Service (MINDS), the guideline committee initially created research questions on POEM and conducted a systematic review and meta-analysis on each topic. The clinical research extracted from databases for these clinical questions and the systematic review mainly comprised a few retrospective studies with a small number of participants and short trial periods; hence, the strength of the evidence and recommendations derived from these results was low. Throughout this process, the guideline committee met thrice: once on May 13, 2017, and again on September 17, 2017, to formulate the draft. A consensus meeting was then held on January 14, 2018, in Tokyo to establish the guideline statements and finalize the recommendations using the modified Delphi method. This manuscript presents clinical guidelines regarding current standards of practice and recommendations in terms of the nine chief topics in POEM.

Bladder pressure monitoring and CO2 gas-related adverse events during per-oral endoscopic myotomy

Per-oral endoscopic myotomy (POEM) is a minimally invasive treatment for esophageal achalasia. However, POEM has the potential risk of inducing carbon dioxide (CO₂) gas-related adverse events, such as pneumoperitoneum, pneumomediastinum, and pneumothorax. The aim of this study was to evaluate the usability of bladder pressure monitoring as an index of CO₂ gas-related pneumoperitoneum. The monitoring of bladder pressure and lung compliance and the incidence of iatrogenic pneumoperitoneum were retrospectively studied in 20 patients who underwent POEM between June 2013 and March 2015. The bladder pressure was measured using a Foley catheter. Abdominal distention was found in nine patients. The bladder pressure was significantly higher in the nine patients with the distention findings compared with patients without distention [7 (6-9) mmHg vs. 1 (0-2) mmHg; P < 0.05]; however, the decrease in dynamic lung compliance was not significantly different compared with patients without distention [- 7 (- 9.3 to - 5.1) vs. - 5 (- 10.2 to - 1.3) ml/cmH₂O; P = 0.62]. Based on postoperative changes on CT scans; the following were the observations: pneumomediastinum (55%), minor pneumothorax (5%), pleural effusion (45%), atelectasis (15%), pneumoperitoneum (85%), and subcutaneous emphysema (15%). No significant clinical status was found among the patients postoperatively. Bladder pressure monitoring might be useful for detecting pneumoperitoneum during POEM.

The safety of endoscopic esophageal procedures under general anesthesia

BACKGROUND

With the increasing demand for general anesthesia for endoscopic esophageal procedures, anesthesiologists should understand the clinical characteristics of post-procedural complications (PPCs).

METHODS

We retrospectively investigated the incidence of and risk factors associated with PPCs of endoscopic esophageal procedures performed under general anesthesia from July 2013 to November 2016. The final analysis included 129 patients; 114 who underwent esophageal endoscopic dissection for esophageal tumors and 15 cases of peroral endoscopic myotomy for achalasia. Frank perforation during the procedure was defined as an endoscopically recognizable or clinically detected perforation during the procedures. A multivariable logistic regression analysis was conducted to identify independent risk factors for PPCs.

RESULTS

The overall incidence of PPCs was 19.4% (25/129). All of the PPCs were managed successfully with conservative measures. The most common PPC was symptomatic, radiologically documented atelectasis (11/25, 44.0%), followed by esophageal perforation-related PPCs (symptomatic pneumomediastinum or pneumoperitoneum; 9/25, 36.0%). In the multivariable analysis, frank perforation during the procedure was the only independent risk factor for PPCs (odds ratio, 8.470, 95% CI, 2.051-34.974, P = 0.003). Although frank perforation during the procedure occurred in 13 patients, 38.5% (5/13) of them did not develop any clinical sequelae after their procedures. Compared with patients without PPCs, patients who developed PPCs took longer to their first oral intake and had prolonged hospital stays (P = 0.047 and 0.026, respectively).

CONCLUSIONS

Iatrogenic perforation during endoscopic esophageal procedures under general anesthesia was the only independent risk factor for PPCs; therefore, proactive measures and close follow-up are necessary.

Anesthesia in per-oral endoscopic myotomy: A large tertiary care centre experience

BACKGROUND AND OBJECTIVES

Per-oral endoscopic myotomy (POEM) is safe and efficacious for the management of achalasia cardia (AC). POEM is usually performed under general anesthesia in an endoscopy suite or operating theatre. The current study was conducted with the aim to analyse anesthetic management of patients with AC who underwent POEM at our institution.

METHODS

We retrospectively analysed the data of patients with AC who underwent POEM at our institution from January 2013 to September 2016. All cases were performed in an endoscopy suite under supervision of an anesthesia management team. Pre-procedure endoscopic evacuation of esophagogastric contents was done in all cases. Management strategies used for gas-related adverse events and outcomes were assessed.

RESULTS

Four hundred and eighty patients (median age 40 years, range 4-77 years) underwent POEM during the study period. The sub-types of AC were type I (163), type II (297), and type III (20). POEM was successfully completed in 97.5% patients. Gas-related events were noted in 30.6% cases including-capno-thorax in 1%, capno-peritoneum in 12.3%, retroperitoneal air in 16.5%, capno-mediastinum in 0.2%, and capno-pericardium in 0.4% patients. Significant rise in end tidal CO2 (> 45) and peak airway pressure were observed in 8.1% and 5.4% cases, respectively. Drainage was required in 12.3% patients. There was no occurrence of aspiration during or after POEM.

CONCLUSIONS

POEM could be safely performed in an endoscopy suite under supervision of an expert anesthesia management team. Gas-related adverse events were common during POEM and could be managed with a standardized approach.

Capnoperitoneum During Peroral Endoscopic Myotomy-Recognition and Management: A Case Report

Peroral endoscopic myotomy (POEM) is a minimally invasive procedure for treating esophageal achalasia. During POEM, carbon dioxide is insufflated under pressure into the esophagus and stomach, which can cause clinically significant capnoperitoneum, capnomediastinum, or capnothorax. We present a case in which gas accumulation in the abdomen during POEM had adverse effects on ventilation. Once the cause was recognized, needle decompression of the abdomen led to immediate improvement in ventilation.

Peroral endoscopic myotomy: procedural complications and pain management for the perioperative clinician

Achalasia refers to the lack of smooth muscle relaxation of the distal esophagus. Although nonsurgical treatments such as pneumatic dilatation of the distal esophagus and botulinum toxin injections have been performed, these procedures have limited duration. Similarly, surgical treatment with Heller myotomy is associated with complications. At our institution, we perform the peroral endoscopic myotomy (POEM) in qualified patients. Briefly, POEM involves endoscopic creation of a mid-esophageal submucosal bleb, creation of a submucosal tunnel with the endoscope, and then a distal myotomy, resulting in relaxation of the distal esophagus. The aim of our study is to document perioperative pain and associated pain management for our initial patients undergoing POEM and to review the literature for perioperative complications of this procedure. Therefore, anesthetic and pain management for our initial eleven patients undergoing POEM were reviewed. Patient demographics, pre-POEM pain medication history, perioperative pain medication requirements, and post-POEM pain scores were examined. We found post-POEM pain was usually in the mild–moderate range; a combination of medications was effective (opioids, nonsteroidal anti-inflammatory drugs, acetaminophen). Our literature search revealed a wide frequency range of complications such as pneumoperitoneum and subcutaneous emphysema, with rare serious events such as capnopericardium leading to cardiac arrest. In conclusion, our experience with POEM suggests pain and can be managed adequately with a combination of medications; the procedure appears to be safe and reasonable to perform in an outpatient endoscopy unit.

Anesthetic considerations for patients with esophageal achalasia undergoing peroral endoscopic myotomy: a retrospective case series review

PURPOSE

Peroral endoscopic myotomy (POEM) is a novel technique for treating esophageal achalasia. During POEM, carbon dioxide (CO₂) is insufflated to aid surgical dissection, but it may inadvertently track into surrounding tissues, causing systemic CO₂ uptake and tension capnoperitoneum. This in turn may affect cardiorespiratory function. This study quantified these cardiorespiratory effects and treatment by hyperventilation and percutaneous abdominal needle decompression (PND).

METHODS

One hundred and seventy-three consecutive patients who underwent POEM were included in this four-year retrospective study. Procedure-related changes in peak inspiratory pressure (p_max), end-tidal CO₂ levels (etCO₂), minute ventilation (MV), mean arterial pressure (MAP), and heart rate (HR) were analyzed. We also quantified the impact of PND on these cardiorespiratory parameters.

RESULTS

During the endoscopic procedure, cardiorespiratory parameters increased from baseline: p_max 15.1 (4.5) vs 19.8 (4.7) cm H₂O; etCO₂ 4.5 (0.4) vs 5.5 (0.9) kPa [34.0 (2.9) vs 41.6 (6.9) mmHg]; MAP 73.9 (9.7) vs 99.3 (15.2) mmHg; HR 67.6 (12.4) vs 85.3 (16.4) min^-1 (P < 0.001 for each). Hyperventilation [MV 5.9 (1.2) vs 9.0 (1.8) L·min^-1, P < 0.001] was applied to counteract iatrogenic hypercapnia. Individuals with tension capnoperitoneum treated with PND (n = 55) had higher peak p_max values [22.8 (5.7) vs 18.4 (3.3) cm H₂O, P < 0.001] than patients who did not require PND. After PND, p_max [22.8 (5.7) vs 19.9 (4.3) cm H₂O, P = 0.045] and MAP [98.2 (16.3) vs 88.6 (11.8) mmHg, P = 0.013] decreased. Adverse events included pneumothorax (n = 1), transient myocardial ischemia (n = 1), and subcutaneous emphysema (n = 49). The latter precluded immediate extubation in eight cases. Postanesthesia care unit (PACU) stay was longer in individuals with subcutaneous emphysema than in those without [74.9 min (34.5) vs 61.5 (26.8 min), P = 0.007].

CONCLUSION

Carbon dioxide insufflation during POEM produces systemic CO₂ uptake and increased intra-abdominal pressure. Changes in cardiorespiratory parameters include increased p_max, etCO₂, MAP, and HR. Hyperventilation and PND help mitigate some of these changes. Subcutaneous emphysema is common and may delay extubation and prolong PACU stay.

[Tension pneumothorax during peroral endoscopic myotomy for treatment of esophageal achalasia under general anesthesia]

More and more endoscopically gastrointestinal procedures require anesthesiologists to perform general anesthesia, such as "peroral endoscopic myotomy". Peroral endoscopic myotomy is a novel invasive treatment for the primary motility disorder of esophagus, called esophageal achalasia. Despite of its minimally invasive feature, there are still complications during the procedure which develop to critical conditions and threat patients' lives. Herein we describe a case about tension pneumothorax subsequent to esophageal rupture during peroral endoscopic myotomy. The emergent management of the complication is stated in detail. The pivotal points of general anesthesia for patients undergoing peroral endoscopic myotomy are emphasized and discussed. Also, intraoperative and post-operative complications mentioned by literature are integrated.

Anesthesia for peroral endoscopic myotomy: A retrospective case series

BACKGROUND AND AIMS

Peroral endoscopic myotomy (POEM) is a safe and minimally invasive modality regarded as the first-line management of all types of achalasia. POEM is performed under general anesthesia with endotracheal intubation using an orally inserted flexible fiberscope. The aim of this study is to describe the anesthetic management of POEM for achalasia.

MATERIAL AND METHODS

A chart review of 21 patients who underwent POEM for achalasia at our center from March 2013 to June 2015 was performed.

RESULTS

In the 21 patients, the end-tidal carbon dioxide was elevated following esophageal carbon dioxide insufflation and required adjustments in ventilation. POEM was successfully completed, and the patients were extubated immediately afterward. Subcutaneous emphysema occurred in five patients. Complications such as mediastinitis, pleural effusion, pneumoperitoneum, and pneumomediastinum were managed conservatively. Esophageal perforation occurred in one patient and needed surgical intervention.

CONCLUSION

For patients with achalasia, POEM offers the efficacy of surgery with the lower cost and morbidity of an endoscopic procedure. Prevention of aspiration and carbon dioxide insufflation-related complications are the two aspects that demand vigilance from the anesthesiologist.

Peroral endoscopic myotomy-initial experience with anesthetic management of 24 procedures and systematic review

Background:

Peroral endoscopic myotomy (POEM) is a novel method of treating achalasia of the esophagus. Very little data are available to guide the anesthesia providers caring for these patients. The anesthetic challenges are primarily related to the risk of pulmonary aspiration. There is also a potential risk of pneumomediastinum, pneumoperitoneum, subcutaneous, or submucosal emphysema, as a result of carbon dioxide tracking into the soft tissues surrounding the esophagus and lower esophageal sphincter.

Methods:

In this retrospective study, electronic charts of 24 patients who underwent POEM over 18 months were reviewed. Demographic data, fasting status, relevant aspiration risks, anesthetic technique, and postoperative care measures were extracted.

Results:

Fasting times for both solids and liquids were variable. None of the patients underwent preprocedural esophageal emptying. Standard induction and intubation were performed in 16, rapid sequence induction (RSI) with cricoid pressure in seven, and modified rapid sequence without application of cricoid pressure in one of the patients. One of the patients aspirated at induction, and the procedure was aborted. However, the procedure was performed successfully after a few weeks, this time a RSI with cricoid pressure was chosen.

Conclusion:

As there are no guidelines for the perioperative management of patients presenting for POEM presently, certain recommendations can be made. Preprocedural esophageal emptying should be considered in patients considered as high-risk, although cultural factors might preclude such an approach. Induction and intubation in a semi-reclining position might be useful. Although debatable, use of RSI with cricoid pressure should be strongly considered.

Evaluation of anesthesia management, feasibility and efficacy of peroral endoscopic myotomy (POEM) for achalasia performed in the endoscopy unit

INTRODUCTION

Data on anesthesia management and outcomes associated with peroral endoscopic myotomy (POEM) performed exclusively in the endoscopy unit are limited. In this prospective study, we evaluated the safety of anesthesia management, and the feasibility and efficacy of POEM performed exclusively in the endoscopy unit.

METHODS

A single-center prospective study of consecutive patients with achalasia treated with POEM in an endoscopy unit was performed. Safety of anesthesia management and POEM were determined by procedure-related adverse events. Feasibility was assessed by completion rate. Short-term efficacy was established by clinical success (Eckardt score ≤ 3) and by comparing Eckardt and dysphagia scores before and after POEM.

RESULTS

Patients (n = 52) underwent POEM under general anesthesia with endotracheal intubation and positive pressure ventilation. Aspiration was prevented by keeping patients on a clear liquid diet before the procedure without requiring a prior esophagogastroduodenoscopy for esophageal content clearance. POEM completion rate was 96 % (50/52 patients). There was no post-POEM bleeding. Postprocedure leak was observed in one patient (3 %). Four patients (7.7 %) experienced mucosal injury, three of them were treated uneventfully endoscopically and one required laparoscopic repair. Clinical success was achieved in 88 % of patients. There was a significant decrease in the mean Eckardt score (8.1 to 1.4) and dysphagia score (2.4 to 0.4) (P < 0.0001) at the one month follow up after POEM.

CONCLUSION

Anesthesia management of POEM is safe in the endoscopy unit and aspiration can be prevented without requiring prior esophagogastroduodenoscopy for esophageal content clearance. Overall, POEM performed by a gastroenterologist in the endoscopy unit was feasible and effective for the treatment of achalasia.

Per-oral endoscopic myotomy: emerging indications and evolving techniques

Esophageal achalasia is a benign esophageal motility disorder resulting from an impaired relaxation of the lower esophageal sphincter. The principles of treatment involve disruption of the sphincter at the esophagogastric junction. Treatment techniques include balloon dilatation, botulinum toxin injection, and surgical myotomy. In 2008, per-oral endoscopic myotomy (POEM) was introduced by Inoue et al. as an endoscopic myotomy with no skin incision. The procedure has been well accepted and widely applied owing to its minimal invasiveness and high cure rates. Moreover, there have been discussions on wider indications for POEM and new technical developments have been reported. The present article reviews the historical background and present status of POEM, as well as future prospects for its application in the treatment of esophageal achalasia.