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

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.

Anesthesia for Advanced Endoscopic Procedures

The gastrointestinal endoscopy paradigm is rapidly changing, and technological advancements are largely responsible. In tandem, anesthesia providers are adapting to the changing needs and demands. The challenges are unique. Complications arising from the procedures are both routine, such as aspiration and hypoxia, and procedure specific, such as bleeding, pneumothorax, pneumopericardium, and pneumoperitoneum. It is crucial for the anesthesia provider to have a good understanding of the techniques employed by the endoscopist. A higher index of suspicion is also essential to diagnose and appropriately manage many of the complications. In this review, an effort is made to discuss both procedural aspects and anesthesia challenges. We hope that both endoscopists and anesthesia providers will benefit from this review.

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.

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.

Reversibility of Endoscopic Features after Treatment for Eosinophilic Esophagitis

PURPOSE

The prevalence and incidence of eosinophilic esophagitis (EoE) are increasing worldwide. Despite increased understanding of inflammatory pathogenesis, changes in endoscopic features after treatment of EoE have not been clearly described. We aimed to investigate the reversibility of endoscopic features of EoE after treatment.

MATERIALS AND METHODS

Out of 58 adult subjects who were diagnosed with EoE at the Yonsei University Health System from July 2006 to August 2019, we recruited 33 subjects (30 males; mean age: 42 years) whose pre-treatment and post-treatment endoscopic images were available. Endoscopic features included both inflammatory and fibrostenotic features. Exudate, edema, furrow, and crepe paper-like mucosa were classified as inflammatory features. Ring and stricture were classified as fibrostenotic features. We compared changes in endoscopic features after treatment for EoE.

RESULTS

After treatment, clinical symptoms improved in all patients. The following endoscopic features were observed before treatment: furrow (81.8%), edema (90.9%), exudate (42.4%), ring (27.3%), crepe paper-like mucosa (15.2%), and stricture (3.0%). Endoscopic remission was achieved in 21 patients (63.6%). Inflammatory features were reversible (72.7%, p<0.001), whereas fibrostenotic features were not (10%, p=0.160). Exudate had resolved in 92.9% of patients, edema in 70% and furrow in 88.9%. Ring and stricture persisted in almost all of the patients (9/10) who had these endoscopic features before treatment.

CONCLUSION

We outlined the reversibility of endoscopic inflammatory features of EoE. Fibrostenotic features were irreversible after esophageal remodeling in patients with EoE. However, further validation studies with long-term follow-up are needed.

Critical Analysis of Guidelines for Providing Sedation to Patients Undergoing Gastrointestinal Endoscopy Procedures

In spite of growing numbers of gastrointestinal endoscopic procedures performed under deep sedation, guidelines are lacking. Hypoxemia and aspiration continue to be the main source of morbidity. Anesthesia providers have tried to address these concerns by modifying their technique and employing newer or improvised devices. In addition, preprocedural evaluation poses many challenges. In many centers, workload pressures determine the time available to perform such an evaluation. A comprehensive history and examination similar to a major surgical procedure is often not possible. As a result, a focused history and examination is essential. This should be followed by an appropriate explanation of risks before obtaining consent. A plan should be in place to manage complications such as aspiration. This paper provides a succinct review of the above aspects.

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.

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.

Adverse events during and after per-oral endoscopic myotomy: prevention, diagnosis, and management

Per-oral endoscopic myotomy (POEM) has surfaced as an effective endoscopic treatment modality for achalasia cardia (AC). Promising results in short- and mid-term follow-up studies have increased the use of POEM for the management of AC. POEM can be safely performed in an endoscopy suit, and major adverse events (AEs) are uncommon. AEs encountered during POEM or during the perioperative period principally include insufflation-related AEs, mucosal injuries, bleeding, pain, and aspiration pneumonia. Most insufflation-related AEs do not require an active intervention and therefore should not be considered as AEs in the true sense. When management of AEs is required, most intraoperative AEs can be managed at the same time without untoward consequences. Occurrences of AEs lessen after completion of the learning curve. However, experience alone does not ensure "zero" incidence of AEs, and early recognition remains essential. Postoperative AEs, like leaks, delayed bleeding, and delayed mucosal perforations, may pose special challenges for diagnosis and management. There is no standardized classification system for grading the severity of AEs associated with POEM, resulting in wide variation in their reported occurrences. Uniform reporting of AEs is not only crucial to comprehensively analyze the safety of POEM but also for comparison with other established treatment modalities like Heller's myotomy. GERD is an important long-term AE after POEM. Unlike the perioperative AEs, little is known regarding the intraoperative or patient-related factors that influence the occurrence of post-POEM GERD. Large prospective studies with long-term follow-up are required to determine the procedural factors associated with GERD after POEM.

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.