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

Factors predicting insufflation-related events in peroral endoscopic myotomy procedures

BACKGROUND

Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic landscape for esophageal achalasia, offering efficacy comparable to that of surgery with the convenience of an endoscopic approach. With the growing popularity of POEM, insufflation-related adverse events (AEs) present unique challenges that have been widely discussed in the literature. This study aimed to investigate the safety profiles and risk factors associated with insufflation-related events in patients undergoing POEM in endoscopy suites.

METHODS

This retrospective analysis included 100 consecutive patients with achalasia treated by POEM at our institute between March 2016 and October 2022. All procedures were performed in an endoscopy suite and employed carbon dioxide insufflation and general anesthesia with endotracheal intubation and positive-pressure ventilation. Variations in cardiopulmonary dynamics, intraprocedural AEs, and postoperative recovery were documented.

RESULTS

All procedures were successfully performed, with an average POEM duration of 92.3 min and an average anesthesia duration of 108.4 min. Of note, 1 major AE involving an esophageal leak and requiring endoscopic stenting was observed, along with a 27% incidence of minor AEs. Insufflation-related events, manifesting as capnoperitoneum, subcutaneous emphysema, or capnomediastinum, were identified in 48% of cases, but none required additional interventions or extended hospitalization. A peak inspiratory pressure increase of ≥20% was identified as the only predictor of insufflation-related events.

CONCLUSION

Performing POEM in an endoscopy suite can generally be considered safe from major AEs related to insufflation. Monitoring peak inspiratory pressure for a ≥20% increase may be an early indicator of other potential insufflation-related events.

The Ventilatory Changes of Pediatric Peroral Endoscopic Myotomy Patients

Objective

Peroral endoscopic myotomy (POEM) has proven to be a successful treatment method for achalasia in both adult and pediatric patients. Yet, there is a lack of evidence for anaesthetic management of pediatric patients who underwent POEM procedure. In this study, we aim to present perioperative and postoperative management strategies for pediatric patients with achalasia from in anaesthesia aspect.

Methods

Medical records were reviewed for 16 pediatric patients at a single center who underwent POEM procedure for achalasia between 2017 and 2020. Patients' data regarding demographics, preoperative diet, body mass index, perioperative monitoring and vitals, airway management, anaesthesia maintenance, mechanical ventilation settings duration of recovery, length of stay, pain management and adverse events were evaluated.

Results

The study cohort included 7 female and 9 male patients with a mean age of 5.5 years. Anaesthesia maintenance was provided with 0.8-1.2 minimum alveolar concentration sevoflurane in a 40-60% O2-air mixture, Remifentanil infusion and bolus doses of Rocuronium. The median age was 3 years for patients ventilated in pressure controlled ventilation mode and 10 years in volume controlled ventilation mode. Respiration rate and minute ventilation were adjusted to maintain end tidal carbon dioxide (ETCO2) below 45 mmHg. Needle decompression was applied for 14 patients (87.5%) for treatment of capnoperitoneum. The mean procedure duration and recovery room duration were 66 (±22.9) minutes and 62 (±21) minutes, respectively. Postoperative pain management is provided with paracetamol and tramadol in total 8 patients (50%). There was no adverse event during postoperative period and all patients discharged in a mean time of 3 days.

Conclusion

POEM has demonstrated encouraging outcomes in terms of safety and effectiveness in pediatric patients. Due to challenging nature of the pediatric patients, it is important to acknowledge that the procedure requires specialized anaesthesia management. Management of perioperative complications of increased ETCO2 requires understanding the physiologic results of pneumo-mediastinum and pneumo-peritoneum. Beside the known anaesthetic management strategies, a tailored approach should be adopted for each patient. Further investigations should be conducted to develop standardized management.

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.

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 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.

Peroral Esophageal Myotomy

Achalasia is a neurodegenerative disorder of the lower esophagus characterized by high lower esophageal pressures and aperistalsis of the esophageal body. It remains a difficult to treat disease with significant burden on patients due to difficulty swallowing leading to malnutrition. Peroral endoscopic myotomy (POEM) is a newer endoscopic treatment of achalasia. It involves dividing the muscular layer of the esophagus through a submucosal tunnel. Ten-year data show POEM is a safe and effective treatment of achalasia. However, postoperative gastroesophageal reflux disease remains an important consideration.