Anesthetic Consideration for Peroral Endoscopic Myotomy

Abstract

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 Advanced Endoscopic Procedures

“…An increase in blood pressure is the likely result of an increase in partial CO 2 > 50 mm Hg. 13 Decompression by inserting a 14-or 16-gauge angiocatheter in the right lower abdomen, approximately 5 cm below the costal margin, preferably guided by ultrasound, may become necessary. The presence of air in the mediastinum may not pose considerable clinical challenges and is typically observed along with subcutaneous emphysema.…”

“…Lung compliance will decrease (with increased airway pressure) along with sinus tachycardia and other cardiac arrhythmias. An increase in blood pressure is the likely result of an increase in partial CO 2 >50 mm Hg [ 13 ]. Decompression by inserting a 14- or 16-gauge angiocatheter in the right lower abdomen, approximately 5 cm below the costal margin, preferably guided by ultrasound, may become necessary.…”

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

“…Solid food residue in the esophagus and food debris around the vocal cords may predispose achalasia patients to aspiration pneumonia following GA for a POEM procedure. Preventive measures include modified rapid sequence induction anesthesia with rocuronium, 19 a prolonged fasting period, and a diagnostic endoscopy to clear up the esophagus prior to GA. Pneumoperitoneum, subcutaneous emphysema, pneumothorax, and/or pneumomediastinum are recognized sequelae of CO 2 ‐related complications 7,20 . Vigilant observation of the peak airway pressure and concurrent discussion with the endoscopist during POEM are important measures to detect and manage these complications.…”

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

“…Multiple case series on POEM anesthesia management have reported fasting times from 8 to 48 hours. [ 16 ] Majority of them have recommended a clear liquid diet for at least 24 hours or a low residue diet for 48 hours prior to the procedure. [ 17 18 ] At our center, we keep patients on clear liquid diet for 24 hours and keep fasting for 12 hours.…”