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

Abstract

AIMTo investigate the anesthetic management of peroral endoscopic myotomy (POEM) and its associated complications.METHODSThis 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.RESULTSThere 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.CONCLUSIONIn 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.

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

“…[ 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. Prophylactic use of esophagogastroduodenoscopy for removal of the residual food is debatable.…”

“…[ 11 19 ] Nishihara et al . [ 18 ] has used gastric tube aspiration before induction in conscious patients for reduction of esophageal pressure. Prophylactic use of proton pump inhibitors, antibiotic prophylaxis and decontamination of oral cavity with chlorhexidine may be beneficial for preventing the postprocedural inflammatory response.…”

Erector spinae plane block for peroral endoscopic myotomy analgesia in pediatric patients

“…Achalasia is a rare motility disorder of the esophagus in children. Among different treatment modalities, peroral endoscopic myotomy (POEM) is becoming more and more popular as a minimally invasive technique with high efficacy and safety in pediatric patients 1 2. However, according to the literature and our observations, POEM may lead to severe postsurgical pain, especially in the first 24 hours 3…”

Problems in beginning a “POEM”

“…While most endoscopic procedures are safely performed without endotracheal intubation, POEM requires general anaesthesia with positive pressure ventilation to have a still patient to perform this technically difficult procedure, prevent CO 2 leaking into various tissue planes, achieve positive intra-thoracic pressures, minimise mediastinal emphysema and prevent aspiration. [1234]…”

“…The muscle fibres and the adventitia are a non-resistant barrier and CO 2 can quickly diffuse into the mediastinum and abdomen. [14] This is normally reabsorbed spontaneously. The normal CO 2 flows of 1-2 l/min used during routine endoscopy maybe excessive, creating higher pressures within the sub-mucosal tunnel.…”