The last innovation in achalasia treatment; per-oral endoscopic myotomy

Abstract

Background/Aims: Per-oral endoscopic myotomy (POEM) is a minimally invasive endoscopic treatment option for patients with achalasia and has been performed since 2010. It is less invasive than Heller myotomy and its use is spreading rapidly worldwide. We present our results of POEM that, to the best of our knowledge, are the first cases in Turkey. Materials and Methods: We enrolled patients between May 2014 and September 2014; 8 patients with achalasia whose complaints recurred after pneumatic balloon dilatation underwent POEM. The procedure was performed under general anesthesia at the endoscopy unit of the gastroenterology clinic. Demographic data was recorded before the procedure, and the results of the procedure were recorded prospectively. Results: The median age of the patients was 42.5 (30-72) years. Preoperative and postoperative median Eckardt scores were 10 (8-12) and 1 (0-2), respectively. The median total duration of the procedure was 101 (71-158) min, and the median myotomy length was 13.5 (10-16) cm. Postoperative oral intake started on median day 1 (1-2) and the length of hospital stay was 4 (3-6) days. In 2 patients, capnoperitoneum developed during the procedure and was treated with a Veress needle. Conclusion: POEM is a safe endoscopic treatment modality for patients with achalasia in centers that are experienced in advanced endoscopic techniques.

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

“…9,12 However, other studies point out that such an application itself immediately before the procedure can lead to aspiration, causing a loss of time and a cost increase. [13][14][15][16] More recent clinical practice guidelines recommend esophageal cleaning before POEM. 17 However, in spite of patients having a 3-day liquid diet and esophageal cleaning 1 day before the procedure in our hospital, 11 of the 220 patients in this study had fluid regurgitation during intubation.…”

“…During submucosal tunneling and myotomy in the esophagus, rapid mediastinal and peritoneal absorption of carbon dioxide may cause pneumomediastinum, cervical/thoracic subcutaneous emphysema, and pneumoperitoneum. 9,15,16 Lack of sufficient barrier formation in the esophagus muscle fibers and adventitia contributes to rapid absorption of CO 2 . In fact, Yang and colleagues identified high rates of pneumomediastinum (37.0%), pneumoperitoneum (43.5%), and subcutaneous emphysema (29.6%) on postoperative computed tomography scans of 108 POEM patients.…”

“…To reduce the risk of aspiration in cases undergoing POEM, several studies suggest the esophageal content should be emptied endoscopically before the procedure 9,12. However, other studies point out that such an application itself immediately before the procedure can lead to aspiration, causing a loss of time and a cost increase 13–16. More recent clinical practice guidelines recommend esophageal cleaning before POEM 17.…”

“…Anesthesiologists need to pay most attention to POEM cases during the submucosal tunnel creation and myotomy stage, which are accompanied by carbon dioxide insufflation. During submucosal tunneling and myotomy in the esophagus, rapid mediastinal and peritoneal absorption of carbon dioxide may cause pneumomediastinum, cervical/thoracic subcutaneous emphysema, and pneumoperitoneum 9,15,16. Lack of sufficient barrier formation in the esophagus muscle fibers and adventitia contributes to rapid absorption of CO 2 .…”

Pneumatic Dilation in Geriatric Achalasia Patients

“…These treatments aim to ease the passage of food from the esophagus to the stomach and to relieve any symptoms by reducing the lower esophageal sphincter pressure (LESP). 2 - 4 People are more likely to have multiple comorbidities together with increased average life expectancy. It has been reported that approximately 65% of patients in the geriatric age group have 3 or more comorbid diseases.…”