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

Table 1 Patient characteristics

Characteristics	Values
Age median (range); yr	51 (42-66)
Sex male (%)	35 (41)
BMI median (range); kg/cm2	20.6 (18.6-22.8)
Preoperative symptoms; n (%)
Weight loss	44 (51)
Chest pain	51 (59)
Dysphagia	84 (98)
Regurgitation	78 (91)
Previous interventions; n (%) (overlapping)
None	44 (51)
Pharmacological therapy	21 (24)
Endoscopic pneumatic balloon dilation	20 (23)
Surgical myotomy	4 (5)
Diagnosis; n (%)
Esophageal achalasia	80 (93)
Jackhammer esophagus	5 (6)
Diffuse esophageal spasm	1 (1)
Preoperative Eckardt score median (range); point	6 (4-7)

Table 2 Anesthetic and surgical factors

Parameters	Values
Cricoid pressure; n (%)	26 (46)
Maintenance with inhalational agents; n (%)	78 (91)
Duration of anesthesia mean ± SD; min	117 ± 31
Duration of surgery mean ± SD; min	83 ± 31
Length of muscular incision
Esophageal side average ± SD; cm	10.4 ± 3.9
Gastric side average ± SD; cm	2.7 ± 0.7
Total average ± SD; cm	13.1 ± 3.9
Perioperative adverse events; n (%)
Aspiration	1 (1)
Subcutaneous emphysema	21 (24)
EtCO2 > 50 mmHg during procedure	34 (40)
Upper abdominal needle decompression required	12 (14)
Airway pressure > 35 cmH2O during operation	3 (3)
Mucosal injury not requiring invasive treatment	9 (10)
Mediastinitis with antibiotic therapy	1 (1)
Hospital stay mean ± SD; d	5.45 ± 2.18
Eckhart score 2 mo later; median (range); point	0 (0–1)

Table 3 Characteristics of three cases

Characteristics	Case 1	Case 2	Case 3
Age; yr	74	61	73
Sex	Female	Male	Female
BMI; kg/cm2	25.9	23.4	21.5
Preoperative symptoms
Weight loss	Yes	None	None
Chest pain	Yes	None	Yes
Dysphagia	Yes	Yes	Yes
Regurgitation	Yes	Yes	Yes
Previous intervention	Pharmacological therapy	None	None
Lower esophageal sphincter pressure; mmHg	31	64	51
Diagnosis	Diffuse esophageal spasm	Jackhammer esophagus	Jackhammer esophagus
Duration of anesthesia; minutes	163	141	229
Maintenance of anesthesia	inhalation	inhalation	inhalation
Length of muscular incision
Esophageal side; cm	18	15	19
Gastric side; cm	3	3	4
Maximum EtCO2; mmHg	67	63	177
Maximum peak airway pressure under 6-8 mL/kg volume controlled ventilation; mmHg	37	40	46

BMI: Body mass index.

Table 4 Review of anesthetic management of peroral endoscopic myotomy in the existing literature

Author	n	Preparation for POEM	Aspiration at induction	CO2-related complications
Löser et al[9]	173	Liquid diet 2 to 5 d prior to POEM Nil per os overnight (for at least eight hours) Esophagoscopy was performed one day before POEM	None	Subcutaneous emphysema in 49 cases
				Pneumothorax in 1 case
Jayan et al[10]	21	Low residue diet 48 h before POEM Fasted from 20:00 on day before POEM	None	Subcutaneous emphysema in 5 cases
Goudra et al[11]	24	Fasting times for both solids and liquids were variable	1	No comment
Yang et al[12]	52	Clear liquid diet for 48 h before POEM Nil per os after midnight on day of POEM	None	Peak airway pressure > 35 cmH2O in 5 cases
Tanaka[13]	28	Nil per os for 24 h before POEM Esophagoscopy was performed before induction of anesthesia	None	Subcutaneous emphysema in 1 case

POEM: Peroral endoscopic myotomy.