Anesthesia for peroral endoscopic myotomy (POEM)

Achalasia of the esophagus is a primary esophageal motor disorder of unknown etiology and a frequent cause of gastroesophageal reflux disease. It is associated with insufficient relaxation of the lower esophageal sphincter and loss of esophageal peristalsis. Dysphagia, regurgitation, weight loss and chest pain are some of the common clinical features. Often these patients sleep with multiple pillows or with head propped up to limit nocturnal symptoms such as cough and potential aspiration. If the pharmacologic approaches are ineffective, invasive interventions are required. Historically Heller's myotomy was the preferred surgical intervention; however, endoscopic interventions are gaining popularity. Botox injections, pneumatic dilation are effective in the short term. Peroral endoscopic myotomy is relatively new endoscopic procedure which involves creation of a submucosal tunnel distal to the mid-esophagus, followed by myotomy of circular muscle layers extending to 2 cm into the cardia. The procedure is performed under general anesthesia. Extended fasting times and a rapid sequence induction and intubation is widely accepted to minimize the risk of aspiration. Some of the potential intraoperative complications include pneumothorax, capnopericardium, mediastinal emphysema, subcutaneous emphysema, and pneumoperitonium. Patients are typically extubated at the end of the procedure; however, overnight admission is necessary.