Background and Aims Peroral endoscopic myotomy (POEM) is a procedure with potential for serious adverse events. Postprocedure imaging is routinely done, yet there is no consensus on the optimal ...imaging protocol. We describe a novel and simple CT esophagram protocol for evaluation after POEM and for reporting the full spectrum of radiographic findings and subsequent interventions. Methods This was a single-center prospective study of consecutive patients treated with POEM evaluated with CT esophagram. Results Eighty-four consecutive patients who had POEM performed underwent CT esophagrams. The most common findings were pneumomediastinum (85.7%), pneumoperitoneum (66.7%), subcutaneous emphysema (52.4%), and pleural effusion (46.4%). Other findings included retroperitoneal air (38.1%), pneumothorax (19%), atelectasis (14.3%), intramural air in the esophagus and/or stomach (13.1%), pericardial effusion (2.4%), and pneumopericardium (2.4%). Five patients required intervention based on CT findings. In 1 patient, a leak was detected on CT esophagram before any clinical manifestation, facilitating prompt intervention and avoiding potential serious outcomes. Four patients were diagnosed with pneumonia and were treated with antibiotics. There was frequent postprocedural atelectasis, which prompted the introduction of routine incentive spirometry in all postoperative POEM cases. Conclusions CT esophagram is a simple and accessible imaging test for routine postoperative POEM evaluation. Numerous and dramatic postprocedure radiographic findings may be expected and demonstrated with this imaging modality. Although most of these findings may not require intervention, some are of potential significance, and early identification may help modify postprocedure management. (Clinical trial registration number: NCT01832779 .)
Introduction:
Data on anesthesia management and outcomes associated with peroral endoscopic myotomy (POEM) performed exclusively in the endoscopy unit are limited. In this prospective study, we ...evaluated the safety of anesthesia management, and the feasibility and efficacy of POEM performed exclusively in the endoscopy unit.
Methods:
A single-center prospective study of consecutive patients with achalasia treated with POEM in an endoscopy unit was performed. Safety of anesthesia management and POEM were determined by procedure-related adverse events. Feasibility was assessed by completion rate. Short-term efficacy was established by clinical success (Eckardt score ≤ 3) and by comparing Eckardt and dysphagia scores before and after POEM.
Results:
Patients (n = 52) underwent POEM under general anesthesia with endotracheal intubation and positive pressure ventilation. Aspiration was prevented by keeping patients on a clear liquid diet before the procedure without requiring a prior esophagogastroduodenoscopy for esophageal content clearance. POEM completion rate was 96 % (50/52 patients). There was no post-POEM bleeding. Postprocedure leak was observed in one patient (3 %). Four patients (7.7 %) experienced mucosal injury, three of them were treated uneventfully endoscopically and one required laparoscopic repair. Clinical success was achieved in 88 % of patients. There was a significant decrease in the mean Eckardt score (8.1 to 1.4) and dysphagia score (2.4 to 0.4) (
P <
0.0001) at the one month follow up after POEM.
Conclusion:
Anesthesia management of POEM is safe in the endoscopy unit and aspiration can be prevented without requiring prior esophagogastroduodenoscopy for esophageal content clearance. Overall, POEM performed by a gastroenterologist in the endoscopy unit was feasible and effective for the treatment of achalasia.
Over the last 40 years, endoscopic retrograde cholangiopancreatography (ERCP) has evolved from being a purely diagnostic to a primarily therapeutic procedure. The 2 recent developments in ERCP-based ...stricture management include the increased use of cholangioscopy-guided sampling and self-expandable metal stents. The role of ERCP in pancreatic diseases continues to evolve; ERCP-based pancreatic therapy requires advanced endoscopic expertise and is associated with a high rate of postprocedure complications. Therefore, a multidisciplinary team approach at a center with expertise in pancreatic therapy should serve as a basis for very careful patient selection.
Complication of Gellhorn pessary use Alexander, Ryan; S Pannu, Davinderbir
Journal of Case Reports and Images in Obstetrics and Gynecology,
2021, Volume:
7
Journal Article
The safety of peroral endoscopic myotomy (POEM) is still debated since comprehensive analysis of adverse events (AEs) associated with the procedure in large multicenter cohort studies has not been ...performed. To study (1) the prevalence of AEs and (2) factors associated with occurrence of AEs in patients undergoing POEM.
Patients who underwent POEM at 12 tertiary-care centers between 2009 and 2015 were included in this case-control study. Cases were defined by the occurrence of any AE related to the POEM procedure. Control patients were selected for each AE case by matching for age, gender, and disease classification (achalasia type I and II vs. type III/spastic esophageal disorders).
A total of 1,826 patients underwent POEM. Overall, 156 AEs occurred in 137 patients (7.5%). A total of 51 (2.8%) inadvertent mucosotomies occurred. Mild, moderate, and severe AEs had a frequency of 116 (6.4%), 31 (1.7%), and 9 (0.5%), respectively. Multivariate analysis demonstrated that sigmoid-type esophagus (odds ratio (OR) 2.28, P=0.05), endoscopist experience <20 cases (OR 1.98, P=0.04), use of a triangular tip knife (OR 3.22, P=0.05), and use of an electrosurgical current different than spray coagulation (OR 3.09, P=0.02) were significantly associated with the occurrence of AEs.
This large study comprehensively assessed the safety of POEM and highly suggests POEM as a relatively safe procedure when performed by experts at tertiary centers with an overall 7.5% prevalence of AEs. Severe AEs are rare. Sigmoid-type esophagus, endoscopist experience, type of knife, and current used can be considered as predictive factors of AE occurrence.
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