Our experience with peroral endoscopic myotomy complications: A case series

Abstract

Achalasia is characterized by the failure of smooth muscle relaxation in the lower part of the esophagus. During peroral endoscopic myotomy (POEM), creating a submucosal tunnel and performing a myotomy can inadvertently create openings between the submucosal space and the mediastinum, retroperitoneal cavity, and intraperitoneal cavity. When carbon dioxide (CO2) is insufflated during the procedure, it can pass through these openings, leading to conditions such as capnothorax, capnomediastinum, capnoperitoneum, or subcutaneous emphysema. In some cases, emergency management may be required. Three of our four patients who experienced these complications developed subcutaneous emphysema, while one had pneumoperitoneum and pneumothorax. Only one of these patients needed medical intervention, while the other three did not. It is now recognized that these complications are an expected part of the procedure rather than unexpected outcomes. Therefore, it is recommended to manage them conservatively unless they cause significant cardiorespiratory distress. In conclusion, having a good understanding of the procedure and remaining vigilant can help ensure the safe execution of POEM, even when these complications arise.

Keywords

• achalasia
• complications
• subcutaneous emphysema