title: Peroral endoscopic myotomy-initial experience with anesthetic management of 24 procedures and systematic review.
abstract: BACKGROUND
  Peroral endoscopic myotomy (POEM) is a novel method of treating achalasia of the esophagus. Very little data are available to guide the anesthesia providers caring for these patients. The anesthetic challenges are primarily related to the risk of pulmonary aspiration. There is also a potential risk of pneumomediastinum, pneumoperitoneum, subcutaneous, or submucosal emphysema, as a result of carbon dioxide tracking into the soft tissues surrounding the esophagus and lower esophageal sphincter.
  
  
  METHODS
  In this retrospective study, electronic charts of 24 patients who underwent POEM over 18 months were reviewed. Demographic data, fasting status, relevant aspiration risks, anesthetic technique, and postoperative care measures were extracted.
  
  
  RESULTS
  Fasting times for both solids and liquids were variable. None of the patients underwent preprocedural esophageal emptying. Standard induction and intubation were performed in 16, rapid sequence induction (RSI) with cricoid pressure in seven, and modified rapid sequence without application of cricoid pressure in one of the patients. One of the patients aspirated at induction, and the procedure was aborted. However, the procedure was performed successfully after a few weeks, this time a RSI with cricoid pressure was chosen.
  
  
  CONCLUSIONS
  As there are no guidelines for the perioperative management of patients presenting for POEM presently, certain recommendations can be made. Preprocedural esophageal emptying should be considered in patients considered as high-risk, although cultural factors might preclude such an approach. Induction and intubation in a semi-reclining position might be useful. Although debatable, use of RSI with cricoid pressure should be strongly considered.
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Hospital of the University of Pennsylvania, 680 Dulles, Philadelphia, USA.
authors.forename: Basavana
authors.initials: B
authors.lastname: Goudra
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, All India Institutes of Medical Sciences, Ansari Nagar East, New Delhi, India.
authors.forename: Preet Mohinder
authors.initials: PM
authors.lastname: Singh
authors.affiliation: Pennoni Honors College, Drexel University, Philadelphia, PA 19104, USA, India.
authors.forename: Gowri
authors.initials: G
authors.lastname: Gouda
authors.affiliation: Department of Anesthesiology and Critical Care Medicine, Drexel University College of Medicine, MS 310, Philadelphia, PA 19102, USA.
authors.forename: Ashish C
authors.initials: AC
authors.lastname: Sinha
keywords: Achalasia; aspiration; cricoid pressure; peroral endoscopic myotomy; pneumomediastinum; pneumoperitoneum; subcutaneous emphysema; submucosal emphysema