Review Article

Anesthesia for Per‑oral endoscopic myotomy (POEM) – not so

poetic!

Soumya Sarkar, Puneet Khanna, Deepak Gunjan1

Departments of Anaesthesiaology, Pain medicine and Critical Care and 1Gastroenterology and Human Nutrition, AIIMS, New Delhi, India

Abstract
Peroral endoscopic myotomy (POEM) is a promising natural orifice transluminal endoscopic procedure for the treatment of
esophageal motility disorders, with similar effectiveness as of Heller myotomy. It is performed under general anesthesia in
endoscopy suite. Creation of submucosal tunnel in the esophageal wall is a key component. The continuous insufflation of
CO2 inadvertently tracks into surrounding tissues and leads to capno mediastinum, capno thorax, capno peritoneum, and
subcutaneous emphysema. Thus, the challenges, for an anesthesiologist are not only providing remote location anesthesia,
increased risk of aspiration during induction, but also early detection of these complications and specific emergency management.
Though a therapeutic innovation, POEM remains an interdisciplinary challenge with no specific anesthesia care algorithms and
evidence‑based recommendations. The purpose of this review is to outline the anesthesia and periprocedural practices based
on existing evidence.

Keywords: Anesthesia, complications, management, POEM

In recent times, peroral endoscopic myotomy (POEM) has the anesthesia and periprocedural practices based on existing
emerged as an effective endoscopic treatment for achalasia evidence.
cardia. It is usually performed under general anesthesia in
an endoscopy suite.[1] Creation of submucosal tunnel and ‘Achalasia’ is derived from the Greek word ‘chalasis’ means
myotomy are a key component during POEM. As a result, relaxation. It is a motility disorder of the lower esophageal
iatrogenic communication can occur between the submucosal sphincter with a prevalence of 10 in 100 000 individuals.[3]
space and the mediastinum, retro‑ and intraperitoneal cavity, It is a chronic debilitating disease that manifests as dysphagia,
which can lead to tension capnothorax, capnomediastinum, regurgitation, chest pain, and weight loss.[4] It usually manifests
or capnoperitoneum by the endoscopically insufflated between 25 and 60 years of age.[5] The management includes
CO2.[2] Thus, the anesthesiologists should not only be pharmacotherapy with calcium‑channel blockers and nitrates,
careful about the risk of aspiration during induction but endoscopic botulinum toxin injections, endoscopic pneumatic
also be aware of these complications and with specific balloon dilatation, laparoscopic Heller myotomy, and
emergency management. Though a therapeutic innovation, POEM.[6] The basic principle of POEM is of “natural orifice
POEM remains an interdisciplinary challenge with no transluminal endoscopic surgery (NOTES)”.[7] POEM has
specific anesthesia care algorithms and evidence‑based emerged as a standard treatment of achalasia since its inception
recommendations. The purpose of this review is to outline in 2010. It possesses similar effectiveness as of Heller myotomy
with comparatively lower cost and morbidity.[8]
Address for correspondence: Dr. Puneet Khanna,
Department of Anaesthesia, Pain Medicine & Critical Care, AIIMS, This is an open access journal, and articles are distributed under the
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How to cite this article: Sarkar S, Khanna P, Gunjan D. Anesthesia for
Per‑oral endoscopic myotomy (POEM) – not so poetic! J Anaesthesiol Clin
Pharmacol 2022;38:28-34.
DOI:
10.4103/joacp.JOACP_179_20 Submitted: 17‑Apr‑2020 Accepted: 09‑Apr‑2021
Published: 03-Dec-2021

28 © 2021 Journal of Anaesthesiology Clinical Pharmacology | Published by Wolters Kluwer - Medknow

 Sarkar, et al.: Anesthetic management of POEM a literature review

Several studies have shown a positive intrathoracic Pre‑anesthetic Preparation

pressure under general anesthesia with endotracheal
intubation is associated with lesser incidence of Patients with retrosternal chest pain should have a preprocedural
iatrogenic events (perforation, bleeding, and CO 2 electrocardiogram (ECG) to rule out any pre‑existing cardiac
insufflation‑related complications) than intravenous ailment. A chest x‑ray is also necessary in patient with clinical
sedation.[9,10] Thus, standard equipment, monitoring, and suspicion of pulmonary infiltrates or history of regurgitation.[12]
mutual understanding along with closed‑loop communication
between anesthesiologists and endoscopists is the key for According to recent American Society for Gastrointestinal
improving patient safety. Endoscopy (ASGE) guidelines, POEM is the preferred
treatment for management of patients with type III
Peroral Endoscopic Myotomy Procedure achalasia.[13] It has been also successfully performed in
diffuse esophageal spasm, nutcracker esophagus, and
The patient is positioned either in supine or left lateral hypercontractile (jackhammer) esophagus.[14] It is avoided
decubitus. At the beginning residual fluid or food is in patients with severe cardiopulmonary or other serious
suctioned and removed from the esophageal lumen with the disease leading to unacceptable surgical risk, pseudoachalasia,
help of esophagogastroduodenoscope (EGD) [Figure 1]. and anticipated difficulty in creation submucosal tunnel
During the POEM, carbon dioxide insufflation is used for due to severe fibrosis and adhesion. Patients with severe
inflation at low flow rate (~1.2 L/min). POEM is done thrombocytopenia (<30,000/mL), myelodysplastic
with EGD and a mucosal cap or hood at its tip. A mucosal syndrome, hypersplenism, patients with mechanical heart
bleb is created 10–12 cm above the gastroesophageal valves requiring high‑dose anticoagulation are not eligible for
junction (GEJ) with normal saline mixed with methylene POEM [Table 1][14] Periprocedural anticoagulation and/or
blue or indigo carmine dye [Figure 2]. Colored dye is antiplatelet therapy is maintained according to the ASGE
used to increase visualization and clear delineation of guidelines [Table 2].[15]
submucosal space. A 2.5 to 3 cm longitudinal mucosal
incision is made with the electrocautery knife to expose the Achalasia patients have an increased risk of aspiration by
submucosal space and entered into the submucosal tunnel. reflux of esophageal contents due to impaired esophageal
Submucosal dissection is done to create submucosal tunnel emptying.[4] However, currently there is no guideline for
by using the electrocautery knife and repeated dyed saline pre‑fasting time for POEM. Multiple case series on POEM
injections till 3 cm below GEJ. Two to three centimeter anesthesia management have reported fasting times from 8 to
distal to the mucosal incision site, selective myotomy of the 48 hours.[16] Majority of them have recommended a clear liquid
circular muscle fibers, sparing the underlying longitudinal diet for at least 24 hours or a low residue diet for 48 hours
fibers is performed with electrocautery knife till 2 cm prior to the procedure.[17,18] At our center, we keep patients
below GEJ [Figures 3 and 4]. At the end, the mucosal on clear liquid diet for 24 hours and keep fasting for 12 hours.
entry point is closed with standard endoscopic hemo Prophylactic use of esophagogastroduodenoscopy for removal
clips [Figure 5].[11] of the residual food is debatable. One case series without

Figure 1: Endoscopic image shoeing dilated esophageal lumen, which is filled Figure 2: Mucosal bleb (blue color) after injection of normal saline mixed with
with food residue methylene blue dye in the submucosal space

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 Sarkar, et al.: Anesthetic management of POEM a literature review

Table 1: Indications and Contraindications for POEM[14]

Indications Contra indications
Classic indication: Absolute contraindications
Type III achalasia Severe cardiopulmonary disease
Type I, type II achalasia Severe thrombocytopenia
Failed prior treatments Pseudoachalasia
Relative indications: Cirrhosis with portal hypertension but
Hypertensive motor no significant esophageal varices
disorders: diffuse Prior extensive esophageal mucosal
esophageal spasm, resection/ablation involving the POEM
jackhammer esophagus field
Relative contraindications
Prior radiation therapy to the esophagus
Severe esophagitis
very large ulcer in the lower esophagus

patients for reduction of esophageal pressure. Prophylactic

Figure 3: Submucosal tunnel after clearing of submucosal space. At 12 O’clock
is the mucosa and at 6 O’clock is the muscle layer of the esophageal wall use of proton pump inhibitors, antibiotic prophylaxis and
decontamination of oral cavity with chlorhexidine may be
beneficial for preventing the postprocedural inflammatory
response.[2]

Monitoring
During the procedure, standardized ASA monitoring of
non‑invasive blood pressure, electrocardiography (lead II),
pulse oximetry, capnography (end tidal CO2), urine output,
and temperature are used. Invasive arterial blood pressure
monitoring and serial arterial blood gas analysis may be
beneficial for patients with known cardiovascular or pulmonary
disease.[2] Periodic checking of abdomen, thorax, and neck
is required to early detection of capnoperitoneum and
subcutaneous emphysema.
Figure 4: Submucosal tunnel after the myotomy. At 12 O’clock is the longitudinal
muscle layer visible after the selective circular muscle myotomy
Anesthesia
Prevention of aspiration during induction of anesthesia is
the most important step. The incidence of aspiration during
induction of general anesthesia in general population is 3 in
10,000.[20] Thus, in majority of the case series, have been
advocated for rapid sequence induction (RSI).[21] There is no
consensus on using of cricoid pressure and positive pressure
ventilation via face mask. There is no ideal i.v. induction agent,
with each having own pro and cons [Table 3].[22]

Succinylcholine‑ the depolarizing neuromuscular blocking

agent usually preferred for RSI due to rapid onset of action.
Alternatively, nondepolarizing neuromuscular blocking
agent like rocuronium can also be used for the RSI. The
Figure 5: Closure of the mucosal incision site by the multiple hemoclips different types and doses of anesthetic agents are individually
selected based up on the patient’s underlying disease and
prophylactic EGDs advocated for the necessity while the other hemodynamic status. Both sevoflurane and propofol have
has found increased risk of aspiration.[11,19] Nishihara et al.[18] no significant impact on the esophageal sphincter pressure
has used gastric tube aspiration before induction in conscious in healthy individuals.[23] However, their effect on achalasia

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 Sarkar, et al.: Anesthetic management of POEM a literature review

Table 2: ASGE guidelines (2016) for antithrombotic agents in patients undergoing GI endoscopy[15]
Drugs Low cardiovascular Risk High Cardio vascular Risk
Anti‑coagulants 1. Discontinue AC 1. Discontinue AC
(AC) 2. Delay reinitiating until adequate hemostasis 2. Bridge therapy
is achieved. 3. Restart warfarin on same day of procedure
4. Delay reinitiating NOACs until adequate hemostasis is achieved
Antiplatelet 1. Continue standard doses of aspirin/NSAIDs* 1. Continue standard doses of aspirin/NSAIDs
agents (APA) 2. Discontinue thienopyridines at least 5 days 2. Discontinue thienopyridines at least 5 days before
before switch to aspirin endoscopy or switch to aspirin
3. Dual APA, hold thienopyridines for at least 3. Dual APA, hold thienopyridines for at least 5 days, continue
5 days, continue aspirin aspirin
1. Defer elective endoscopic procedures, possibly up to 12 months, if clinically acceptable from the time of PCI to DES placement. 2. Avoid cessation of clopidogrel (even
when aspirin is continued) within the first 30 days after PCI and either DES or BMS placement when possible. 3. Avoid cessation of all antiplatelet therapies after PCI
with stent placement. 4. Perform endoscopic procedures, particularly those associated with bleeding risk, 5‑7 days after thienopyridine drug cessation. 5. Aspirin should
be continued. 6. Resumption of thienopyridine and ASA drug therapy after the procedure once hemostasis is achieved. A loading dose of the former should be considered
among patients at risk for thrombosis

Table 3: Induction agent considerations[22]

Induction agent Advantages Disadvantages Suggested use
Sodium thiopental Clear endpoint; rapid one arm brain circulation Postoperative nausea Traditional choice
3‑7 mg kg−1 time and vomiting
Propofol 2‑4 mg kg−1 Greater suppression of laryngeal reflexes CVS depression When intubating
Familiarity conditions are a concern
Etomidate 0.3 mg kg−1 CVS stability Adrenal suppression CVS instability
Ketamine 1‑2 mg kg−1 Bronchodilation CVS stimulant; maintains cerebral Increases ICP Asthma, Shocked states
perfusion pressure in hypotensive situations

patient has not been studied. Desflurane may be useful for peak airway pressure (Ppeak) should immediately be informed
earlier recovery. Cuffed flexometallic endotracheal tubes are to the endoscopist for decompressing the stomach by suctioning
preferred in view of less chance of kinking or obstruction.[23] excess/CO2. It may be an early indicator of capnothorax.
Another study has used endotracheal tube with supraglottic
suction port but unable to show any added advantage.[24] Löser et al.[26] has found cases with 20% increase from the
After intubation, the endotracheal tube is generally fixed to baseline Ppeak required percutaneous abdominal needle
the right side of the mouth to facilitate entry of the EGD. decompression (PND). However, there is no consensus
The nasotracheal intubation is expected to has a relatively regarding the optimal level of Ppeak. Another study has reported
less chance of tube displacement in the oral cavity due to successful management of cases with Ppeak >38 cmH2O by
endoscopic maneuvers, with increased risk of nasal bleeding, pulling back the endoscope and suctioning the excess CO2.
in comparison to orotracheal intubation.[16] Accessibility to the PND was performed only with simultaneous rise in Pmax
airway may be difficult as the endoscopist usually stands by and EtCO2.[11]
the patient’s head. So, securing the proper depth and fixation
of the endotracheal tube, and protection of the eyes is utmost Periodic assessment of the upper abdomen is also necessary
priority before starting the procedure.[25] for early detection of capnoperitoneum and there by prevention
of abdominal compartment syndrome.[11]
Adequate neuromuscular relaxation is critical as any
untoward movement of the patient during the procedure Apert from pre‑existing pulmonary conditions or extensive
may be detrimental. Pressure control mode of ventilation emphysema, usually patients are extubated immediately after
is preferred as it uses decelerating flow, which tends to the procedure whenever possible. A cuff leak test should be
compensate for any potential reduction in ventilation caused done before extubation. Although the incidence of post POEM
by pressure limitation and allows gas to be distributed more gastroesophageal reflux between 8.5%‑ 21.3%, aspiration
evenly to areas of the lung with both long‑ and short‑time during emergence after extubation has not been reported.[26]
constants. Adjustment of minute ventilation to maintain an
end‑tidal carbon dioxide tension (ETCO2) of 35–45 mmHg Physiological Changes
is necessary.[11] If hyperventilation alone is insufficient to
control the rising ETCO2 the procedure should be temporarily During the procedure, continuous gas insufflation is essential
interrupted for several minutes. Sudden rise in ETCO2 or for the creation of a submucosal tunnel and visualization.

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 Sarkar, et al.: Anesthetic management of POEM a literature review

CO2 is the preferred gas as it is colorless, non‑combustible, compromised cardiopulmonary functions. If Pnp occurs
water‑soluble, systemically absorbed and excreted by the percutaneous abdominal needle decompression is required.
lungs with reduced risk of embolism. Use of air insufflation A study has proposed for a needle decompression in the event
in POEM is contraindicated.[21] General anesthesia and of ETCO2 > 50 mm Hg, or peak airway pressure (Pmax)
CO2 insufflation causes significant physiological changes. >35 cm H 2O along with abdominal distension. [26]
Similar to laparoscopic procedure, there is rise in mean Intra‑abdominal pressure cannot be measured directly during
arterial pressure (MAP) and heart rate (HR) during POEM but the Pmax act as an indirect marker for it. Another
POEM. Systemic absorption, sympathetic stimulation and study has suggested that Pmax <38 cm H2O reduces the risk
increased catecholamine release may be the cause.[27] Due to of capnoperitoneum.[11]
persistent CO2 insufflation, impaired systemic CO2 balance
may lead to respiratory acidosis and increases in peak airway The crucial factor for minimizing these events is the total
pressure. Raised peak airway pressure implies increase in amount of gas insufflated. It has been found in a recent
intra‑abdominal pressure. It may be due to gastric distension, study that a low‑flow CO2 tubing caused no events of Pnp in
retro‑ or capnoperitoneum.[16] The minute ventilation can be comparison to medium‑ or high‑flow CO2 tubing resulting into
controlled in intubated patients under general anesthesia. 36.7% tense capnoperitoneum.[35] It is has been found that a
CO2 uptake by insufflation may be alleviated to some degree sparing use of CO2 in a flow around 1.2 L/min is associated
by hyperventilation. However, hyperventilation is not useful with negligible complication.
for maintaining normocapnia in subcutaneous emphysema.[16]
The control of Peak airway pressure during POEM is a
challenging task. It increases due to gastric distension or
POEM‑related Adverse Events capnocapnoperitoneum. A low tidal volume with increased
respiratory rate may be helpful for maintaining minute
Early adverse events are mucosal injur y, bleeding, ventilation. However, Inoue et al.[10] concluded that positive
subcutaneous emphysema, capnothorax, capnomediastinum, pressure ventilation with higher pressures than those generated
capnoperitoneum, and pleural effusion. Symptomatic by endoscopic CO2 insufflation is necessary for reducing the
gastroesophageal reflux disease and esophagitis are the risk of mediastinal emphysema and embolization.
late complications.[28] The most common adverse events
associated with POEM are related to CO2 insufflation. In Although the POEM‑related adverse events are usually
contrast to laparoscopic surgery, CO2 flow is regulated during well managed without clinical morbidity, patient’s pain and
POEM.[26] Continuous insufflation by CO2 inadvertently increased use of resources should be reduced. Thus, early
track into surrounding tissues and cause capnomediastinum, detection of the preceding signs with close communication and
capnothorax, capnoperitoneum, and subcutaneous cooperation are valuable with endoscopists. Finally, a quick
emphysema. The incidences of insufflation‑related adverse procedure may also be helpful for averting these incidents.
events, ranges from 7.5% to 55.5%.[29,30] About 5.1% of
the patients develop capnothorax and mucosal tear during Postoperative Care
POEM has been reported between 0–7%.[31] These are now
considered as an integral part of the procedure rather than POEM results in a considerable amount of postoperative
complications.[32] Mucosal injury, subcutaneous emphysema, pain. It is not only one of the most undesirable experience
and capnoperitoneum can be managed conservatively. but also bears undesirable cardiovascular effects, respiratory
Tense capnoperitoneum and capnothorax require needle depression, urinary and neuroendocrine dysfunction.[16]
decompression and chest tube placement.[33] Patient‑controlled analgesia (PCA) with an opioid may
be beneficial. However, they may lead to nausea, vomiting,
Subcutaneous emphysema is the common insufflation related pruritus, and respiratory depression. Use of multi‑modal
adverse event. Earlier detection is important. It has been found analgesia by using non‑steroidal anti‑inflammatory drugs,
that 60% of the instances of raised ETCO2 >50 mm Hg is ketamine, and anti‑emetics, has been used to minimize
associated with subcutaneous emphysema.[34] For extensive opioid‑related side effects.[36]
cases hyperventilation is not useful, subcutaneous needle drain
is required. A careful assessment of airway is necessary due Exposure to general anesthesia and use of opioids for
to potential risk of airway obstruction. postoperative pain management can cause postoperative
nausea and vomiting (PONV). PONV immediately after
The capnoperitoneum (Pnp) may also lead to inferior the procedure can precipitate bleeding and mucosal tear or
vena cava compression, preload reduction, and subsequent esophageal perforation. Women, non‑smoker, history of motion

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 Sarkar, et al.: Anesthetic management of POEM a literature review

sickness, and the use of postoperative opioids are known as indication, and outcomes. Thorac Surg Clin 2011;21:519‑25.
11. Yang D, Pannu D, Zhang Q, White JD, Draganov PV. Evaluation
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dexamethasone have been used for prevention. Alternatively, endoscopy unit. Endosc Int Open 2015;3:E289‑95.
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13. Khashab MA, Vela MF, Thosani N, Agrawal D, Buxbaum JL,
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intravenous antibiotics. After ensuring no evidence of leakage 15. ASGE Standards of Practice Committee, Acosta RD, Abraham NS,
by water‑soluble contrast esophagogram on a postoperative Chandrasekhara V, Chathadi KV, Early DS, et al. The management
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16. Bang YS, Chunghyun P. Anesthetic consideration for peroral
endoscopic myotomy. Clin Endosc 2019;52:549‑55.
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18. Nishihara Y, Yoshida T, Ooi M, Obata N, Izuta S, Mizobuchi S.
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