Anesthesia for Patients Undergoing Peroral Endoscopic Myotomy Procedures: A Review of the Literature

Idiopathic achalasia is a motility disorder of the esophagus with important implications on anesthesia and periprocedural management. As new and more complex treatment options develop, anesthesiologists are increasingly involved with these patients. The cardinal symptoms of achalasia are as follows: dysphagia, regurgitation, chest pain, and weight loss. Achalasia is also associated with an increased risk of aspiration. Patients are frequently treated by endoscopic botulinum toxin injections, pneumatic dilation of the lower esophageal sphincter, laparoscopic Heller myotomy, or peroral endoscopic myotomy (POEM). The POEM procedure is based on the concept of "natural orifice transluminal endoscopic surgery." Because the integrity of the esophageal wall is deliberately interrupted during POEM, the mediastinum and the peritoneal cavity may be exposed. Thus, the insufflated carbon dioxide frequently causes hypercapnia, tension capnoperitoneum, capnomediastinum, or pneumothoraces. An interdisciplinary team, skilled in diagnostics and emergency measures such as therapeutic hyperventilation, percutaneous abdominal needle decompression, or pleural drainage, is essential for the successful periprocedural management of POEM. POEM is one endoscopic procedure that requires general anesthesia. But neither anesthesia-specific care algorithms nor evidence-based recommendations are currently available for these patients. Because institutional experience varies broadly across the globe, this review examines anesthesia recommendations and perioperative management of POEM procedures based on 7 retrospective case series, 1 prospective study, and our personal experience.