Prevention, detection and management of adverse events of third-space endoscopy

Third space endoscopy (TSE) or sub-mucosal endoscopy using a mucosal flap valve (SEMF) enables the endoscopist to operate in the deeper layers of the gastrointestinal tract or gain access to the mediastinal/peritoneal cavity for natural orifice transoral endoscopic surgery (NOTES). TSE procedures are essentially endoscopic surgical procedures with a variable learning curve. Adverse events (AEs) during TSE are specific and follow a certain pattern across the spectrum of TSE procedures. These can be broadly categorized according to either type of AE, time of presentation relative to the procedure or according to degree of severity. Three major categories of AEs encountered during TSE include insufflation related AEs, mucosal injuries (MIs) and bleeding. Other relevant AEs include infectious complications, aspiration pneumonia, post-procedural chest/abdominal pain, atelectasis, cardiac arrhythmias, pleural effusion and pulmonary embolism. Reported incidence of AEs during TSE procedures varies according to the type and complexity of procedure. Acquaintance regarding potential risk factors, technical tips and precautions, alarm signs for early recognition, assessment of degree of severity, morphological characterization of AEs and finally, expeditious selection of appropriate management strategy are crucial and imperative for successful clinical outcomes. The current review discusses the current evidence and practical guidelines for prevention, early detection and management of TSE-related AEs.