Factors predicting insufflation-related events in peroral endoscopic myotomy procedures

Peroral endoscopic myotomy (POEM) has revolutionized the therapeutic landscape for esophageal achalasia, offering efficacy comparable to that of surgery with the convenience of an endoscopic approach. With the growing popularity of POEM, insufflation-related adverse events (AEs) present unique challenges that have been widely discussed in the literature. This study aimed to investigate the safety profiles and risk factors associated with insufflation-related events in patients undergoing POEM in endoscopy suites.

This retrospective analysis included 100 consecutive patients with achalasia treated by POEM at our institute between March 2016 and October 2022. All procedures were performed in an endoscopy suite and employed carbon dioxide insufflation and general anesthesia with endotracheal intubation and positive-pressure ventilation. Variations in cardiopulmonary dynamics, intraprocedural AEs, and postoperative recovery were documented.

All procedures were successfully performed, with an average POEM duration of 92.3 min and an average anesthesia duration of 108.4 min. Of note, 1 major AE involving an esophageal leak and requiring endoscopic stenting was observed, along with a 27% incidence of minor AEs. Insufflation-related events, manifesting as capnoperitoneum, subcutaneous emphysema, or capnomediastinum, were identified in 48% of cases, but none required additional interventions or extended hospitalization. A peak inspiratory pressure increase of ≥20% was identified as the only predictor of insufflation-related events.

Performing POEM in an endoscopy suite can generally be considered safe from major AEs related to insufflation. Monitoring peak inspiratory pressure for a ≥20% increase may be an early indicator of other potential insufflation-related events.