Susanne Eberl

ACHALASIA AND PERORAL ENDOSCOPIC MYOTOMY POEM

patient experienced an aspiration after a standard induction. Procedure was cut short and

recapped on a later moment when the patient was successfully intubated after a rapid

sequence induction with cricoid pressure. Anaesthesia was maintained with sevoflurane,

desflurane or propofol. In contrast to our own experiences, the authors stated that POEM is

relatively painless requiring only small amounts of opioids.

Regarding airway management,

Saxena et al.

suggest in a reply letter to Tanaka et al.

the use of a special tube with the

possibility of suction of irrigation fluid under the glottis and above the cuff (TaperGuard

Evac, Covidien). The authors intubated 35 patients who underwent POEM with this special

tube and experienced no aspiration.

However, this also can be achieved by using the

suction canal of the endoscope during withdrawal from the oesophagus.

Own experiences

Nearly 160 POEM procedures have been performed in the AMC. All patients scheduled for

POEM have to follow a strict liquid diet for three days prior to the procedure. Twenty-four

hours before procedure they may only take clear liquid and 8 hours before nothing more by

mouth. During time out, patients will be asked about their own feeling of stasis of food in the

oesophagus. All patients are intubated in a RSI setting without cricoid pressure. In doubt of

stasis in the oesophagus, awake fiberoptic intubation with remaining airway reflexes is the

option of choice. Until now, we did not have any aspiration during intubation. Alternatively,

it is an option to start with an oesophago-gastroscopy under light sedation to remove

remaining food in the oesophagus and stomach. We have not yet applied thismethod. There

is no specific protocol for medication during induction or for maintenance of anaesthesia.

Our data show that POEM is a painful procedure. Therefore, all patients receive multimodal

intravenous pain therapy with acetaminophen, non-steroidal anti-inflammatory drugs

(NSAIDs) or alternatively metamizol, esketamine, and an opioid combined with co-

analgesics like clonidine and dexamethasone.

The first hours after procedure, patients stay in the recovery room and are titrated with

morphine as necessary. Usually, intravenous treatment with paracetamol, NSAID, or

metamizol is sufficient. The first 24 hours patients are not allowed to eat and drink, so

they are treated with a crystalloid and glucose infusion for this time. After the barium

swallow on the first postprocedural day, patients start with clear liquid followed by liquid

diet that is slowly extended. Patients are treated with omeprazole for two weeks after the

procedure. For most patients pain medication is still necessary in the first two to three days

postoperatively.