Anesthesia for Per-oral endoscopic myotomy (POEM) - not so poetic!

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.