10.7.3 Peroral Endoscopic Myotomy
POEM, and more largely any intervention requiring access to the submucosal space (also called third space endoscopy to differentiate it from the luminal and extraluminal cavities), including esophageal or pyloric myotomies but also resection of submucosal tumors, has become a standard procedure in tertiary specialized centers. These techniques offer new possibilities of treatment, potentially more effective than surgery in selected cases. They are, however, associated with specific complications. In one of the largest series to date,119 (1,680 patients treated with POEM), major complications occurred in 55 (3.3%) patients, including 13 (0.8%) postoperative mucosa breach, 3 (0.2%) delayed bleeding, 8 (0.5%) hydrothorax, 25 (1.5%) pneumothorax that required thoracic tube placement, and 6 (0.4%) other complications. Four patients required ICU admission and 14 (0.8%) stayed more than 10 days in the hospital. The rate of major complications decreased over time and reached a plateau of 1% after 3.5 years. Multivariate analysis identified experience < 1 year (odds ratio [OR], 3.00; 95% confidence interval [CI], 1.12–8.06), air insufflation (OR, 2.78; 95% CI, 1.03–7.52), and mucosal edema (OR 1.92; 95% CI, 1.05–3.49) as risk factors. Other than the need for case volume and experience, it is clear that CO2 insufflation is essential when performing such procedures.
When performed by experienced physicians, these techniques are very safe, but one must be aware about incidental imaging findings such as pneumomediastinum, pneumothorax, and pneumoperitoneum, which are not as common with other endoscopic techniques. When pneumoperitoneum occurs during the procedure, it must be relieved when associated with hemodynamic disturbances. The presence of free air must only be considered when associated with clinical symptoms and one should understand this to avoid unnecessary interventions.120
10.8 Conclusion
Therapeutic endoscopy continues to progress and therefore potential complications need to be recognized and properly prevented and treated. Prevention of complications relies on a fine knowledge of the patient’s condition and procedural indications. Scheduling must consider the available resources, evaluate if proper experience is available, and draw different strategies for managing complications. Early diagnosis of complications and multidisciplinary approach are paramount. The best approach will, in most cases, be dictated by local expertise. Concentration of cases will become necessary with the sophistication of techniques, which will require more resources and experience and patient education about the risks. Local expertise will remain a cornerstone in management.
10.9 Key Points
• Avoidance of unnecessary invasive examinations is the best way to prevent adverse events.
• Preprocedural patient information and informed consent are paramount.
• Acquiring and maintaining experience and competency in specific procedures is essential to reduce the risk of adverse events. Inexperienced and/or undertrained endoscopists should avoid performing advanced complex, therapeutic endoscopic procedures.
• Standardization of training and adherence to guidelines are required in order to prevent and manage adverse events.
• Assessing center- and operator-specific complication rates are important issues leading to improved quality and safety.
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