A CASE OF BILATERAL PNEUMOTHORACES, PNEUMOMEDIASTINUM, PNEUMOPERITONEUM, SUBCUTANEOUS EMPHYSEMA AFTER PERORAL ENDOSCOPIC MYOTOMY PROCEDURE

Abstract

SESSION TITLE: Fellows Procedures Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: October 18-21, 2020 INTRODUCTION: Peroral endoscopic myotomy (POEM) is a form of natural orifice transluminal endoscopic surgery. It is a relatively safe procedure, with 8% of reported adverse events. These include pneumoperitoneum, subcutaneous emphysema, pneumothorax, and gastroesophageal reflux. However, the occurrence of bilateral pneumothoraces, pneumomediastinum pneumoperitoneum,pneumoretroperitoneum with subcutaneous emphysema in the same patient is a rare occurence. CASE PRESENTATION: Our case depicts a 60-year-old female with a history of dyslipidemia, mild intermittent asthma, gastroesophageal reflux disease who presented with complaints of worsening epigastric pain for one year. She also reported occasional episodes of chest tightness along with odynophagia and dysphagia to both solids and liquids. Patient underwent fluoroscopic imaging of esophagus that revealed a large-sized hiatal hernia, patulous mid to upper esophagus with non-propulsive tertiary contractions involving the distal third portion of the esophagus. Esophagogastroduodenoscopy showed Barrett's esophagus with low-grade dysplasia, a large hiatal hernia, and gastroparesis in the fundus. A working diagnosis of distal esophageal spasm was confirmed with manometry. She thus underwent a POEM procedure for diffuse esophageal spasm. Patient reported dyspnea with pleuritic chest pain in the immediate post operative period. A chest X-ray, later a Computerized tomography scan was obtained showing large bilateral pneumothoraces, pneumomediastinum, subcutaneous emphysema along with intraperitoneal and retroperitoneal air. Her vital signs were stable; there was reduced intensity of breath sounds bilaterally on chest auscultation, with remaining normal systemic physical examination. Patient underwent bilateral tube thoracostomies. A contrast evaluation was performed for the integrity of the gastroesophageal junction which was negative for extravasation. Over the course of the hospitalization, there was complete resolution of the pneumothoraces, pneumomediastinum and pneumoperitoneum and pneumoretroperitoneum. Thereupon, bilateral chest tubes were removed. DISCUSSION: Gas related complications are seen after POEM procedure because of gas insufflation into esophageal wall during the procedure and the close proximity to pleura and mediastinal structures, leading to gas leak. To minimize the risk of complications, the use of insufflation and CO2 flow should be minimized especially when the endoscope is within submucosal tunnel. Particular attention to the changes in airway pressures and hemodynamic changes allow early detection and prompt intervention during the procedure. Tension pneumothorax and tension pneumopericardium are life-threatening complications CONCLUSIONS: Our case highlights the realm of complications after POEM procedure. Endoscopists, anesthesiologists, and perioperative clinicians must be aware of the complications. Reference #1: Khashab MA, El Zein M, Kumbhari V, et al. Comprehensive analysis of efficacy and safety of peroral endoscopic myotomy performed by a gastroenterologist in the endoscopy unit: a single-center experience. Gastrointest Endosc. 2016;83(1):117–125. Reference #2: Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). DISCLOSURES: No relevant relationships by Nafiisah Rajabalee, source=Web Response No relevant relationships by Roberto Solis, source=Web Response No relevant relationships by Rishitha Yelisetti, source=Web Response