Int J Gastrointest Interv 2022; 11(3): 139-142
Published online July 31, 2022 https://doi.org/10.18528/ijgii210057
Copyright © International Journal of Gastrointestinal Intervention.
Seokin Kang1,2 , Yuri Kim1 , and Do Hoon Kim1,*
1Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
2Department of Internal Medicine, Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea
Correspondence to:*Department of Gastroenterology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 05505, Korea.
E-mail address: dohoon.md@gmail.com (D.H. Kim).
This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/bync/4.0) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Peroral endoscopic myotomy (POEM) can be safely performed for achalasia. During POEM, gas is insufflated via the endoscope inside the submucosal tunnel. Gas-related complications often cannot be avoided because of the lack of serosa in the esophagus and the inability of the adventitia to function as a resistant barrier to gas. However, tension pneumothorax causing respiratory failure is a rare complication of POEM. Herein, we describe a 32-year-old female who developed tension pneumothorax after POEM. She showed respiratory compromise after POEM, and emergency chest radiography revealed pneumothorax with mediastinal shift. Tension pneumothorax was managed by chest tube drainage with the application of negative-suction pressure via the tube, after which her vital signs stabilized. On post-procedural day 4, the tube was removed. Our case suggests the importance of considering tension pneumothorax if respiratory compromise occurs despite oxygen administration after POEM even in the absence of immediate complications during the procedure, and performing chest radiography promptly.
Keywords: Esophageal achalasia, Myotomy, Pneumothorax
Peroral endoscopic myotomy (POEM) is a relatively novel minimally invasive endoscopic intervention for achalasia; it was first introduced by Inoue et al1 in 2010. Since then, POEM has rapidly gained popularity and has become one of the standard procedures for achalasia.2 POEM is performed by creating a submucosal bleb in the mid-esophagus, followed by partial (circular) or full-thickness myotomy while preserving the underlying mucosa. Various studies have reported the efficacy and safety of POEM.3–6 There are some POEM-related complications, including infections, pleural effusion, major bleeding, and viscus perforation; among them, the most common are gas-related complications such as subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, and pneumothorax.7–9
A recent meta-analysis has reported that the incidence rate of pneumothorax during or after POEM is 1.2%.10 In most cases, pneumothorax can be treated conservatively or by needle decompression. However, tension pneumothorax causing respiratory failure rarely occurs. Herein, we report a rare case of tension pneumothorax after POEM that was managed by chest tube drainage with the application of negative-suction pressure via the tube.
A 32-year-old previously healthy female visited our outpatient clinic with the complaint of dysphagia. She was diagnosed with achalasia and was scheduled to undergo POEM. On physical examination, her body mass index was 20.5 kg/m2 (based on a height and body weight of 160 cm and 52.4 kg, respectively). Her laboratory test results were within the normal limits. Esophagogastroduodenoscopy, which was carried out on the day before POEM, showed no esophageal food stasis.
POEM was performed under general anesthesia using positive pressure ventilation (positive end-expiratory pressure of 2–3 cmH2O). The air supplier was connected to an endoscope (Olympus GIF-HQ290; Olympus, Tokyo, Japan), and air was insufflated via the endoscope at a constant rate of 1.5 L/min during POEM. Esophagogastroduodenoscopy revealed high resistance at the gastroesophageal junction, and an endoscopic functional luminal imaging probe with a 16-cm catheter (EndoFLIP® EF-322N; Medtronic, Inc., Shoreview, MN, USA) revealed lower esophageal sphincter (LES) distensibility of 0.4 mm2/mmHg with 60-mL volume inflation (the examination before POEM took 15 minutes). The gastroesophageal junction was located 41 cm from the upper incisor (UI). Mucosotomy was made 32 cm from the UI, followed by submucosal tunneling down to 45 cm from the UI. Dissection of the circular muscular layer was started at 33 cm from the UI and continued toward 44 cm from the UI. Full-thickness myotomy was also performed at the distal esophagus and cardia with a length of 4 cm. After LES distensibility was measured at 5.6 mm2/mmHg with a 60-mL volume inflation, the mucosal insertion site was closed with endoclips. The procedure took 43 minutes, and there were no immediate complications (Fig. 1). After extubation, the patient was moved to the recovery room. The total anesthesia time was 88 minutes. Five minutes after arrival in the recovery room, she complained of dyspnea, and the use of respiratory accessory muscles was observed. Her respiratory rate was 27–28 breaths/min. She showed an oxygen saturation of 85% to 87% while receiving 15 L/min of oxygen by a reserve mask and a heart rate of 120–130 beats/min with sinus rhythm. An emergency portable chest radiograph revealed large right-sided pneumothorax with mediastinal shift, suggesting tension pneumothorax. Right thoracostomy was performed with a 24-Fr tube under sterile conditions. Her dyspnea was relieved to some degree, but follow-up chest radiography showed no significant changes in pneumothorax. Chest computed tomography (CT) showed total collapse of the right lung with mediastinal shift and no definite perforation of the esophagus (Fig. 2). After applying a suction pressure of –15 cmH2O via the tube, the right lung re-expanded as the negative pressure in the pleural cavity was restored. Her vital signs stabilized, and her dyspnea subsided. On post-procedural day 4, the tube was removed. Serial chest radiographs are demonstrated in Fig. 3. On the following days, esophagography showed no passage disturbance at the gastroesophageal junction and no contrast leakage from the esophagus. The patient ate her meals without complaining of dysphagia, and her condition was stable. The patient was discharged from the hospital on post-procedural day 8.
Achalasia is an uncommon disease, with a global incidence of 0.03–1.63/100,000 persons per year,11 and it is a primary esophageal motility disorder characterized by the absence of esophageal peristalsis and incomplete relaxation of the LES in response to deglutition.12 The treatment of achalasia aims to reduce the pressure at the LES, improve esophageal emptying, and alleviate the symptom of dysphagia. The conventional treatment of achalasia consists of pharmacological therapy (nitrates, 5-phosphodiesterase inhibitors, anticholinergics, and calcium channel blockers), endoscopic intervention (botulinum toxin injection and pneumatic balloon dilatation), and surgery (open or laparoscopic Heller’s myotomy and esophagectomy).13
POEM has been reported as an effective and safe procedure for achalasia.3–6 During POEM, a submucosal bleb is created in the mid-esophagus and the endoscope is inserted into the submucosal tunnel, which can be referred to as the third space. Gas is insufflated via the endoscope into the submucosal tunnel. Due to the lack of serosa in the esophagus and the inability of the adventitia to function as a resistant barrier to gas, gas-related complications such as subcutaneous emphysema, pneumomediastinum, pneumoperitoneum, and pneumothorax often occur during or after the procedure, even in the absence of esophageal rupture or perforation. Most gas-related complications can be managed conservatively. Some gas-related complications may be regarded as normal post-procedural changes, and gas-related complications may need to be re-defined.9,14 According to some studies, the occurrence of gas-related complications can be minimized by the use of carbon dioxide (CO2) instead of air. CO2 diffuses approximately 20 times faster than air; therefore, it is more easily absorbed in the serum than air.9,14 However, tension pneumothorax cannot be completely prevented by the use of CO2; a few cases were reported that tension pneumothorax occurred during POEM even when CO2 was used.15,16
Tension pneumothorax has a high mortality rate if left untreated.17 The definition of tension pneumothorax varies; however, it is widely accepted as a pneumothorax resulting in significant respiratory or hemodynamic compromise that can be improved by thoracic decompression. In addition, the mediastinal shift sign on the chest radiograph helps the diagnosis of tension pneumothorax.18,19 In our case, the patient had a respiratory rate of 27–28 breaths/min and an oxygen saturation of 85% to 87% while receiving 15 L/min of oxygen via the reserve mask, indicating significant respiratory compromise. Moreover, chest radiograph revealed a large right-sided pneumothorax with mediastinal shift.
Tension pneumothorax is a rare complication of POEM. To the best of our knowledge, only a few cases of tension pneumothorax during POEM have been reported. Li et al20 reported a case of tension pneumothorax, which was secondary to esophageal rupture during POEM. Gong et al15 and Rajmohan et al16 reported cases of tension pneumothorax during POEM, although CO2 was used for insufflation. In our case, the patient successfully underwent POEM without developing any immediate complications, and tension pneumothorax was detected after POEM. In addition, a post-procedural CT scan revealed no esophageal perforation.
In summary, we presented a case of tension pneumothorax after POEM, which was treated by chest tube drainage with the application of negative-suction pressure via the tube. It is important to consider tension pneumothorax if respiratory compromise is observed despite sufficient oxygen administration after POEM even in the absence of immediate complications during the procedure, and to perform chest radiography promptly.
No potential conflict of interest relevant to this article was reported.
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