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Preventing aspiration during peroral endoscopic myotomy
Payal Saxena
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1
Richard Pippenger
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1
Mouen A. Khashab
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1
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R. Pippenger Department of Anesthesia, The Johns Hopkins Medical Institutions
,
Baltimore, MD 21205, USA
1
P. Saxena M. A. Khashab (&) Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institutions
, 1800 Orleans St, Suite 7125B,
Baltimore, MD 21205, USA
-
To the Editor:
We read with interest Tanaka et al.s [1] case series
raising the importance of preventing aspiration pneumonia
as an anesthesia consideration specific to peroral
endoscopic myotomy (POEM).
At our institution, a total of 35 patients underwent
POEM for treatment of achalasia or spastic esophageal
disorders. To facilitate efficient submucosal dissection
there is frequent need to irrigate significant volumes of
fluid which is performed using the water jet channel of the
gastroscope (GIF-HQ 190; Olympus, Tokyo, Japan) [2].
The endoscopist works in the proximal esophagus which is
generally dilated with high lower esophageal sphincter
pressures. Hence, the irrigated fluid can regurgitate toward
the pharynx, leading to a risk of aspiration.
In order to reduce the risk of micro-aspiration events, we
use an endotracheal tube with a taper-shaped cuff with an
evacuation port and suction lumen (TaperGuard Evac,
Covidien, Mansfield, MA). The tube is designed to provide
subglottic secretion drainage which has been shown to
protect against micro-aspiration and ventilator assisted
pneumonia [3]. Approximately 100 ml of fluid is aspirated
through the specialized endotracheal tube during POEM
which was successfully performed in the endoscopy unit in
all patients with a mean procedure time of 110 min. There
were no episodes of aspiration or pneumonia in our cohort.
Prevention of aspiration is important not only during
induction of anesthesia but also for the duration of the
procedure. We recommend use of an endotracheal tube
with capabilities for subglottic secretion drainage to
minimize the risk during a procedure where frequent
esophageal irrigation is required.
(...truncated)