Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis

Abstract

<b>Background and study aims: </b>Peroral endoscopic myotomy (POEM) is now a widely used treatment for esophageal achalasia, supported by several large cohort studies. Although major perioperative adverse events (mAE) are rare, in-depth investigations of related risks and preventive measures are lacking. The aim of this study was to systematically assess mAEs during POEM by analyzing their incidence, risks, prevention, and management. <b>Patients and methods: </b>This retrospective single-center analysis included all patients (n = 1680) undergoing POEM between August 2010 and July 2015 at Zhongshan Hospital. Major adverse events were defined as: vital-sign instability, intensive care unit (ICU) stay, hospital readmission, conversion to open surgery, invasive postoperative procedure, blood transfusion, or prolonged (> 5 days) hospitalization for functional impairment. <b>Results: </b>A total of 55 patients (3.3 %, 95 % confidence interval [CI] 2.5 % – 4.2 %) experienced mAEs: delayed mucosal barrier failure (n = 13, 0.8 %; 95 %CI 0.4 % – 1.3 %), delayed bleeding (n = 3, 0.2 %; 95 %CI 0.04 % – 0.5 %), hydrothorax (n = 8, 0.5 %; 95 %CI 0.2 % – 0.9 %), pneumothorax (n = 25, 1.5 %; 95 %CI 1.0 % – 2.2 %), and miscellaneous (n = 6, 0.4 %; 95 %CI 0.1 % – 0.8 %). Four patients (0.2 %) required ICU admission. No surgical conversion occurred, and 30-day mortality was zero. In stepwise multivariate regression, institution experience of < 1 year (odds ratio [OR] 3.85, 95 %CI 1.49 – 9.95), air insufflation (OR 3.41, 95 %CI 1.37 – 8.50), and mucosal edema (OR 2.01, 95 %CI 1.14 – 3.53) were identified as related risk factors. After introducing CO₂ insufflation, the mAE rate declined to 1.9 % (95 %CI 1.2 % – 2.7 %) and seemed to plateau after 3.5 years at ~ 1 %. <b>Conclusion: </b>In general, POEM appears to be a safe procedure. Major adverse events were rare and could usually be prevented or anticipated, and were all managed effectively.