In the current era of third space endoscopy, intramural esophageal interventions such as per-oral endoscopic myotomy (POEM) are becoming standard of care for achalasia disorders and its variants (1). Clinicians need to be aware of the potential complications such as esophageal leaks but also of potentially benign entities such as capnomediastinum and capnoperitoneum (2).
An 80-year-old female patient was referred for an esophagogastric junction outflow obstruction. She presented with severe dysphagia, regurgitations and weight loss. The patient underwent a posterior POEM procedure under general anaesthesia with CO2 insufflation. A selective, short 5 cm myotomy of the circular muscular fibres at the gastroesophageal junction was followed by an uneventful clip closure of the mucosotomy.
During the procedure, a moderate rise in end tidal CO2 levels was noted. At the end of the intervention, abdominal distension was present. Given the normal hemodynamic and respiratory status, Veress needle decompression was not performed.
Postoperative recovery was remarkable for significant diffuse and persistent subcutaneous emphysema in an otherwise asymptomatic patient. A CT scan following the administration of oral iodinated contrast was performed (Figure 1A–C). Complete resolution of the subcutaneous emphysema was noted after 4 days following conservative treatment. Three months postoperative follow-up is unremarkable.
Figure 1.
CT images following administration of intravenous and oral contrast reveal (A) evidence of massive subcutaneous cervical emphysema with CO2 tracking towards both upper arms; (B) extensive pneumomediastinum and subcutaneous thoracic emphysema and (C) massive pneumoperitoneum in the upper abdomen with subcutaneous emphysema in the abdominal wall.
Post intervention air leakage into the mediastinal or peritoneal cavity is usually synonym with gastrointestinal tract leak. As this case illustrates, even massive capnomediastinum and capnoperitoneum post-POEM can be safely treated conservatively in a hemodynamically stable patient, once a perforation has been ruled out.
References
- 1. Shiwaku H, Inoue H, Onimaru M, et al. Multicenter collaborative retrospective evaluation of peroral endoscopic myotomy for esophageal achalasia: Analysis of data from more than 1300 patients at eight facilities in Japan. Surg Endosc 2020;34(1):464–8. [DOI] [PubMed] [Google Scholar]
- 2. Lee E, Brodsky JB, Rivas H, et al. Capnoperitoneum during peroral endoscopic myotomy-recognition and management: A case report. A A Case Rep 2017;8(6):145–6. [DOI] [PubMed] [Google Scholar]