Pneumomediastinum and pneumoperitoneum on computed tomography after peroral endoscopic myotomy (POEM): postoperative changes or complications?

Abstract

Background

Many of the acute alterations after peroral endoscopic myotomy (POEM) may be of little clinical significance, while others may herald major clinical problems. The question whether pneumomediastinum/pneumoperitoneum is a normal postoperative finding after POEM, or should be regarded as a sign of a complication needs to be evaluated. Familiarity with these findings in computed tomography (CT) is essential for radiologists.

Purpose

To evaluate whether or not pneumomediastinum/pneumoperitoneum detected by chest CT is a sign of a complication after POEM using CO₂ insufflation for esophageal achalasia.

Material and Methods

One hundred and eight patients with esophageal achalasia who underwent chest CT within 30 hours after POEM were included. CT findings were retrospectively reviewed by two radiologists in consensus. The correlation between pneumomediastinum and/or pneumoperitoneum shown on CT and the development of complications was analyzed.

Results

Abnormal findings were identified on post-treatment CT, including pneumomediastinum and/or pneumoperitoneum (53.7%, 58/108), pneumothorax (0.9%, 1/108), subcutaneous emphysema (29.6%, 32/108), pleural effusion (69.4%, 75/108), segmental atelectasis of lung tissue (29.6%, 32/108), minor inflammation of lungs (69.4%, 75/108), and ascites (0.9%, 1/108). Pneumomediastinum and pneumoperitoneum were observed simultaneously in 29 cases. The incidence rate of mild complications was high (79.6%, 86/108), while the rate of severe complications was low (2.8%, 3/108). There was no significant correlation between the occurrence of pneumomediastinum and/or pneumoperitoneum on CT and the development of complications (P = 0.542), or the development of severe complications including delayed hemorrhage, esophageal perforation, and retroperitoneal abscess.

Conclusion

Pneumomediastinum and pneumoperitoneum detected by CT occur frequently after POEM and may be regarded as normal postoperative changes.

Keywords

Esophageal achalasia peroral endoscopic myotomy (POEM)Computed tomography (CT)X-ray complications

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References

O’Neill

Johnston

Coleman

. Achalasia: a review of clinical diagnosis, epidemiology, treatment and outcomes. World J Gastroenterol 2013; 19: 5806–5812.

Pasricha

Hawari

Ahmed

. Submucosal endoscopic esophageal myotomy: a novel experimental approach for the treatment of achalasia. Endoscopy 2007; 39: 761–764.

Inoue

Minami

Kobayashi

. Peroral endoscopic myotomy (POEM) for esophageal achalasia. Endoscopy 2010; 42: 265–271.

Friedel

Modayil

Iqbal

. Per-oral endoscopic myotomy for achalasia: An American perspective. World J Gastrointest Endosc 2013; 5: 420–427.

Von Renteln

Fuchs

Fockens

. Peroral endoscopic myotomy for the treatment of achalasia: an international prospective multicenter study. Gastroenterology 2013; 145: 309–311.

Zhou

Yao

. Peroral endoscopic remyotomy for failed Heller myotomy: a prospective single-center study. Endoscopy 2013; 45: 161–166.

Swanstrom

Kurian

Dunst

. Long-term outcomes of an endoscopic myotomy for achalasia: the POEM procedure. Ann Surg 2012; 256: 659–667.

Ren

Zhong

Zhou

. Perioperative management and treatment for complications during and after peroral endoscopic myotomy (POEM) for esophageal achalasia (EA) (data from 119 cases). Surg Endosc 2012; 26: 3267–3272.

Millitz

Moote

Sparrow

. Pneumoperitoneum after laparoscopic cholecystectomy: frequency and duration as seen on upright chest radiographs. Am J Roentgenol 1994; 163: 837–839.

10.

Hope

Heniford

Norton

. Duration and clinical significance of radiographically detected “free air” after laparoscopic nephrectomy. Surg Laparosc Endosc Percutan Tech 2009; 19: 415–418.

11.

Watari

Tomita

Toyoshima

. The incidence of “silent” free air and aspiration pneumonia detected by CT after gastric endoscopic submucosal dissection. Gastrointest Endosc 2012; 76: 1116–1123.

12.

Maeda

Hirasawa

Fujita

. A pilot study to assess mediastinal emphysema after esophageal endoscopic submucosal dissection with carbon dioxide insufflation. Endoscopy 2012; 44: 565–571.

13.

Shimizu

Kato

Yamamoto

. Endoscopic clip application for closure of esophageal perforations caused by EMR. Gastrointest Endosc 2004; 60: 636–639.

14.

De Lutio di Castelguidone

Pinto

Merola

. Role of spiral and multislice computed tomography in the evaluation of traumatic and spontaneous oesophageal perforation. Our experience. Radiol Med 2005; 109: 252–259.

15.

Chen

. Esophagography after pneumomediastinum without CT findings of esophageal perforation: is it necessary? Am J Roentgenol 2013; 201: 977–984.

16.

White

Templeton

Attar

. Esophageal perforation: CT findings. Am J Roentgenol 1993; 160: 767–770.

17.

Tamiya

Nakahara

Kominato

. Pneumomediastinum is a frequent but minor complication during esophageal endoscopic submucosal dissection. Endoscopy 2010; 42: 8–14.

18.

Maeda

Hirasawa

Fujita

. Mediastinal emphysema after esophageal endoscopic submucosal dissection: its prevalence and clinical significance. Dig Endosc 2011; 23: 221–226.

19.

Gayer

Jonas

Apter

. Postoperative pneumoperitoneum as detected by CT: prevalence, duration, and relevant factors affecting its possible significance. Abdom Imaging 2000; 25: 301–305.