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.