Perioperative aspiration risk mitigation in a patient with type II achalasia undergoing laparoscopic Heller’s myotomy: A case report.

Vanessa Anza Mukhuba; Claudia Currie Meg; Mogane Palesa N

doi:10.51168/6tr0pw27

Authors

Dr Mukhuba Anza Vanessa Department of Anesthesia at University of the Witwatersrand,Chris hani Baragwanath academic hospital
Dr Claudia Meg Currie Registrar, Department of Anaesthesia at University of the Witwatersrand. Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa
Mogane Palesa N Head of the department, Department of Anaesthesia at University of the Witwatersrand. Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.

DOI:

https://doi.org/10.51168/6tr0pw27

Keywords:

achalasia, pulmonary aspiration, rapid sequence induction

Abstract

Background

Achalasia is a rare oesophageal motility disorder characterised by impaired lower oesophageal sphincter relaxation and absent peristalsis. Progressive oesophageal dilatation results in retained food and secretions despite prolonged fasting, placing patients at high risk of regurgitation and pulmonary aspiration during general anaesthesia. There are no validated perioperative aspiration risk guidelines specific to achalasia. This report aims to describe the perioperative anaesthetic management and aspiration risk mitigation strategies employed in a patient with type II achalasia undergoing a Heller’s myotomy.

Case presentation

This report describes the anaesthetic management of a 20-year-old male with type II achalasia undergoing laparoscopic Heller myotomy. Despite prolonged fasting of 15 hours for solids and 12 hours for clear fluids, pre-induction nasogastric decompression yielded approximately 800 mL of particulate oesophageal material. Anaesthetic management included head-up positioning, rapid sequence induction with cricoid pressure, continuous nasogastric suctioning, and the use of the suction-assisted laryngoscopy and airway decontamination (SALAD) technique. Endotracheal intubation was successful on the first attempt without regurgitation. Surgery and recovery were uneventful.

Take-away lessons

Patients with achalasia should be considered high aspiration risk regardless of fasting duration. Prolonged fasting alone may not eliminate retained oesophageal contents. Individualised perioperative planning incorporating dietary modification, oesophageal decompression, protected airway management, and cautious extubation may reduce aspiration risk. Further prospective research is needed to establish evidence-based perioperative management protocols for achalasia.

Author Biographies

Dr Mukhuba Anza Vanessa, Department of Anesthesia at University of the Witwatersrand,Chris hani Baragwanath academic hospital

is a medical officer in anaesthesiology at Chris Hani Baragwanath Academic Hospital (CHBAH) and is due to commence a registrar post in the near future. Her clinical and academic interests include paediatric anaesthesia, peri-operative anaesthesia, and pain management.
Dr Claudia Meg Currie, Registrar, Department of Anaesthesia at University of the Witwatersrand. Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa

is a medical registrar in anaesthesiology at Chris Hani Baragwanath Academic Hospital (CHBAH). Her clinical and academic interests include paediatric anaesthesia and difficult airway management.
Mogane Palesa N, Head of the department, Department of Anaesthesia at University of the Witwatersrand. Chris Hani Baragwanath Academic Hospital, Johannesburg, South Africa.

is a specialist anaesthesiologist actively involved in undergraduate and postgraduate teaching, examination, and research supervision. Her clinical and academic interests include paediatric anaesthesia, critical care, and peri-operative risk assessment.

References

1. Patel DA, Lappas BM, Vaezi MF. An overview of achalasia and its subtypes. Gastroenterol Hepatol (N Y).2017;13(7):411-421. PMID: 28867969; PMCID: PMC5572971.

2. Vaezi MF, Pandolfino JE, Yadlapati RH, Greer KB, Kavitt RT. ACG clinical guidelines: diagnosis and management of achalasia. Am J Gastroenterol. 2020;115(9):1393-1411. https://doi.org/10.14309/ajg.0000000000000731

3. Yadlapati R, et al. Esophageal motility disorders on high-resolution manometry: Chicago classification version 4.0. Neurogastroenterol Motil. 2021;33(1):e14058. doi:10.1111/nmo. 14058

4. Sanli M, Akbulut S, Ucar M, Bilgic Y. Evaluation of anesthesia management during peroral endoscopic myotomy in patients with achalasia: a retrospective study. J Clin Med. 2025;14(18):6504. https://doi.org/10.3390/jcm14186504

5. El-Boghdadly K, Wojcikiewicz T, Perlas A. Perioperative point-of-care gastric ultrasound. BJA Educ. 2019;19(7):219-26. https://doi.org/10.1016/j.bjae.2019.03.003

6. Sadowski DC, Ackah F, Jiang B, Svenson LW. Achalasia: incidence, prevalence, and survival. A population-based study. Neurogastroenterol Motil. 2010;22(9):e256-e261. https://doi.org/10.1111/j.1365-2982.2010.01511.x

7. Mohapatra S, Mashar G, Bhaskar B, Aneez A. Anaesthetic challenges of achalasia cardia. Int J Med Anesthesiol. 2023;6(1):126-129. https://doi.org/10.33545/26643766.2023.v6.i1b.384

8. Warner MA, Warner Me, Weber JG. Clinical significance of pulmonary aspiration during the perioperative period. Anesthesiology 1993: 78: 56-62 https://doi.org/10.1097/00000542-199301000-00010

9. Son YG, Shin J, Ryu HG. Pneumonitis and pneumonia after aspiration. J Dent Anesth Pain Med. 2017;17(1):1-12. https://doi.org/10.17245/jdapm.2017.17.1.1

10. Robinson M, Davidson A. Aspiration under anaesthesia: risk assessment and decision-making. Continuing Education in Anaesthesia, Critical Care and Pain. 2014;14(4):171-5. https://doi.org/10.1093/bjaceaccp/mkt053

11. Tanaka E, Murata H, Minami H, Sumikawa K. Anesthetic management of peroral endoscopic myotomy for esophageal achalasia: a retrospective case series. J Anesth. 2014;28(3):456-459. https://doi.org/10.1007/s00540-013-1735-0

12. Nishihara Y, Yoshida T, Ooi M, et al. Anesthetic management and associated complications of peroral endoscopic myotomy: a case series. World J Gastrointest Endosc. 2018;10(9):193-199. https://doi.org/10.4253/wjge.v10.i9.193

13. Haraguchi-Suzuki K, Aso C, Nomura M, Saito S. Anesthetic management of a patient with achalasia, a disease with a considerable risk for aspiration under anesthesia. JA Clin Rep. 2023;9(1):59. https://doi.org/10.1186/s40981-023-00650-8

14. Darisetty S, Nabi Z, Ramchandani M, et al. Anesthesia in per-oral endoscopic myotomy: a large tertiary care centre experience. Indian J Gastroenterol. 2017;36(4):305-312. https://doi.org/10.1007/s12664-017-0782-0

15. Yang D, Pannu D, Zhang Q, White JD, Draganov PV. Evaluation of anesthesia management, feasibility, and efficacy of peroral endoscopic myotomy (POEM) for achalasia was performed in the endoscopy unit. Endosc Int Open. 2015;3(4):E289-E295. https://doi.org/10.1055/s-0034-1392054

16. Jayan N, Jacob JS, Mathew M, Mukkada RJ. Anesthesia for peroral endoscopic myotomy: a retrospective case series. J Anaesthesiol Clin Pharmacol. 2016;32(3):379-381. https://doi.org/10.4103/0970-9185.188829

17. Goudra B, Singh PM, Gouda G, Sinha AC. Peroral endoscopic myotomy: initial experience with anesthetic management of 24 procedures and systematic review. Anesth Essays Res. 2016;10(2):297-300. https://doi.org/10.4103/0259-1162.171462

18. Löser B, Werner YB, Punke MA, et al. Anesthetic considerations for patients with esophageal achalasia undergoing peroral endoscopic myotomy: a retrospective case series review. Can J Anaesth. 2017;64(5):480-488. https://doi.org/10.1007/s12630-017-0820-5

19. Vanhauwaert E, et al. Low-residue and low-fiber diets in gastrointestinal disease management. Adv Nutr. 2015;6(6):820-7. https://doi.org/10.3945/an.115.009688

20. Lijoi D, et al. Bowel preparation before laparoscopic gynaecological surgery in benign conditions using a 1-week low fibre diet: a surgeon-blinded, randomized and controlled trial. Arch Gynecol Obstet. 2009;280(5):713-8. https://doi.org/10.1007/s00404-009-0986-3

21. Zhu S, et al. Sonographic anatomy of the cervical esophagus. J Clin Ultrasound. 2004;32(4):163-71. https://doi.org/10.1002/jcu.20017

22. Ip JYC, Lo KM. Perioperative management of patients with aspiration risk. Anaesth Intensive Care Med. 2024;25(8):550-4. https://doi.org/10.1016/j.mpaic.2024.06.020

23. Ali, T.O., El-Boghdadly, K. The Role of Cricoid Pressure in Rapid Sequence Induction. Curr Anesthesiol Rep 14, 497-502 (2024). https://doi.org/10.1007/s40140-024-00643-y

24. Root, C.W. et al. Suction-assisted laryngoscopy and airway decontamination (salad): A technique for improved emergency airway management, Resuscitation Plus. 2020, 1-2, p.100005. https://doi.org/10.1016/j.resplu.2020.100005