S2258 Subcutaneous Emphysema of the Penile Shaft: A Rare Complication of Peroral Endoscopic Myotomy

Introduction: Peroral endoscopic myotomy (POEM) is a procedure introduced in 2010 that has gained notoriety in recent years for the treatment of achalasia, largely replacing the conventional Heller myotomy. It has been shown to have less complications than traditional management and many patients no longer require symptomatic management after the procedure. As with any procedure, adverse events can occur. In the case of POEM, these include perforation, bleeding, and events related to insufflation, such as pneumothorax, pneumoperitoneum, and subcutaneous emphysema. Case Description/Methods: A 64 y.o male with a past medical history of hypertension and GERD underwent POEM for persistent achalasia. FLIP panometry showed evidence of Type 1 achalasia. Gas insufflation with CO2 was utilized to distend the esophagus and mucosal tissues in order to create a submucosal tunnel. A full thickness myotomy in a posterior orientation was started at 35cm from the incisors and was extended to 42 cm from the incisors, with extension into the cardia by 3cm. The tunnel was closed with endoscopic clips and hemostasis was obtained. During the procedure, there was build-up of CO2 in the abdomen during the procedure, necessitating needle decompression after the POEM was completed. During the decompression, while under anesthesia, the patient had a violent coughing episode. During post-operative recovery, asymptomatic crepitus of the penile shaft was discovered, presumably due to the coughing episode and tracking of carbon dioxide into the distal tissues. Patient continued to display crepitus during the remainder of his hospital stay that was nontender and did not interfere with urination. Discussion:: Peroral Endoscopic myotomy (POEM) is now considered the first line for treatment of achalasia due to its safety and effectiveness of symptom reduction shown by multiple meta-analyses. Although adverse events are rare, the highest risk is for insufflation complications, especially subcutaneous emphysema. This case presentation is unique because this is the first mention of subcutaneous emphysema of the penile shaft, as extension is typically only into the legs, chest, head neck, labia, or scrotum.