Large Postperoral Endoscopic Myotomy Capnomediastinum and Capnoperitoneum: A Benign Entity
Bibliographic record
Abstract
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. 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.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.001 | 0.005 |
| Meta-epidemiology (narrow) | 0.002 | 0.001 |
| Meta-epidemiology (broad) | 0.001 | 0.001 |
| Bibliometrics | 0.003 | 0.002 |
| Science and technology studies | 0.003 | 0.003 |
| Scholarly communication | 0.002 | 0.003 |
| Open science | 0.001 | 0.002 |
| Research integrity | 0.006 | 0.003 |
| Insufficient payload (model declined to judge) | 0.003 | 0.001 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".