A prospective, randomized, double-blind, controlled trial on the efficacy of carbon dioxide insufflation in gastric endoscopic submucosal dissection

Background and study aims: Carbon dioxide (CO₂) insufflation is expected to be safe and effective in endoscopic submucosal dissection (ESD) as well as in other endoscopic procedures. The present study aimed to clarify the usefulness and safety of CO₂ insufflation in gastric ESD.

Patients and methods: A total of 102 consecutive patients were randomly assigned to CO₂ insufflation (CO₂ group, n = 54) or air insufflation (Air group, n = 48). Abdominal pain and distension were chronologically recorded on a 100-mm visual analog scale (VAS). The volume of residual gas in the digestive tract was measured by computed tomography performed immediately after ESD.

Results: Abdominal pain on a 100-mm VAS in the CO₂ vs. Air group was 4 vs. 3 immediately after ESD, 4 vs. 4 one hour after the procedure, 3 vs. 3 three hours after the procedure, and 1 vs. 4 the next morning, showing no difference between the groups. In addition, there was no difference in abdominal distension on the 100-mm VAS over the time course of the study. The volume of residual gas in the digestive tract in the CO₂ group was significantly smaller than that in the Air group (643 mL vs. 1037 mL, P < 0.001). The dose of sedative drugs did not differ between the groups. Neither the incidences of complications nor clinical courses differed between the groups.

Conclusions: Compared with air insufflation, CO₂ insufflation during gastric ESD significantly reduced the volume of residual gas in the digestive tract but not the VAS score of abdominal pain and distension.

• References

• 1 Evan D, James H, Ian G et al. The use of carbon dioxide for insufflations during GI endoscopy: a systematic review. Gastrointestinal Endoscopy 2009; 69: 843-849
• 2 Rogers BH. The safety of carbon dioxide insufflation during colonoscopic electrosurgical polypectomy. Gastrointest Endosc 1974; 20: 115-117
• 3 Bretthauer M, Hoff GS, Thiis-Evensen E et al. Air and carbon dioxide volumes insufflated during colonoscopy. Gastrointest Endosc 2003; 58: 203-206
• 4 Church J, Delaney C. Randomized, controlled trial of carbon dioxide insufflation during colonoscopy. Dis Colon Rectum 2003; 46: 322-326
• 5 Sumanac K, Zealley I, Fox BM et al. Minimizing postcolonoscopy abdominal pain by using CO₂ insufflation: a prospective, randomized, double blind, controlled trial evaluating a new commercially available CO₂ delivery system. Gastrointest Endosc 2002; 56: 190-194
• 6 Maple JT, Keswani RN, Hovis RM et al. Carbon dioxide insufflations during ERCP for reduction of postprocedure pain: a randomized, double-blind, control trial. Gastrointestinal Endoscopy 2009; 70: 278-283
• 7 Evan D, James H, Ian G et al. The use of carbon dioxide for insufflations during GI endoscopy: a systematic review. Gastrointestinal Endoscopy 2009; 69: 843-849
• 8 Nonaka T, Saito Y, Takisawa H et al. Safety of carbon dioxide insufflations for upper gastrointestinal tract endoscopic treatment of patients under deep sedation. Surg Endosc 2010; 24: 1638-1645
• 9 Suzuki T, Minami H, Komatsu T et al. Prolonged carbon dioxide insufflations under general anesthesia for endoscopic submucosal dissection. Endoscopy 2010; 42: 1021-1029
• 10 Saito Y, Uraoka T, Matsuda T et al. A pilot study to assess the safety and efficacy of carbon dioxide insufflations during colorectal endoscopic submucosal dissection with the patient under conscious sedation. Gastrointest Endosc 2007; 65: 537-542
• 11 Kikuchi T, Fu K, Saito Y et al. Transcutaneous monitoring of partial pressure of carbon dioxide during endoscopic submucosal dissection of early colorectal neoplasia with carbon dioxide insufflation: a prospective study. Surg Endosc 2010; 24: 2231-2235
• 12 Maeda Y, Hirasawa D, Fujita N et al. A pilot study to assess mediastinal emphysema after esophageal endoscopic submucosal dissection with insufflation of carbon dioxide. Endoscopy 2012; 44: 565-571
• 13 Committee for the Third Edition of the COPD Guidelines of The Japanese Respiratory Society. Guidelines for the diagnosis and treatment of COPD (chronic obstructive pulmonary disease). 3rd. edition Tokyo: The Japanese Respiratory Society; 2009
• 14 Oyama T, Tomori A, Hotta K et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol 2005; 3: 67-70
• 15 Hirasawa D, Fujita N, Ishida K et al. Handmade outer flashing channel for safe endoscopic submucosal dissection. Dig Endosc 2005; 17: 183-185
• 16 Yamagata T, Hirasawa D, Fujita N et al. Efficacy of propofol sedation for endoscopic submucosal dissection (ESD): assessment with prospective data collection. Intern Med 2011; 50: 1455-1460
• 17 Imagawa A, Fujiki S, Kawahara Y et al. Satisfaction with bispectral index monitoring of propofol-mediated sedation during endoscopic submucosal dissection: a prospective, randomized study. Endoscopy 2008; 40: 905-909
• 18 Faigel DO, Baron TH, Goldstein JL et al. Guidelines for the use of deep sedation and anesthesia for GI endoscopy. Gastrointest Endosc 2002; 56: 613-617
• 19 Training Committee. Training guideline for use of propofol in gastrointestinal endoscopy. Gastrointest Endosc 2004; 60: 167-172
• 20 Aizawa I, Muramatsu Y, Nomura K et al. Variation in the quality of CT images of the upper abdomen when CT automatic exposure control is employed (Article in Japanese). Nihon Hoshasen Gijutsu Gakkai Zasshi 2010; 66: 185-192
• 21 Funama Y, Sugaya Y, Miyazaki O et al. Automatic exposure control at MDCT based on the contrast-to-noise ratio: theoretical background and phantom study. Phys Med In press 2011. DOI: 10.1016/j.ejmp.2011.11.004.
• 22 Lee TY, Chhem RK. Impact of new technologies on dose reduction in CT. Eur J Radiol 2010; 76: 28-35
• 23 Kalra MK, Naz N, Rizzo SM et al. Computed tomography radiation dose optimization: scanning protocols and clinical applications of automatic exposure control. Curr Probl Diagn Radiol 2005; 34: 171-181
• 24 Matsumoto K, Ohno Y, Koyama H et al. 3D automatic exposure control for 64-detector row CT: radiation dose reduction in chest phantom study. Eur J Radiol 2011; 77: 522-527
• 25 Bretthauer M, Seip B, Aasen S et al. Carbon dioxide insufflation for more comfortable endoscopic retrograde cholangiopancreatography: a randomized, controlled, double-blind trial. Endoscopy 2007; 39: 58-64
• 26 Stevenson GW, Wilson JA, Wilkinson J et al. Pain following colonoscopy: elimination with carbon dioxide. Gastrointest Endosc 1992; 38: 564-567
• 27 Bretthauer M, Thiis-Evensen E, Huppertz-Hauss G et al. NORCCAP (Norwegian colorectal cancer prevention): a randomised trial to assess the safety and efficacy of carbon dioxide versus air insufflation in colonoscopy. Gut 2002; 50: 604-607
• 28 Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer 2011; 14: 101-112
• 29 Oda I, Gotoda T, Hamanaka H. Endoscopic submucosal dissection for early gastric cancer: technical feasibility, operation time, and complication from a large consecutive series. Dig Endosc 2005; 17: 54-58
• 30 Gotoda T. Endoscopic resection of early gastric cancer. Gastric Cancer 2007; 10: 1-11
• 31 Takizawa K, Oda I, Gotoda T et al. Routine coagulation of visible vessels may prevent delayed bleeding after endoscopic submucosal dissection: an analysis of risk factors. Endoscopy 2008; 40: 179-183
• 32 Saltzman HA, Sieker HO. Intestinal response to changing gaseous environments: normobaric and hyperbaric observations. Ann N Y Acad Sci 1968; 150: 31-39
• 33 Domagk D, Bretthauer M, Lenz P et al. Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: a randomized, controlled, double-blind trial. Endoscopy 2007; 39: 1064-1067
• 34 Hirai F, Beppu T, Nishimura T et al. Cabon dioxide insufflation compared with air insufflation in double-balloon enteroscopy: a prospective, randomized, double-blind trial. Gastrointest Endosc 2011; 73: 743-749
• 35 Dellon ES, Velayudham A, Clarke BW et al. A randomized, controlled, double-blind trial of air insufflation versus carbon dioxide insufflation during ERCP. Gastrointest Endosc 2010; 72: 68-77
• 36 Kuwatani M, Kawakami H, Hayashi T et al. Carbon dioxide insufflation during endoscopic retrograde cholangiopancreatography reduces bowel gas volume but does not affect visual analogue scale scores of suffering: a prospective, double-blind, randomized, controlled trial. Surg Endosc 2011; 25: 3784-3790
• 37 Sadove MS, Balagot RC. Pentazocine – a new nonaddicting analgesic. A double-blind evaluation in postoperative pain. JAMA 1965; 193: 887-892
• 38 Magno R, Medegard A, Bengtsson R et al. Acid base balance during laparoscopy: the effect of intraperitoneal insufflation of carbon dioxide and nitrous oxide on acid-base balance during controlled ventilation. Acta Obstet Gynecol Scand 1979; 58: 81-85
• 39 Wolf Jr JS. Pathophysiologic effects of prolonged laparoscopic operation. Semin Surg Oncol 1996; 12: 86-95
• 40 Uen YH, Liang AI, Lee HH. Randomized comparison of conventional carbon dioxide insufflation and abdominal wall lifting for laparoscopic cholecystectomy. J Laparoendosc Adv Surg Tech A 2002; 12: 7-14
• 41 Nakajima K, Lee SW, Sonoda T et al. Intraoperative carbon dioxide colonoscopy: a safe insufflation alternative for locating colonic lesions during laparoscopic surgery. Surg Endosc 2005; 19: 321-325
• 42 Finsterer J, Stöllberger C, Bastovansky A. Cardiac and cerebral air embolism from endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol 2010; 22: 1157-1162
• 43 Boxel GI, Hommers CE, Dash I et al. Myocardial and cerebral infarction due to massive air embolism following endoscopic retrograde cholangiopancreatography (ERCP). Endoscopy 2010; 42: E80-E81
• 44 Katzgraber F, Glenewinkel F, Fischler S et al. Mechanism of fatal air embolism after gastrointestinal endoscopy. Int J Legal Med 1998; 111: 154-156
• 45 Nayagam J, Ho KM, Liang J. Fatal systemic air embolism during endoscopic retrograde cholangio-pancreatography. Anaesth Intensive Care 2004; 32: 260-264
• 46 Stabile L, Cigada M, Stillittano D et al. Fatal cerebral air embolism after endoscopic retrograde cholangiopancreatography. Acta Anaesthesiol Scand 2006; 50: 648-649
• 47 Bisceglia M, Simeone A, Forlano R et al. Fatal systemic venous air embolism during endoscopic retrograde cholangiopancreatography. Adv Anat Pathol 2009; 16: 255-262
• 48 Green B, Tendler DA. Cerebral air embolism during upper endoscopy: case report and review. Gastrointest Endosc 2005; 61: 620-622
• 49 Morley AP, Lau JY, Young RJ. Tension pneumothorax complicating a perforation of a duodenal ulcer during ERCP with endoscopic sphincterotomy. Endoscopy 1997; 29: 332
• 50 Rai A, Iftikhan S. Tension pneumothorax complicating diagnostic upper endoscopy: a case report. Am J Gastroenterol 1999; 94: 845-847
• 51 Cohnen M, Vogt C, Beck A et al. Feasibility of MDCT Colonography in ultra-low-dose technique in the detection of colorectal lesions: comparison with high-resolution video colonoscopy. AJR Am J Roentgenol 2004; 183: 1355-1359
• 52 Lubner MG, Pickhardt PJ, Tang J et al. Reduced image noise at low-dose multidetector CT of the abdomen with prior image constrained compressed sensing algorithm. Radiology 2011; 260: 248-256
• 53 Hirofuji Y, Aoyama T, Koyama S et al. Evaluation of patient dose for barium enemas and CT colonography in Japan. Br J Radiol 2009; 82: 219-227
• 54 Gelder RE, Venema HW, Florie J et al. CT colonography: feasibility of substantial dose reduction-comparison of medium to very low doses in identical patients. Radiology 2004; 232: 611-620
• 55 Anupindi S, Perumpillichira J, Jaramillo D et al. Low-dose CT colonography in children: initial experience, technical feasibility, and utility. Pediatr Radiol 2005; 35: 518-524
• 56 Florie J, Gelder R, Schutter M et al. Feasibility study of computed tomography colonography using limited bowel preparation at normal and low-dose levels study. Eur Radiol 2007; 17: 3112-3122
• 57 Hough D, Kuntz M, Fidler J et al. Detection of occult colonic perforation before CT colonography after incomplete colonoscopy: perforation rate and use of a low-dose diagnostic scan before CO2 insufflation. AJR Am J Roentgenol 2008; 191: 1077-1081