Insufflation with carbon dioxide reduces pneumoperitoneum after percutaneous endoscopic gastrostomy (PEG): a randomized controlled trial

Background and study aims: Pneumoperitoneum following PEG placement has been reported in up to 60 % of cases, and while usually benign and self-limited, it can lead to evaluation for suspected perforation. This study was designed to determine whether using CO₂ compared to ambient air for insufflation during PEG reduces post-procedure pneumoperitoneum.

Patients and Methods: Prospective, double-blind, randomized trial of 35 consecutive patients undergoing PEG at a single academic medical center. Patients were randomized to insufflation with CO₂ or ambient air. The primary outcome was pneumoperitoneum determined by left-lateral decubitus abdominal x-rays 30 minutes after PEG placement. Secondary endpoints included abdominal distention, pain, and bloating.

Results: PEG was successfully placed in 17 patients using CO₂ and 18 patients using ambient air. Three patients in each arm were unable or declined to have x-rays completed and were excluded. Pneumoperitoneum was identified in 2/14 (14.3 %) using CO₂ and 8/15 (53.3 %) using ambient air (P = 0.05). There was no significant difference in abdominal distention, visual analog scale (VAS) scores for pain or bloating between CO₂ and ambient air.

Conclusion: Utilizing CO₂ significantly reduces the frequency of post-procedural pneumoperitoneum compared to use of ambient air during PEG placement, with no difference in waist circumference, pain or bloating between CO₂ and ambient air. CO₂ appears to be safe and effective for use and may be the insufflation agent of choice during PEG.

• References

• 1 Gauderer MW, Ponsky JL, Izant RJ. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Ped Surg 1980; 15: 872-875
• 2 Schrag SP, Sharma R, Jaik NP et al. Complications related to percutaneous endoscopic gastrostomy (PEG) tubes. A comprehensive clinical review. J Gastrointestin Liver Dis 2007; 16: 407-418
• 3 Dulabon GR, Abrams JE, Rutherford EJ. The incidence and significance of free air after percutaneous endoscopic gastrostomy. Am Surg 2002; 68: 590-593
• 4 Wiesen AJ, Sideridis K, Fernandes A et al. True incidence and clinical significance of pneumoperitoneum after PEG placement: a prospective study. Gastrointest Endosc 2006; 64: 886-889
• 5 Wojtowycz MM, Arata Jr. JA, Micklos TJ et al. CT findings after uncomplicated percutaneous gastrostomy. AJR Am J Roentgenol 1988; 151: 307-309
• 6 Gottfried EB, Plumser AB, Clair MR. Pneumoperitoneum following percutaneous endoscopic gastrostomy. A prospective study. Gastrointest Endosc 1986; 32: 397-399
• 7 Nishiwaki S, Araki H, Hayashi M et al. Inhibitory effects of carbon dioxide insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy. World J Gastroenterol 2012; 18: 3565-3570 ( DOI: 10.3748/wjg.v18.i27.3565. )
• 8 Snape J, Poon M, Green J et al. Pneumoperitoneum following PEG insertion: a clinical dilemma. Acute Med 2010; 9: 120-121
• 9 Wu J, Hu B. The role of carbon dioxide insufflation in colonoscopy: a systematic review and meta-analysis. Endoscopy 2012; 44: 128-136 ( DOI: 10.1055/s-0031-1291487. )
• 10 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
• 11 Maple JT, Keswani RN, Hovis RM et al. Carbon dioxide insufflation during ERCP for reduction of postprocedure pain: a randomized, double-blind, controlled trial. Gastrointest Endosc 2009; 70: 278-283 ( DOI: 10.1016/j.gie.2008.12.050. )
• 12 Dellon ES, Hawk JS, Grimm IS et al. The use of carbon dioxide for insufflation during GI endoscopy: a systematic review. Gastrointest Endosc 2009; 69: 843-849 ( DOI: 10.1016/j.gie.2008.05.067. )
• 13 Paspatis GA, Dumonceau JM, Barthet M et al. Diagnosis and management of iatrogenic endoscopic perforations: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2014; 46: 693-711
• 14 Seo EH, Kim TO, Park MJ et al. The efficacy and safety of carbon dioxide insufflation during colonoscopy with consecutive esophagogastroduodenoscopy in moderately sedated outpatients: a randomized, double-blind, controlled trial. J Clin Gastroenterol 2013; 47: 45-49