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Endoscopy 2013; 45(05): 335-341
DOI: 10.1055/s-0032-1326199
Original article
© Georg Thieme Verlag KG Stuttgart · New York

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

Y. Maeda
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
D. Hirasawa
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
N. Fujita
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
T. Obana
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
T. Sugawara
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
T. Ohira
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
Y. Harada
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
T. Yamagata
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
K. Suzuki
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
Y. Koike
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
J. Kusaka
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
M. Tanaka
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
,
Y. Noda
Department of Gastroenterology, Sendai City Medical Center, Sendai, Japan
› Author Affiliations
Further Information

Publication History

submitted 14 August 2012

accepted after revision 20 November 2012

Publication Date:
06 March 2013 (online)

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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
    CrossrefPubMedGoogle Scholar
  • 2 Rogers BH. The safety of carbon dioxide insufflation during colonoscopic electrosurgical polypectomy. Gastrointest Endosc 1974; 20: 115-117
    CrossrefPubMedGoogle Scholar
  • 3 Bretthauer M, Hoff GS, Thiis-Evensen E et al. Air and carbon dioxide volumes insufflated during colonoscopy. Gastrointest Endosc 2003; 58: 203-206
    CrossrefPubMedGoogle Scholar
  • 4 Church J, Delaney C. Randomized, controlled trial of carbon dioxide insufflation during colonoscopy. Dis Colon Rectum 2003; 46: 322-326
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    Google Scholar
  • 14 Oyama T, Tomori A, Hotta K et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol 2005; 3: 67-70
    CrossrefPubMedGoogle Scholar
  • 15 Hirasawa D, Fujita N, Ishida K et al. Handmade outer flashing channel for safe endoscopic submucosal dissection. Dig Endosc 2005; 17: 183-185
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 19 Training Committee. Training guideline for use of propofol in gastrointestinal endoscopy. Gastrointest Endosc 2004; 60: 167-172
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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.
    PubMedGoogle Scholar
  • 22 Lee TY, Chhem RK. Impact of new technologies on dose reduction in CT. Eur J Radiol 2010; 76: 28-35
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 26 Stevenson GW, Wilson JA, Wilkinson J et al. Pain following colonoscopy: elimination with carbon dioxide. Gastrointest Endosc 1992; 38: 564-567
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 28 Japanese Gastric Cancer Association. Japanese classification of gastric carcinoma: 3rd English edition. Gastric Cancer 2011; 14: 101-112
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 30 Gotoda T. Endoscopic resection of early gastric cancer. Gastric Cancer 2007; 10: 1-11
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Saltzman HA, Sieker HO. Intestinal response to changing gaseous environments: normobaric and hyperbaric observations. Ann N Y Acad Sci 1968; 150: 31-39
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 37 Sadove MS, Balagot RC. Pentazocine – a new nonaddicting analgesic. A double-blind evaluation in postoperative pain. JAMA 1965; 193: 887-892
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 39 Wolf Jr JS. Pathophysiologic effects of prolonged laparoscopic operation. Semin Surg Oncol 1996; 12: 86-95
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 42 Finsterer J, Stöllberger C, Bastovansky A. Cardiac and cerebral air embolism from endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol 2010; 22: 1157-1162
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 45 Nayagam J, Ho KM, Liang J. Fatal systemic air embolism during endoscopic retrograde cholangio-pancreatography. Anaesth Intensive Care 2004; 32: 260-264
    PubMedGoogle Scholar
  • 46 Stabile L, Cigada M, Stillittano D et al. Fatal cerebral air embolism after endoscopic retrograde cholangiopancreatography. Acta Anaesthesiol Scand 2006; 50: 648-649
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 48 Green B, Tendler DA. Cerebral air embolism during upper endoscopy: case report and review. Gastrointest Endosc 2005; 61: 620-622
    CrossrefPubMedGoogle Scholar
  • 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
    Article in Thieme ConnectPubMedGoogle Scholar
  • 50 Rai A, Iftikhan S. Tension pneumothorax complicating diagnostic upper endoscopy: a case report. Am J Gastroenterol 1999; 94: 845-847
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    PubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar
  • 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
    CrossrefPubMedGoogle Scholar