Prolonged carbon dioxide insufflation under general anesthesia for endoscopic submucosal dissection

Background and study aims: Carbon dioxide (CO₂) insufflation for endoscopy has been reported to provide superior recovery and is expected to reduce the risk of serious complications, including air embolism and tension pneumothorax, whereas general anesthesia offers some advantages not found under intravenous sedation. Little is known about the effect of prolonged CO₂ insufflation into gastrointestinal tracts on arterial CO₂ tension (PaCO₂). Here we introduce the use of general anesthesia with CO₂ insufflation for esophagogastroduodenal endoscopic submucosal dissection (ESD).

Patients and methods: A prospective observational study was conducted in a university-affiliated hospital. A total of 100 patients were scheduled for esophagogastroduodenal ESD under general anesthesia with CO₂ insufflation, using standardized anesthesia techniques and unchanged ventilatory settings. Arterial blood gas analyses were repeated at predetermined time intervals.

Results: Of the initial 100 participants, 94 patients undergoing ESD and four patients undergoing endoscopic mucosal resection completed the study. The median procedure time was 122 minutes (range 29 – 309 minutes). The median baseline PaCO₂ of 28 mmHg increased to a median peak PaCO₂ of 39 mmHg (P < 0.001), with marked inter-individual variability in the time courses of changes in PaCO₂. The correlation coefficient of PaCO₂ with the procedure time was low (r = 0.194; n = 577, P < 0.0001). FEV_1.0 % (forced expiratory volume in 1 second/forced vital capacity) of < 70 % and esophagoscopy vs. gastroduodenoscopy were relative enhancement factors of PaCO₂.

Conclusion: Increases of PaCO₂ during esophagogastroduodenal ESD under general anesthesia with CO₂ insufflation remained within acceptable or readily controllable ranges, and are little enhanced by prolongation of the procedure. Esophagogastroduodenal ESD can be performed safely and feasibly with this procedure.

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