Background and study aims Ambient air is the most commonly used gas for insufflation in endoscopic procedures worldwide. However, prolonged absorption of air during endoscopic examinations may cause pain and abdominal distension. Carbon dioxide insufflation (CO2i) has been increasingly used as an alternative to ambient air insufflation (AAi) in many endoscopic procedures due to its fast diffusion properties and less abdominal distention and pain. For endoscopic retrograde cholangiopancreatography (ERCP), use of CO2 for insufflation is adequate because this procedure is complex and prolonged. Some randomized controlled trials (RCTs) have evaluated the efficacy and safety of CO2 as an insufflation method during ERCP but presented conflicting results. This systematic review and meta-analysis with only RCTs evaluated the efficacy and safety of CO2i versus AAi during ERCP. Methods A literature search was performed using online databases with no restriction regarding idiom or year of publication. Data were extracted by two authors according to a predefined data extraction form. Outcomes evaluated were abdominal pain and distension, complications, procedure duration, and CO2 levels. Results Eight studies (919 patients) were included. Significant results favoring CO2i were less abdominal distension after 1 h (MD: −1.41 [−1.81; −1.0], 95 % CI, I² = 15 %, P < 0.00001) and less abdominal pain after 1 h (MD: −23.80 [−27.50; −20.10], 95 %CI, I² = 9 %, P < 0.00001) and after 6 h (MD: −7.00 [−8.66; −5.33]; 95 % CI, I² = 0 %, P < 0.00001). Conclusion Use of CO2i instead of AAi during ERCP is safe and associated with less abdominal distension and pain after the procedure.

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Situs inversus totalis is an extremely rare autosomal recessive disorder occurring in 0.01% of the population. The reversal of visceral organs poses technical difficulties for therapeutic intervention during endoscopic retrograde cholangiopancreatography (ERCP). We describe a unique case of a patient with situs inversus who underwent therapeutic ERCP for management of choledocholithiasis. Case StudyA 37-year-old woman with a history of situs inversus totalis, complex congenital cyanotic heart disease, polysplenia and laparoscopic partial cholecystectomy performed 10 years prior, presented with post-prandial right upper quadrant pain and nausea. She had elevated bilirubin, and computed tomography (CT) scan showed cholelithiasis in the remnant gallbladder. An endoscopic retrograde cholangiopancreatography (ERCP) was performed for possible choledocholithiasis. Patient was placed in the left oblique position. There was altered anatomy of the gastric curvature and the ampulla was located in the 2 o'clock position. Biliary access was achieved by keeping the scope in the long position, rotating the duodenoscope 180o, and rotating the sphincterotome to the right side. Cholangiogram showed a mirror image of the transposed biliary tree and remnant gallbladder with filling defectsconsistent with cholelithiasis. Biliary sphincterotomy was performed and balloon sweep showed biliary stone fragments, consistent with choledocholithiasis. She subsequently underwent cholecystectomy for removal of the remnant gallbladder.Situs inversus is a rare benign congenital anomaly that may pose difficulty during ERCP [1]. Different techniques have been used for biliary access in patients with situs inversus such as, a "mirror image" ERCP technique with the endoscopic maneuvers performed in an inverse fashion, or positioning the patient lying prone on her right side [2,3]. In our case biliary access is easily achievable in patients with situs inversus by keeping the patient in the left oblique position, along with maneuvering the duodenoscope and sphincterotome towards the inversed position of the ampulla.

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