Capnographic Monitoring during Endoscopic Submucosal Dissection with Patients under Deep Sedation: A Prospective, Crossover Trial of Air and Carbon Dioxide Insufflations

Abstract

Background and Aims: The safety of carbon dioxide (CO₂) insufflation has not been fully established for esophageal and gastric endoscopic submucosal dissection (ESD) under deep sedation, because CO₂ retention is not only caused by CO₂ insufflation but also by the sedation level and the patient’s respiratory status. To clarify the clinical safety of CO₂ insufflation, we conducted a crossover trial of air and CO₂ insufflations. Methods: A total of 60 patients with early esophageal or gastric cancers underwent ESD during which insufflation was switched from CO₂ to air or from air to CO₂; transcutaneous partial pressure CO₂ (PtcCO₂) was monitored in all patients. We also assessed respiratory function, arterial blood gas analysis, and smoking history. Results: Although significant increases in PtcCO₂ from baseline were observed, there were no significant differences in PtcCO₂ levels during CO₂ insufflation compared with levels during air insufflation in groups that received CO₂ preceding air or air preceding CO₂. All patients underwent ESD safely without adverse events, including 20 patients with subclinical respiratory dysfunction. The sedation protocol was the only significant predictor of CO₂ retention, independent of CO₂ insufflation. Conclusions: CO₂ insufflation can be used as safely as air insufflation during ESD under deep sedation.

Meta‐analysis: the use of carbon dioxide insufflation vs. room air insufflation for gastrointestinal endoscopy

“…Thirty‐five abstracts appeared relevant and the full studies were assessed. Further 14 studies were rejected for being a meeting abstract without detailed information or crossover trial, having a nonrandomised control or no control, being a technique survey or animal experiment, involving peroral cholangioscopy or a barium enema, or being a clinical perspective review . Twenty‐one publications were deemed by both authors to be original research and to fit the search criteria.…”

The use of carbon dioxide in gastrointestinal endoscopy

“…52,53 CO 2 , by virtue of its rapid absorption, may reduce the secondary deleterious effects of perforation and is therefore commonly used during high-risk endoscopic procedures. 29 Indeed, extraluminal gas may not even be detected on radiography in patients with ESD-induced perforation, when CO 2 has been used as the insufflation agent. 54,55 A double-blind, randomized, controlled trial comparing CO 2 and air as insufflation agents in 102 patients undergoing gastric ESD found no difference in the mean procedure time, end-tidal CO 2 pressure levels, or minimum oxygen saturation levels.…”

Efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection: a randomized, double-blind, controlled, prospective study

“…Most studies did not focus on procedure-related pain but rather on safety and feasibility. 13,14,31 A PubMed search yielded only one study exploring the efficacy of CO 2 insufflation during gastric ESD. 17 In that study, Maeda et al 17 found that the GI tract contained less gas after CO 2 insufflation, but no between-group difference in either postprocedural pain or discomfort was noted.…”