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

Abstract

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.

Symptomatic Pneumoperitoneum After Gastrostomy Tube Placement Managed by Pneumocentesis

“…A recent randomized trial showed that patients who had insufflation with carbon dioxide had more rapid reabsorption and resolution of their pneumoperitoneum than those who received ambient air. 5 Although pneumoperitoneum in these patients is typically benign, the risk cannot be neglected because in the presence of peritoneal signs, it may indicate intestinal perforation, which would necessitate exploratory laparotomy. 6 If patients are asymptomatic without any signs of peritonitis, no further intervention is typically necessary other than monitoring.…”

Clinical practice guidelines for percutaneous endoscopic gastrostomy

“…However, the visual analog scale scores for abdominal distention, pain, and bloating did not differ between the groups. 103 In a study conducted in Japan, pneumoperitoneum was detected in patients who underwent air insufflation (air group) but not in patients who underwent CO 2 insufflation (CO 2 group). 104 In a previous study, the incidence of small bowel distention was significantly decreased in the CO 2 group compared to that in the air group at 10 min and 24 hours post-PEG, although the incidence of large bowel distention did not differ between the groups.…”

“…6 , Supplementary Table 9 ). 98 , 99 , 103 , 104 Therefore, the use of CO 2 during PEG cannot be recommended. The Committee for the Development of Clinical Practice Guidelines for Percutaneous Endoscopic Gastrostomy drafted a preliminary recommendation to determine the expert opinion: “The use of CO 2 during PEG may reduce the occurrence of pneumoperitoneum.” Initially, 68.4% of experts consented to the first version of the recommendation.…”

Prevention and management of major complications in percutaneous endoscopic gastrostomy

“…Consider the use of carbon dioxide insufflation instead of ambient air (in a randomised controlled trial this significantly reduced the frequency of postprocedural pneumoperitoneum). 43 …”

“…42 Prevention ► Consider the use of carbon dioxide insufflation instead of ambient air (in a randomised controlled trial this significantly reduced the frequency of postprocedural pneumoperitoneum). 43 Management options ► If benign: apply conservative treatment (pneumoperitoneum is usually self-limiting within 72 hours of PEG insertion). ► If peritoneal signs: further investigation and/or early actions are required (eg, CT-scan)…”