Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: a randomized, controlled, double-blind trial

Background and study aims: Double-balloon enteroscopy (DBE) has been proven effective for deep intubation of the small bowel. However, intubation depth is limited by distention of the small bowel due to air insufflation during the procedure. The present trial investigated whether carbon dioxide (CO₂) instead of standard air insufflation would improve intubation depth during DBE, as well as reduce postprocedure pain.

Patients and methods: One hundred and twelve consecutive patients scheduled for DBE at two centers were randomly assigned to either CO₂ or air insufflation during DBE. Patients and endoscopists were blinded with regard to the type of gas used. Intubation depth was registered using a validated form. Patients scored pain and discomfort during and after the examination on a 100-mm visual analog scale.

Results: One hundred patients were eligible for data analysis (48 in the CO₂ group and 52 in the air group). The mean small-bowel intubation depth was extended by 30 % in the CO₂ group compared to the air group (230 vs. 177 cm, P = 0.008). The superiority was most pronounced for oral DBE, with a 71-cm improvement in intubation depth when using CO₂ (295 cm in the CO₂ group vs. 224 cm in the air group, P < 0.001). Patient pain and discomfort were significantly reduced in the CO₂ group at 1 and 3 hours after the examination.

Conclusions: CO₂ insufflation significantly extended intubation depth in DBE. CO₂ insufflation also reduces patient discomfort. CO₂ insufflation may lead to a higher diagnostic and therapeutic yield of DBE, with reduced patient discomfort.

References

• 1 Yamamoto H, Sekine Y, Saito Y. et al . Total enteroscopy with a non-surgical steerable double-balloon method.  Gastrointest Endosc. 2001;  53 216-220
• 2 May A, Nachbar L, Wardak A. et al . Double-balloon enteroscopy: preliminary experience in patients with obscure gastrointestinal bleeding or chronic abdominal pain.  Endoscopy. 2003;  35 985-991
• 3 May A, Nachbar L, Ell C. Double-balloon enteroscopy (push-and-pull enteroscopy) of the small bowel: feasibility and diagnostic and therapeutic yield in patients with suspected small bowel disease.  Gastrointest Endoc. 2005;  62 62-70
• 4 Ell C, May A, Nachbar L. et al . Push-and-pull enteroscopy in the small bowel using the double-balloon technique: results of a prospective European multicenter study.  Endoscopy. 2005;  37 613-616
• 5 Hussein A MJ. Carbon dioxide insufflation for more comfortable colonoscopy.  Gastrointest Endosc. 1984;  30 68-70
• 6 Stevensen G W. et al . Pain following colonoscopy: elimination with carbon dioxide.  Gastrointest Endosc. 1992;  38 564-567
• 7 Bretthauer M, Thiis-Evensen E, Hoff G. et al . A randomized controlled trial to assess the safety and efficacy of carbon dioxide insufflation in colonoscopy.  Gut. 2002;  50 604-607
• 8 Bretthauer M, Hoff G, Thiis-Evensen E. et al . Carbon dioxide insufflation reduces discomfort due to flexible sigmoidoscopy in colorectal cancer screening.  Scand J Gastroenterol. 2002;  37 1103-1108
• 9 Sumanac K, Zealley I, Fox B. 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
• 10 Bretthauer M, Seip B, Aasen S. et al . Carbon dioxide insufflation for more comfortable ERCP: a randomized controlled double-blind trial.  Endoscopy. 2007;  39 58-64
• 11 May A, Nachbar L, Schneider M. et al . Push-and-pull enteroscopy using the double-balloon technique: method of assessing depth of insertion and training of the endoscopy technique using the Erlangen endo-trainer.  Endoscopy. 2005;  37 66-70
• 12 Carter H G. Explosion in the colon during electrodesiccation of polyps.  Am J Surg. 1952;  84 514-516
• 13 Josemanders D FGM, Spillenaar Bilgen E J, van Sorge A A. et al. Colonic explosion during endoscopic polypectomy: avoidable complication or bad luck?.  Endoscopy. 2006;  38 943-944
• 14 Church J, Delaney C. Randomized, controlled trial of carbon dioxide insufflation during colonoscopy.  Dis Colon Rectum.. 2003;  46 322-326
• 15 Aabakken L, Bretthauer M, Line P D. Double balloon enteroscopy for endoscopic retrograde cholangiography in patients with Roux-Y anastomoses.  Endoscopy. 2007;  39 1068-1071