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). FEV1.0 % (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.
References
-
1
Inoue H, Sato Y, Sugaya S. et al .
Endoscopic mucosal resection for early-stage gastrointestinal cancers.
Best Pract Res Clin Gastroenterol.
2005;
19
871-887
-
2
Gotoda T, Yamamoto H, Soetikno R M. et al .
Endoscopic submucosal dissection of early gastric cancer.
J Gastroenterol.
2006;
41
929-942
-
3
Katzgraber F, Glenewinkel F, Fischler S. et al .
Mechanism of fatal air embolism after gastrointestinal endoscopy.
Int J Legal Med.
1998;
111
154-156
-
4
Green B, Tendler D A.
Cerebral air embolism during upper endoscopy: case report and review.
Gastrointest Endosc.
2005;
61
620-622
-
5
Nayagam J, Ho K M, Liang J.
Fatal systemic air embolism during endoscopic retrograde cholangio-pancreatography.
Anaesth Intensive Care.
2004;
32
260-264
-
6
Stabile L, Cigada M, Stillittano D. et al .
Fatal cerebral air embolism after endoscopic retrograde cholangiopancreatography.
Acta Anaesthesiol Scand.
2006;
50
648-649
-
7
Bisceglia M, Simeone A, Forlano R. et al .
Fatal systemic venous air embolism during endoscopic retrograde cholangiopancreatography.
Adv Anat Pathol.
2009;
16
255-262
-
8
Morley A P, Lau J Y, Young R J.
Tension pneumothorax complicating a perforation of a duodenal ulcer during ERCP with endoscopic sphincterotomy.
Endoscopy.
1997;
29
332
-
9
Rai A, Iftikhan S.
Tension pneumothorax complicating diagnostic upper endoscopy: a case report.
Am J Gastroenterol.
1999;
94
845-847
-
10
Bretthauer M, Thiis-Evensen E, Huppertz-Hauss G. et al .
NORCCAP (Norwegian colorectal cancer prevention): a randomised trial to assess the safety and efficacy of carbon dioxide versus air insufflation in colonoscopy.
Gut.
2002;
50
604-607
-
11
Sumanac K, Zealley I, Fox B M. 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
-
12
Church J, Delaney C.
Randomized, controlled trial of carbon dioxide insufflation during colonoscopy.
Dis Colon Rectum.
2003;
46
322-326
-
13
Bretthauer M, Lynge A B, Thiis-Evensen E. et al .
Cabon dioxide insufflations in colonoscopy: safe and effective in sedated patients.
Endoscopy.
2005;
37
706-709
-
14
Bretthauer M, Seip B, Aasen S. et al .
Carbon dioxide insufflation for more comfortable endoscopic retrograde cholangiopancreatography: a randomized, controlled, double-blind trial.
Endoscopy.
2007;
39
58-64
-
15
Domagk D, Bretthauer M, Lenz P. et al .
Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: a randomized, controlled, double-blind trial.
Endoscopy.
2007;
39
1064-1067
-
16
Nonaka S, Saito Y, Takisawa H. et al .
Safety of carbon dioxide insufflation for upper gastrointestinal tract endoscopic treatment of patients under deep sedation.
Surg Endosc.
2010;
24
1638-1645
-
17
Riphaus A, Wehrmann T, Weber B. et al .
S3 guideline: sedation for gastrointestinal endoscopy 2008.
Endoscopy.
2009;
41
787-815
-
18
Saito Y, Uraoka T, Matsuda T. et al .
A pilot study to assess the safety of carbon dioxide insufflation during colorectal endoscopic submucosal dissection with the patient under conscious sedation.
Gastrointest Endosc.
2007;
65
537-542
-
19
Kikuchi T, Fu K I, Saito Y. et al .
Transcutaneous monitoring of partial pressure of carbon dioxide during endoscopic submucosal dissection of early colorectal neoplasia with carbon dioxide insufflation: a prospective study.
Surg Endosc.
2010;
24
2231-2235
-
20
Freeman M L, Hennessy T, Cass O W. et al .
Carbon dioxide retention and oxygen desaturation during gastrointestinal endoscopy.
Gastroenterology.
1993;
105
331-339
-
21
Murray A W, Morran C G, Kenny G N. et al .
Examination of cardiorespiratory changes during upper gastrointestinal endoscopy. Comparison of monitoring of arterial oxygen saturation, arterial pressure and the electrocardiogram.
Anaesthesia.
1991;
46
181-184
-
22
Bretthauer M, Hoff G S, Thiss-Evenssen E. et al .
Air and carbon dioxide volumes insufflated during colonoscopy.
Gastrointestinal Endosc.
2003;
58
203-206
-
23
Hsieh C H.
Laparoscopic cholecystectomy for patients with chronic obstructive pulmonary disease.
J Laparoendosc Adv Surg Tech A.
2003;
13
5-9
-
24
Salihoglu Z, Demiroluk S, Baca B. et al .
Effects of pneumoperitoneum and positioning on respiratory mechanics in chronic obstructive pulmonary disease patients during Nissen fundoplication.
Surg Laparosc Endosc Percuta in Tech.
2008;
18
437-440
-
25
Cullen D J, Eger 2nd E I.
Cardiovascular effects of carbon dioxide in man.
Anesthesiology.
1974;
41
345-349
-
26
Kiely D G, Cargill R I, Lipworth B J. et al .
Effects of hypercapnia on hemodynamic, inotropic, lusitropic, and electrophysiologic indices in humans.
Chest.
1996;
109
1215-1221
-
27
Akça O.
Optimizing the intraoperative management of carbon dioxide concentration.
Curr Opin Anaesthesiol.
2006;
19
19-25
-
28
Leaver S K, Evans T W.
Acute respiratory distress syndrome.
Br Med J.
2007;
335
389-394
-
29
Kadam P G, Marda M, Shah V R.
Carbon dioxide absorption during laparoscopic donor nephrectomy: a comparison between retroperitoneal and transperitoneal approaches.
Transplant Proc.
2008;
40
1119-1121
-
30
Pacilli M, Pierro A, Kingsley C. et al .
Absorption of carbon dioxide during laparoscopy in children measured using a novel mass spectrometric technique.
Br J Anaesth.
2006;
97
215-219
-
31
Lister D R, Rudston-Brown B, Warriner C B. et al .
Carbon dioxide absorption is not linearly related to intraperitoneal carbon dioxide insufflation pressure in pigs.
Anesthesiology.
1994;
80
129-136
-
32
Lamireau T, Dubreuil M, Daconceicao M.
Oxygen saturation during esophagogastroduodenoscopy in children: general anesthesia versus intravenous sedation.
J Pediatr Gastroenterol Nutr.
1998;
27
172-175
T. SuzukiMD, PhD
Department of Anesthesia
Showa University Northern Yokohama Hospital
35-1 Chigasaki-chuo
Tsuzuki-ku
Yokohama 224-8503
Japan
Fax: +81-45-9497365
Email: tksuzuki@med.showa-u.ac.jp
