Case Study
A pilot study to assess the safety and efficacy of carbon dioxide insufflation during colorectal endoscopic submucosal dissection with the patient under conscious sedation

https://doi.org/10.1016/j.gie.2006.11.002Get rights and content

Background

Endoscopic submucosal dissection (ESD) is accepted as one of the treatments for en bloc resection of large superficial colorectal lesions. This procedure is performed by using air insufflation, is time consuming, and is associated with severe abdominal discomfort. The safety and efficacy of carbon dioxide (CO2) insufflation during colonoscopy already has been assessed in some trials.

Objective

To assess the safety and efficacy of CO2 insufflation instead of air insufflation during colorectal ESD with the patient under conscious sedation.

Design

A case-control series with a historical control.

Patients

A total of 35 consecutive patients were enrolled in this study. Another 35 consecutive patients who previously received colorectal ESDs by using air insufflation were included as a historical control.

Interventions

Arterial partial pressure of CO2 (pCO2) was measured before and after each procedure with the total dose of midazolam used as an index of abdominal discomfort.

Main Outcome Measurements and Results

The mean (standard deviation [SD]) operation time was 90 ± 57 minutes in the CO2 group and 100 ± 80 minutes in the control group (not significant). In the CO2 group, the mean (SD) dose of midazolam was significantly lower than that of the control group; 5.6 ± 4.9 mg and 9.7 ± 5.9 mg, respectively (P = .005). Blood analysis revealed a slight pCO2 elevation in the CO2 group; however, only 2 patients complained of mild abdominal discomfort.

Limitations

Abdominal discomfort and pCO2 were not evaluated in the control group.

Conclusions

This study strongly suggests that CO2 insufflation is safe and effective during lengthy colonic endoscopic procedures, eg, ESD, with the patient under conscious sedation.

Section snippets

Patients

Between November 2004 and May 2005, a total of 35 consecutive patients were enrolled in this study at the National Cancer Center Hospital (NCCH) in Tokyo. All ESD procedures were performed by one or the other of 2 highly experienced colonoscopists (Y.S., T.U.).

Colorectal ESDs with air insufflation performed in 35 other consecutive patients by the same 2 colonoscopists between September 2003 and November 2004 were compared as a historical control group. Patients with severe chronic occlusive

Results

There were no differences in clinicopathologic characteristics between the groups (Table 1). The mean (SD) size of the resected specimens was 32 ± 15 mm in the CO2 group and 30 ± 14 mm in the control group, with no statistical difference (NS). En bloc resection was achieved in 30 of 35 cases (86%) in the CO2 group and 31 of 35 cases (89%) in the control group.

Histopathologic evaluation revealed 5 low-grade dysplasias, 24 high-grade dysplasias, and 6 submucosal (sm) carcinomas in the CO2 group.

Discussion

Based on the results of this pilot study, CO2 insufflation proved to be safe and effective during lengthy colonic endoscopic procedures (eg, ESD) with the patient under conscious sedation. Patient discomfort was considerably lower in the CO2 group, probably because of a more rapid absorption of CO2 than was caused by conventional air insufflation, as evidenced by the lower total dosage of midazolam.

In the field of conventional colonoscopy, the safety and efficacy of CO2 insufflation has already

Conclusions

This study strongly suggests that CO2 insufflation is safe and effective during lengthy colonic endoscopic procedures (eg, ESD) with the patient under conscious sedation. It is possible, however, that a significant component of the reduced midazolam dosage in the CO2 group might have been the technical improvement of the experienced endoscopists between the time of the control cases and the current series.

Acknowledgments

We thank Dr Yoshitaka Murakami for reading our draft and giving us suggestions on statistical analyses.

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    Presented in part at the American Society for Gastrointestinal Endoscopy meeting, May 23, 2006, Los Angeles, California.

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