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Jin X, Ding Y, Weng Q, Sun C, Liu D, Min J. Continuous cuff pressure control on middle-aged and elderly patients undergoing endoscopic submucosal dissection of the esophagus effect of airway injury. Esophagus 2024; 21:456-463. [PMID: 39020058 DOI: 10.1007/s10388-024-01061-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Accepted: 04/25/2024] [Indexed: 07/19/2024]
Abstract
OBJECTIVE Assessment of the effect of continuous cuff pressure control on airway injury in middle-aged and elderly patients undergoing endoscopic submucosal dissection (ESD). METHOD A total of 104 eligible middle-aged and elderly patients requiring esophageal ESD from July 2022-September 2023 at the First Affiliated Hospital of Nanchang University were selected and randomly divided into two groups: the group undergoing general anesthesia tracheal intubation with continuous control of cuff pressure after intubation (Group A, n = 51) and the group undergoing general anesthesia tracheal intubation with continuous monitoring without control of cuff pressure (Group B, n = 53). After endotracheal intubation in Group A, under the guidance of an automatic cuff pressure controller, the air was used to inflate the tracheal cuff until the cuff pressure was 25-30cmH2O. The cuff pressure after intubation was recorded, and then the cuff pressure parameters were directly adjusted in the range of 25-30cmH2O until tracheal extubation after the operation. After endotracheal intubation, patients in Group B inflated the tracheal cuff with clinical experience, then monitored and recorded the cuff pressure with a handheld cuff manometer and instructed the cuff not to be loosened after being connected to the handheld cuff manometer-continuous monitoring until the tracheal extubation, but without any cuff pressure regulation. The patients of the two groups performed esophageal ESD. The left recumbent position was taken before the operation, and the cuff's pressure was recorded. Then, insert the gastrointestinal endoscope to find the lesion site and perform appropriate CO2 inflation to display the diseased esophageal wall for surgical operation fully. After determining the location, the cuff pressure of the two groups was recorded when the cuff pressure was stable. After the operation, the upper gastrointestinal endoscope was removed and the cuff pressure of the two groups was recorded. Postoperative airway injury assessment was performed in both groups, and the incidence of sore throat, hoarseness, cough, and blood in sputum was recorded. The incidence of postoperative airway mucosal injury was also observed and recorded in both groups: typical, episodic congestion spots and patchy local congestion. RESULT The incidence of normal airway mucosa in Group A was higher than that in Group B (P < 0.05). In comparison, the incidence of occasional hyperemia and local plaque congestion in Group A was lower than in Group B (P < 0.05). CONCLUSION Continuous cuff pressure control during operation can reduce airway injury in patients with esophageal ESD and accelerate their early recovery after the operation.
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Affiliation(s)
- Xianwei Jin
- Department of Graduate School, Jiangxi Medical College, Nanchang University, Nanchang, China
- Department of Anesthesiology, Medical Center of Anesthesiology and Pain, the 1st affiliated hospital, Jiangxi Medical College, Nanchang University, 17 Yongwai Zheng Street, Donghu District, Nanchang, 330006, Jiangxi, China
| | - Yuewen Ding
- Department of Graduate School, Jiangxi Medical College, Nanchang University, Nanchang, China
- Department of Anesthesiology, Medical Center of Anesthesiology and Pain, the 1st affiliated hospital, Jiangxi Medical College, Nanchang University, 17 Yongwai Zheng Street, Donghu District, Nanchang, 330006, Jiangxi, China
| | - Qiaoling Weng
- Department of Anesthesiology, the Second Affiliated Hospital of Nanchang University, Nanchang, China
| | - Chumiao Sun
- Department of Graduate School, Jiangxi Medical College, Nanchang University, Nanchang, China
- Department of Anesthesiology, Medical Center of Anesthesiology and Pain, the 1st affiliated hospital, Jiangxi Medical College, Nanchang University, 17 Yongwai Zheng Street, Donghu District, Nanchang, 330006, Jiangxi, China
| | - Dongbo Liu
- Department of Graduate School, Jiangxi Medical College, Nanchang University, Nanchang, China
- Department of Anesthesiology, Medical Center of Anesthesiology and Pain, the 1st affiliated hospital, Jiangxi Medical College, Nanchang University, 17 Yongwai Zheng Street, Donghu District, Nanchang, 330006, Jiangxi, China
| | - Jia Min
- Department of Anesthesiology, Medical Center of Anesthesiology and Pain, the 1st affiliated hospital, Jiangxi Medical College, Nanchang University, 17 Yongwai Zheng Street, Donghu District, Nanchang, 330006, Jiangxi, China.
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Wlodarczyk J, Gupta A, Lee SW. Combined Endoscopy-Laparoscopy Surgery: When and How to Utilize This Tool. Clin Colon Rectal Surg 2024; 37:309-317. [PMID: 39132203 PMCID: PMC11309789 DOI: 10.1055/s-0043-1770945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2024]
Abstract
Combined endoscopic and laparoscopic surgery (CELS) has been used to resect colon polyps since the 1990s. These colon-sparing techniques, however, have not yet been widely adopted. With the evolution of technology in both diagnosing and treating colon cancer, colorectal surgeons should strive for a diverse and complete armamentarium through which they can best serve their patients. In this article, we hope to provide clarity on CELS by discussing three topics: (1) the history and fruition of CELS; (2) the techniques involved in CELS; and (3) the utility of CELS within different clinical scenarios. Our goal is to educate readers and stimulate consideration of CELS in select patients who might benefit greatly from these techniques.
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Affiliation(s)
- Jordan Wlodarczyk
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California Norris Cancer Center, Los Angeles, California
| | - Abhinav Gupta
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California Norris Cancer Center, Los Angeles, California
| | - Sang W. Lee
- Division of Colorectal Surgery, Keck School of Medicine, University of Southern California Norris Cancer Center, Los Angeles, California
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Wen XP, Wan QQ. Nomogram to predict gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions: Clinical significance. World J Gastrointest Endosc 2024; 16:5-10. [PMID: 38313461 PMCID: PMC10835473 DOI: 10.4253/wjge.v16.i1.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Revised: 12/13/2023] [Accepted: 12/29/2023] [Indexed: 01/15/2024] Open
Abstract
Transoral endoscopic resections in treating upper gastrointestinal submucosal lesions have the advantages of maintaining the integrity of the gastrointestinal lumen, avoiding perforation and reducing gastrointestinal fistulae. They are becoming more widely used in clinical practice, but, they may also present a variety of complications. Gas-related complications are one of the most common, which can be left untreated if the symptoms are mild, but in severe cases, they can lead to rapid changes in the respiratory and circulatory systems in a short period, which can be life-threatening. Therefore, it is important to predict the occurrence of gas-related complications early and take preventive measures actively. Based on the authors' results in the prepublication of the article "Nomogram to predict gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions," and in conjunction with our evaluation and additions to the relevant content, radiographs may help screen patients at high risk for gas-related complications. Controlling blood glucose levels, shortening the duration of surgery, and choosing the most appropriate surgical resection may positively impact the prognosis of patients at high risk for gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions.
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Affiliation(s)
- Xu-Peng Wen
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai 200030, China
| | - Qi-Quan Wan
- Department of Transplant Surgery, The Third Xiangya Hospital of Central South University, Changsha 410013, Hunan Province, China
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Yang J, Chen ZG, Yi XL, Chen J, Chen L. Nomogram to predict gas-related complications during transoral endoscopic resection of upper gastrointestinal submucosal lesions. World J Gastrointest Endosc 2023; 15:649-657. [DOI: 10.4253/wjge.v15.i11.649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 09/21/2023] [Accepted: 10/16/2023] [Indexed: 11/10/2023] Open
Abstract
BACKGROUND Gas-related complications present a potential risk during transoral endoscopic resection of upper gastrointestinal submucosal lesions. Therefore, the identification of risk factors associated with these complications is essential.
AIM To develop a nomogram to predict risk of gas-related complications following transoral endoscopic resection of the upper gastrointestinal submucosal lesions.
METHODS We collected patient data from the First Affiliated Hospital of the Army Medical University. Patients were randomly allocated to training and validation cohorts. Risk factors for gas-related complications were identified in the training cohort using univariate and multivariate analyses. We then constructed a nomogram and evaluated its predictive performance based on the area under the curve, decision curve analysis, and Hosmer-Lemeshow tests.
RESULTS Gas-related complications developed in 39 of 353 patients who underwent transoral endoscopy at our institution. Diabetes, lesion origin, surgical resection method, and surgical duration were incorporated into the final nomogram. The predictive capability of the nomogram was excellent, with area under the curve values of 0.841 and 0.906 for the training and validation cohorts, respectively.
CONCLUSION The ability of our four-variable nomogram to efficiently predict gas-related complications during transoral endoscopic resection enhanced postoperative assessments and surgical outcomes.
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Affiliation(s)
- Jia Yang
- Department of Gastroenterology, The First Affiliated Hospital (Southwest Hospital) to Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Zhi-Guo Chen
- Department of Gastroenterology, The First Affiliated Hospital (Southwest Hospital) to Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Xing-Lin Yi
- Department of Pulmonology, The First Affiliated Hospital (Southwest Hospital) to Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Jing Chen
- Department of Gastroenterology, The First Affiliated Hospital (Southwest Hospital) to Third Military Medical University (Army Medical University), Chongqing 400038, China
| | - Lei Chen
- Department of Gastroenterology, The First Affiliated Hospital (Southwest Hospital) to Third Military Medical University (Army Medical University), Chongqing 400038, China
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Helgeson SA, Lewis KL, Carter LE, Saunders H, Patel NM. Safety of chronic obstructive pulmonary disease patients undergoing carbon dioxide insufflation in extended endoscopic procedures. Lung India 2020; 37:407-410. [PMID: 32883900 PMCID: PMC7857370 DOI: 10.4103/lungindia.lungindia_74_20] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
Introduction: Carbon dioxide (CO2) insufflation for endoscopies has been shown to be more comfortable and safe, but only in patients without underlying chronic obstructive pulmonary disease (COPD). The aim of this study was to show that using CO2 is safe in COPD patients. Methods: Patients were retrospectively identified who underwent extended endoscopic procedures during the time period of January 2012 to December 2017. Patients were included if they also had COPD. A matched control group without COPD was created during the same timeframe. All the patients were sedated with continuous monitoring of their CO2 levels by end-tidal CO2 (EtCO2). Results: One hundred and ten patients had COPD and underwent an extended endoscopic procedure. These patients had a higher severity of their comorbidities (American Society of Anesthesiologists class 3 or 4) (93.6% [95% confidence interval [CI], 87.4%–96.9%] vs. 60.3% [95% CI, 51.1%–69.0%]; P < 0.01) and an increase of co-existing obstructive sleep apnea (33.6% vs. 6.3%, P < 0.01). There was no difference in baseline EtCO2, but the peak EtCO2 and postprocedure EtCO2 were both significantly higher in the COPD group. The only postprocedural complication found was an inability to be extubated immediately following the procedure with subsequent need to hospitalize the patient, which occurred in three patients (2.8%; 95% CI, 0.9%–7.9%) in the COPD group and one (0.9%; 95% CI, 0.2%–4.9%) in the non-COPD group (P = 0.37). Conclusion: The present study, which was the only study looking at CO2 insufflation specifically in COPD patients, provides evidence that CO2 insufflation is safe in COPD despite a slight increase in EtCO2.
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Affiliation(s)
- Scott A Helgeson
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Kristyn L Lewis
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Laurel E Carter
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Hollie Saunders
- Department of Internal Medicine, Mayo Clinic, Jacksonville, FL, USA
| | - Neal M Patel
- Department of Pulmonary Medicine, Mayo Clinic, Jacksonville, FL, USA
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Iacucci M, Cannatelli R, Tontini GE, Panaccione R, Danese S, Fiorino G, Matsumoto T, Kochhar GS, Shen B, Kiesslich R, Ghosh S. Improving the quality of surveillance colonoscopy in inflammatory bowel disease. Lancet Gastroenterol Hepatol 2020; 4:971-983. [PMID: 31696831 DOI: 10.1016/s2468-1253(19)30194-3] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/28/2018] [Revised: 05/27/2019] [Accepted: 06/04/2019] [Indexed: 12/13/2022]
Abstract
Several recommendations have addressed the topic of improving the quality of surveillance colonoscopy in inflammatory bowel disease. However, there is variation between these recommendations, in part due to the absence of well-defined quality indicators, suggesting that these quality indicators should be studied and developed. We did a systematic review of evidence related to surveillance colonoscopy in inflammatory bowel disease to look at the different variables in this practice and offer a critique of the quality control measures before, during, and after the procedure. We identified several key quality measures that could be adopted in clinical practice, including control of inflammation, optimal bowel preparation, ideal time allocation, training, sedation, detection and characterisation of lesions, therapeutic management of the lesions, and colonoscopic reports. However, further primary research and consensus reports are needed to continue developing roadmaps at a global level.
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Affiliation(s)
- Marietta Iacucci
- Institute of Translational of Medicine, NIHR Biomedical Research Centre, University of Birmingham and University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Immunology and Immunotherapy, NIHR Biomedical Research Centre, University of Birmingham and University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK.
| | - Rosanna Cannatelli
- Institute of Translational of Medicine, NIHR Biomedical Research Centre, University of Birmingham and University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Immunology and Immunotherapy, NIHR Biomedical Research Centre, University of Birmingham and University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK; Department of Gastroenterology, Spedali Civili di Brescia, University of Milan, Milan, Italy
| | - Gian Eugenio Tontini
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy; Gastroenterology and Endoscopy Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Remo Panaccione
- Department of Gastroenterology and Hepatology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Silvio Danese
- Inflammatory Bowel Diseases Center, Department of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Gionata Fiorino
- Inflammatory Bowel Diseases Center, Department of Gastroenterology, Humanitas Research Hospital, Rozzano, Milan, Italy; Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Takayuki Matsumoto
- Department of Gastroenterology, Iwate Medical University, Morioka, Japan
| | - Gursimran S Kochhar
- Department of Gastroenterology, Allegheny General Hospital, Pittsburgh, PA, USA
| | - Bo Shen
- Department of Gastroenterology, Hepatology & Nutrition, Cleveland Clinic, Cleveland, OH, USA
| | - Ralf Kiesslich
- Department of Medicine, Helios HSK Wiesbaden, Wiesbaden, Germany
| | - Subrata Ghosh
- Institute of Translational of Medicine, NIHR Biomedical Research Centre, University of Birmingham and University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK; Institute of Immunology and Immunotherapy, NIHR Biomedical Research Centre, University of Birmingham and University Hospitals, Birmingham NHS Foundation Trust, Birmingham, UK
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Sugiyama T, Araki H, Ozawa N, Takada J, Kubota M, Ibuka T, Shimizu M. Carbon dioxide insufflation reduces residual gas in the gastrointestinal tract following colorectal endoscopic submucosal dissection. Biomed Rep 2018; 8:257-263. [DOI: 10.3892/br.2018.1044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 01/10/2018] [Indexed: 11/05/2022] Open
Affiliation(s)
- Tomohiko Sugiyama
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu 501‑1194, Japan
| | - Hiroshi Araki
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu 501‑1194, Japan
| | - Noritaka Ozawa
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu 501‑1194, Japan
| | - Jun Takada
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu 501‑1194, Japan
| | - Masaya Kubota
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu 501‑1194, Japan
| | - Takashi Ibuka
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu 501‑1194, Japan
| | - Masahito Shimizu
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, Gifu 501‑1194, Japan
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Li X, Dong H, Zhang Y, Zhang G. CO2 insufflation versus air insufflation for endoscopic submucosal dissection: A meta-analysis of randomized controlled trials. PLoS One 2017; 12:e0177909. [PMID: 28542645 PMCID: PMC5443502 DOI: 10.1371/journal.pone.0177909] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2017] [Accepted: 05/05/2017] [Indexed: 12/21/2022] Open
Abstract
Background Carbon dioxide (CO2) insufflation is increasingly used for endoscopic submucosal dissection (ESD) owing to the faster absorption of CO2 as compared to that of air. Studies comparing CO2 insufflation and air insufflation have reported conflicting results. Objectives This meta-analysis is aimed to assess the efficacy and safety of use of CO2 insufflation for ESD. Methods Clinical trials of CO2 insufflation versus air insufflation for ESD were searched in PubMed, Embase, the Cochrane Library and Chinese Biomedical Literature Database. We performed a meta-analysis of all randomized controlled trials (RCTs). Results Eleven studies which compared the use of CO2 insufflation and air insufflation, with a combined study population of 1026 patients, were included in the meta-analysis (n = 506 for CO2 insufflation; n = 522 for air insufflation). Abdominal pain and VAS scores at 6h and 24h post-procedure in the CO2 insufflation group were significantly lower than those in the air insufflation group, but not at 1h and 3h after ESD. The percentage of patients who experienced pain 1h and 24h post-procedure was obviously decreased. Use of CO2 insufflation was associated with lower VAS scores for abdominal distention at 1h after ESD, but not at 24h after ESD. However, no significant differences were observed with respect to postoperative transcutaneous partial pressure carbon dioxide (PtcCO2), arterial blood carbon dioxide partial pressure (PaCO2), oxygen saturation (SpO2%), abdominal circumference, hospital stay, white blood cell (WBC) counts, C-Reactive protein (CRP) level, dosage of sedatives used, incidence of dysphagia and other complications. Conclusion Use of CO2 insufflation for ESD was safe and effective with regard to abdominal discomfort, procedure time, and the residual gas volume. However, there appeared no significant differences with respect to other parameters namely, PtcCO2, PaCO2, SpO2%, abdominal circumference, hospital stay, sedation dosage, complications, WBC, CRP, and dysphagia.
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Affiliation(s)
- Xuan Li
- Department of Gastroenterology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Gastroenterology, the First School of Clinical Medicine of Nanjing Medical University, Nanjing, China
| | - Hao Dong
- Department of Cardiology, the Second Hospital of Nanjing, Nanjing, China
| | - Yifeng Zhang
- Department of Gastroenterology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Gastroenterology, the First School of Clinical Medicine of Nanjing Medical University, Nanjing, China
| | - Guoxin Zhang
- Department of Gastroenterology, the First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Department of Gastroenterology, the First School of Clinical Medicine of Nanjing Medical University, Nanjing, China
- * E-mail:
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Baniya R, Upadhaya S, Khan J, Subedi SK, Mohammed TS, Ganatra BK, Bachuwa G. Carbon Dioxide versus Air Insufflation in Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Clin Endosc 2017; 50:464-472. [PMID: 28516756 PMCID: PMC5642065 DOI: 10.5946/ce.2016.161] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2016] [Revised: 03/26/2017] [Accepted: 03/29/2017] [Indexed: 12/20/2022] Open
Abstract
Background/Aims Endoscopic submucosal dissection (ESD) with air insufflation is commonly used for the staging and treatment of early gastric carcinoma. However, carbon dioxide (CO2) use has been shown to cause less post-procedural pain and fewer adverse events. The objective of this study was to compare the post-procedural pain and adverse events associated with CO2 and air insufflation in ESD. Methods A systematic search was conducted for randomized control trials (RCTs) comparing the two approaches in ESD. The Mantel-Haenszel method was used to analyze the data. The mean difference (MD) and odds ratio (OR) were used for continuous and categorical variables, respectively. Results Four RCTs with a total of 391 patients who underwent ESD were included in our meta-analysis. The difference in maximal post-procedural pain between the two groups was statistically significant (MD, -7.41; 95% confidence interval [CI], -13.6 – -1.21; p=0.020). However, no significant differences were found in the length of procedure, end-tidal CO2, rate of perforation, and postprocedural hemorrhage between the two groups. The incidence of overall adverse events was significantly lower in the CO2 group (OR, 0.51; CI, 0.32–0.84; p=0.007). Conclusions: CO2 insufflation in gastric ESD is associated with less post-operative pain and discomfort, and a lower risk of overall adverse events compared with air insufflation.
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Affiliation(s)
- Ramkaji Baniya
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Sunil Upadhaya
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Jahangir Khan
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Suresh K Subedi
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Tabrez S Mohammed
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Balvant K Ganatra
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
| | - Ghassan Bachuwa
- Department of Internal Medicine, Hurley Medical Center/Michigan State University, Flint, MI, USA
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Ishibashi C, Hayashida M, Sugasawa Y, Yamaguchi K, Tomita N, Kajiyama Y, Inada E. Effects of dexmedetomidine on hemodynamics and respiration in intubated, spontaneously breathing patients after endoscopic submucosal dissection for cervical esophageal or pharyngeal cancer. J Anesth 2016; 30:628-36. [PMID: 27125210 DOI: 10.1007/s00540-016-2175-4] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 04/17/2016] [Indexed: 01/28/2023]
Abstract
PURPOSE We evaluated the hemodynamic and respiratory effects of dexmedetomidine in intubated, spontaneously breathing patients after endoscopic submucosal dissection (ESD) for cervical esophageal or pharyngeal cancer. METHODS This retrospective study included 129 patients aged 66.5 ± 8.3 years, who underwent ESD under general anesthesia, and who were kept intubated overnight to prevent airway obstruction, receiving sedation with dexmedetomidine. Constant dexmedetomidine infusion at 0.51 ± 0.16 μg/kg/h was started intraoperatively (n = 109) or postoperatively (n = 20), following (n = 29) or not following (n = 100) loading doses, and continued until extubation. Hemodynamic and respiratory variables, and Richmond Agitation-Sedation Scale (RASS) score, were recorded. RESULTS Postoperatively, 129 patients remained intubated while breathing spontaneously for 16.4 ± 3.3 h, and 124 patients could be sedated solely with dexmedetomidine, whereas 5 required rescue sedatives. During infusion, blood pressure decreased progressively until 12 h, whereas heart rate decreased only at 3 h. Hemodynamic alterations during dexmedetomidine infusion greatly depended not only on its hemodynamic effects but also on baseline hemodynamics before anesthesia. No serious adverse effect was noted. CONCLUSION Dexmedetomidine in intubated, spontaneously breathing patients after ESD was safe and effective. Patient baseline hemodynamics could significantly affect hemodynamics during drug infusion. Without loading doses, plasma drug concentrations were expected to increase progressively. A progressive decrease in blood pressure and unchanged heart rate after an initial decrease suggested that hemodynamic effects of dexmedetomidine in our patients might differ from those reported in young volunteers, although further studies are required to elucidate these points.
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Affiliation(s)
- Chika Ishibashi
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Masakazu Hayashida
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Yusuke Sugasawa
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan.
| | - Keisuke Yamaguchi
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
| | - Natsumi Tomita
- Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Yoshiaki Kajiyama
- Department of Esophageal and Gastroenterological Surgery, Juntendo University School of Medicine, Tokyo, Japan
| | - Eiichi Inada
- Department of Anesthesiology and Pain Medicine, Juntendo University School of Medicine, 3-1-3 Hongo, Bunkyo-ku, Tokyo, 113-8431, Japan
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12
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Yamashita K, Shiwaku H, Ohmiya T, Shimaoka H, Okada H, Nakashima R, Beppu R, Kato D, Sasaki T, Hoshino S, Nimura S, Yamaura K, Yamashita Y. Efficacy and safety of endoscopic submucosal dissection under general anesthesia. World J Gastrointest Endosc 2016; 8:466-471. [PMID: 27433293 PMCID: PMC4937162 DOI: 10.4253/wjge.v8.i13.466] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 04/21/2016] [Accepted: 05/27/2016] [Indexed: 02/05/2023] Open
Abstract
AIM: To evaluate the efficacy and safety of endoscopic submucosal dissection (ESD) under general anesthesia.
METHODS: From January 2011 to July 2014, 206 consecutive patients had undergone ESD under general anesthesia for neoplasms of the stomach, esophagus, and colorectum were enrolled in this retrospective study. The efficacy and safety of ESD under general anesthesia were assessed.
RESULTS: The en bloc resection rate of esophageal, gastric, and colorectal lesions was 100.0%, 98.3%, and 96.1%, respectively. The complication rate of perforation and bleeding were 0.0% and 0.0% in esophageal ESD, 1.7% and 1.7% in gastric ESD, and 3.9% and 2.0% in colorectal ESD, respectively. No cases of aspiration pneumonia were observed. All complications were managed by conservative treatment, with no surgical intervention required.
CONCLUSION: With the cooperation of an anesthesiologist, ESD under general anesthesia appears to be a useful method, decreasing the risk of complications.
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Tetzlaff JE, Maurer WG. Preprocedural Assessment for Sedation in Gastrointestinal Endoscopy. Gastrointest Endosc Clin N Am 2016; 26:433-41. [PMID: 27372768 DOI: 10.1016/j.giec.2016.02.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The role of the anesthesia service in sedation for gastrointestinal endoscopy (GIE) has been steadily increasing. The goals of preprocedural assessment are determined by the specific details of the procedure, the issues related to the illness that requires the endoscopy, comorbidities, the goals for sedation, and the risk of complications from the sedation and the endoscopic procedure. Rather than consider these issues as separate entities, they should be considered as part of a continuum of preparation for GIE. This is told from the perspective of an anesthesiologist who regularly participates in the full range of sedation for GIE.
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Affiliation(s)
- John E Tetzlaff
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Department of General Anesthesia, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA.
| | - Walter G Maurer
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Department of General Anesthesia, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, Ohio 44195, USA
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Imaeda H, Nakajima K, Hosoe N, Nakahara M, Zushi S, Kato M, Kashiwagi K, Matsumoto Y, Kimura K, Nakamura R, Wada N, Tsujii M, Yahagi N, Hibi T, Kanai T, Takehara T, Ogata H. Percutaneous endoscopic gastrostomy under steady pressure automatically controlled endoscopy: First clinical series. World J Gastrointest Endosc 2016; 8:186-191. [PMID: 26862369 PMCID: PMC4734978 DOI: 10.4253/wjge.v8.i3.186] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Revised: 11/08/2015] [Accepted: 12/11/2015] [Indexed: 02/05/2023] Open
Abstract
AIM: To elucidate the safety of percutaneous endoscopic gastrostomy (PEG) under steady pressure automatically controlled endoscopy (SPACE) using carbon dioxide (CO2).
METHODS: Nine patients underwent PEG with a modified introducer method under conscious sedation. A T-tube was attached to the channel of an endoscope connected to an automatic surgical insufflator. The stomach was inflated under the SPACE system. The intragastric pressure was kept between 4-8 mmHg with a flow of CO2 at 35 L/min. Median procedure time, intragastric pressure, median systolic blood pressure, partial pressure of CO2, abdominal girth before and immediately after PEG, and free gas and small intestinal gas on abdominal X-ray before and after PEG were recorded.
RESULTS: PEG was completed under stable pneumostomach in all patients, with a median procedural time of 22 min. Median intragastric pressure was 6.9 mmHg and median arterial CO2 pressure before and after PEG was 42.1 and 45.5 Torr (NS). The median abdominal girth before and after PEG was 68.1 and 69.6 cm (NS). A mild free gas image after PEG was observed in two patients, and faint abdominal gas in the downstream bowel was documented in two patients.
CONCLUSION: SPACE might enable standardized pneumostomach and modified introducer procedure of PEG.
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Efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection: a randomized, double-blind, controlled, prospective study. Gastrointest Endosc 2015; 82:1018-24. [PMID: 26142555 DOI: 10.1016/j.gie.2015.05.043] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 05/25/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic submucosal dissection (ESD) is commonly performed under air insufflation and is often accompanied by abdominal discomfort. CO2 is absorbed more rapidly by the body than is air; however, the use of CO2 insufflation in ESD remains controversial. This randomized, double-blind, controlled, prospective study was designed to assess the efficacy of CO2 versus air insufflation in gastric ESD. METHODS Between May 2012 and August 2014, a total of 110 patients with gastric tumors were randomly assigned to the CO2 insufflation (CO2 group, n = 54) or air insufflation group (air group, n = 56). Abdominal pain after ESD was chronologically recorded via visual analog scale (VAS) scores. Secondary outcome measurements were adverse events, abdominal circumference, amount of sedatives prescribed, and use of analgesics. RESULTS Neither the baseline patient characteristics nor the mean procedural time differed between the groups. The VAS score for abdominal pain was 35.2 in the CO2 insufflation group versus 48.5 in the air insufflation group 1 hour after ESD (P = .026), 27.8 versus 42.5 three hours after ESD (P = .007), 18.4 versus 34.8 six hours after ESD (P = .001), and 9.2 versus 21.9 one day after ESD (P < .001). Changes in abdominal circumference, the amounts of sedative drugs taken, and the adverse events did not differ between the groups. However, the air insufflation group required more analgesics than did the CO2 insufflation group (CO2 group, 22.0% [11/50]; air group, 42.3% [22/52]; P = .028). CONCLUSIONS CO2 insufflation during gastric ESD significantly reduced abdominal pain and analgesic usage compared with air insufflation. ( CLINICAL TRIAL REGISTRATION NUMBER NCT01579071.)
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Takada J, Araki H, Onogi F, Nakanishi T, Kubota M, Ibuka T, Shimizu M, Moriwaki H. Safety and efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection. World J Gastroenterol 2015; 21:8195-8202. [PMID: 26185394 PMCID: PMC4499365 DOI: 10.3748/wjg.v21.i26.8195] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Revised: 02/13/2015] [Accepted: 03/19/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the safety and efficacy of carbon dioxide (CO2) and air insufflation during gastric endoscopic submucosal dissection (ESD).
METHODS: This study involved 116 patients who underwent gastric ESD between January and December 2009. After eliminating 29 patients who fit the exclusion criteria, 87 patients, without known pulmonary dysfunction, were randomized into the CO2 insufflation (n = 36) or air insufflation (n = 51) groups. Standard ESD was performed with a CO2 regulation unit (constant rate of 1.4 L/min) used for patients undergoing CO2 insufflation. Patients received diazepam for conscious sedation and pentazocine for analgesia. Transcutaneous CO2 tension (PtcCO2) was recorded 15 min before, during, and after ESD with insufflation. PtcCO2, the correlation between PtcCO2 and procedure time, and ESD-related complications were compared between the two groups. Arterial blood gases were analyzed after ESD in the first 30 patients (12 with CO2 and 18 with air insufflation) to assess the correlation between arterial blood CO2 partial pressure (PaCO2) and PtcCO2.
RESULTS: There were no differences in respiratory functions, median sedative doses, or median procedure times between the groups. Similarly, there was no significant difference in post-ESD blood gas parameters, including PaCO2, between the CO2 and air groups (44.6 mmHg vs 45 mmHg). Both groups demonstrated median pH values of 7.36, and none of the patients exhibited acidemia. No significant differences were observed between the CO2 and air groups with respect to baseline PtcCO2 (39 mmHg vs 40 mmHg), peak PtcCO2 during ESD (52 mmHg vs 51 mmHg), or median PtcCO2 after ESD (50 mmHg vs 50 mmHg). There was a strong correlation between PaCO2 and PtcCO2 (r = 0.66; P < 0.001). The incidence of Mallory-Weiss tears was significantly lower with CO2 insufflation than with air insufflation (0% vs 15.6%, P = 0.013). CO2 insufflation did not cause any adverse events, such as CO2 narcosis or gas embolisms.
CONCLUSION: CO2 insufflation during gastric ESD results in similar blood gas levels as air insufflation, and also reduces the incidence of Mallory-Weiss tears.
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Mathew J, Parker C, Wang J. Pulseless electrical activity arrest due to air embolism during endoscopic retrograde cholangiopancreatography: a case report and review of the literature. BMJ Open Gastroenterol 2015; 2:e000046. [PMID: 26462286 PMCID: PMC4599162 DOI: 10.1136/bmjgast-2015-000046] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Revised: 06/04/2015] [Accepted: 06/05/2015] [Indexed: 12/12/2022] Open
Abstract
While most gastroenterologists are aware of the more common complications of endoscopy such as bleeding, infection and perforation, air embolism remains an under-recognised and difficult to diagnose problem due to its varying modes of presentation. This is the case of a 55-year-old man with right upper quadrant pain and imaging notable for cholecystitis and choledocholithiasis, who underwent endoscopic retrograde cholangiopancreatography (ERCP). During the ERCP, and shortly after a sphincterotomy was performed, he became hypotensive and hypoxic, quickly decompensating into pulseless electrical activity. While advanced cardiac life support was initiated, the patient passed away. Autopsy revealed air in the pulmonary artery suggestive of a pulmonary embolism. While air embolism remains a rare complication of upper endoscopy, increased awareness and prompt recognition of signs that may point to this diagnosis may potentially save lives by allowing for earlier possible interventions.
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Affiliation(s)
- Jacob Mathew
- Department of Medicine , Tripler Army Medical Center , Honolulu, Hawaii , USA
| | - Calvin Parker
- Department of Medicine , Tripler Army Medical Center , Honolulu, Hawaii , USA
| | - James Wang
- Department of Medicine , Tripler Army Medical Center , Honolulu, Hawaii , USA
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Minami H, Inoue H, Haji A, Isomoto H, Urabe S, Hashiguchi K, Matsushima K, Akazawa Y, Yamaguchi N, Ohnita K, Takeshima F, Nakao K. Per-oral endoscopic myotomy: emerging indications and evolving techniques. Dig Endosc 2015; 27:175-81. [PMID: 25040806 DOI: 10.1111/den.12328] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2014] [Accepted: 06/27/2014] [Indexed: 12/14/2022]
Abstract
Esophageal achalasia is a benign esophageal motility disorder resulting from an impaired relaxation of the lower esophageal sphincter. The principles of treatment involve disruption of the sphincter at the esophagogastric junction. Treatment techniques include balloon dilatation, botulinum toxin injection, and surgical myotomy. In 2008, per-oral endoscopic myotomy (POEM) was introduced by Inoue et al. as an endoscopic myotomy with no skin incision. The procedure has been well accepted and widely applied owing to its minimal invasiveness and high cure rates. Moreover, there have been discussions on wider indications for POEM and new technical developments have been reported. The present article reviews the historical background and present status of POEM, as well as future prospects for its application in the treatment of esophageal achalasia.
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Affiliation(s)
- Hitomi Minami
- Department of Gastroenterology and Hepatology, Nagasaki University Hospital, Nagasaki, Japan
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Takada J, Araki H, Onogi F, Nakanishi T, Kubota M, Ibuka T, Shimizu M, Moriwaki H. Safety of carbon dioxide insufflation during gastric endoscopic submucosal dissection in patients with pulmonary dysfunction under conscious sedation. Surg Endosc 2014; 29:1963-9. [PMID: 25318364 DOI: 10.1007/s00464-014-3892-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Accepted: 09/08/2014] [Indexed: 12/16/2022]
Abstract
BACKGROUND Carbon dioxide (CO2) insufflation is effective for gastric endoscopic submucosal dissection (ESD). However, its safety is unknown in patients with pulmonary dysfunction. This study aimed to investigate the safety of CO2 insufflation during gastric ESD in patients with pulmonary dysfunction under conscious sedation. METHODS We analyzed 322 consecutive patients undergoing ESD using CO2 insufflation (1.4 L/min) for gastric lesions. Pulmonary dysfunction was defined as a forced expiratory volume in 1.0 s/forced vital capacity (FEV1.0%) <70% or vital capacity <80%. Transcutaneous partial pressure of CO2 (PtcCO2) was recorded before, during, and after ESD. RESULTS In total, 127 patients (39%) had pulmonary dysfunction. There were no significant differences in baseline PtcCO2 before ESD, peak PtcCO2 during ESD, and median PtcCO2 after ESD between the pulmonary dysfunction group and normal group. There was a significant correlation between PtcCO2 elevation from baseline and ESD procedure time (r = 0.22, P < 0.05) only in the pulmonary dysfunction group. In patients with FEV1.0% <60%, the correlation was much stronger (r = 0.39, P < 0.05). Neither the complication incidences nor the hospital stay differed between the two groups. CO2 narcosis or gas embolism was not reported in either group. CONCLUSIONS CO2 insufflation during gastric ESD in patients with pulmonary dysfunction under conscious sedation is safe with regard to complication risk and hospital stay. However, in patients with severe obstructive lung disease, especially in those with FEV1.0% <60%, longer procedure time may induce CO2 retention, thus requiring CO2 monitoring.
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Affiliation(s)
- Jun Takada
- Department of Gastroenterology/Internal Medicine, Gifu University Graduate School of Medicine, 1-1 Yanagido, Gifu, 501-1194, Japan,
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Ge N, Sun S, Wang S, Liu X, Wang G, Guo J. Endoscopic Ultrasound-Assisted Tunnel-Type Endoscopic Submucosal Dissection for the Treatment of Esophageal Tumors Arising in the Muscularis Propria (with video). Endosc Ultrasound 2014; 2:11-5. [PMID: 24949361 PMCID: PMC4062232 DOI: 10.7178/eus.04.004] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2013] [Accepted: 01/29/2013] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVE Esophageal tumors arising in the muscularis propria are difficult to be resected endoscopically using standard electro-surgical techniques, even the endoscopic submucosal dissection (ESD) technique appeared recently. Our purpose is to investigate the efficacy of endoscopic ultrasound (EUS)-assisted tunnel-type ESD for resection of these tumors. METHODS A total of 17 patients were included in this study. A standard endoscope was used. The submucosal tunnel was created with the triangle knife according to the standard ESD technique, about 5 cm proximal to the lesion. EUS was performed within the tunnel to detect the tumor, and then the tumor was separated both from the submucosal and the muscle layers. After the tumor was removed, several clips were used to close the mucosal defect. EUS was performed to evaluate the healing quality 1 week after the procedure. RESULT In all the cases, the tumors were completely resected. Mean tumor size was 24.2 mm (12-50 mm) in diameter. The histo-logical diagnoses were leiomyoma (16/17) and gastrointestinal stromal tumor (GIST, 1/17). Subcutaneous emphysema was found in 2 patients after the procedure, but disappeared by the third day. No patients sustained perforation or developed significant hem-orrhage, and there were no other immediate severe complications after the procedure. The healing quality was satisfying in 16/17 patients evaluated by EUS 1 week after the procedure. No recurrence has been found during follow-up (mean 7 months, range 3-13 months). CONCLUSION EUS-assisted tunnel-type ESD is effective and safe in treatment of esophageal tumors arising in the muscularis pro-pria.
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Affiliation(s)
- Nan Ge
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Siyu Sun
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Sheng Wang
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Xiang Liu
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Guoxin Wang
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
| | - Jintao Guo
- Endoscopy Center, Shengjing Hospital, China Medical University, Shenyang 110004, Liaoning Province, China
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Tetzlaff JE, Vargo JJ, Maurer W. Nonoperating room anesthesia for the gastrointestinal endoscopy suite. Anesthesiol Clin 2014; 32:387-394. [PMID: 24882126 DOI: 10.1016/j.anclin.2014.02.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Anesthesia services are increasingly being requested for gastrointestinal (GI) endoscopy procedures. The preparation of the patients is different from the traditional operating room practice. The responsibility to optimize comorbid conditions is also unclear. The anesthetic techniques are unique to the procedures, as are the likely events that require intervention by the anesthesia team. The postprocedure care is also unique. The future needs for anesthesia services in GI endoscopy suite are likely to expand with further developments of the technology.
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Affiliation(s)
- John E Tetzlaff
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA.
| | - John J Vargo
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Cleveland, OH 44195, USA
| | - Walter Maurer
- Department of General Anesthesia, Anesthesiology Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195, USA
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Miyoshi H, Shimatani M, Kato K, Sumimoto K, Kurishima A, Kusuda T, Fukata N, Ikeura T, Takaoka M, Okazaki K. Transcutaneous monitoring of partial pressure of carbon dioxide during endoscopic retrograde cholangiopancreatography using a double-balloon endoscope with carbon dioxide insufflation under conscious sedation. Dig Endosc 2014; 26:436-41. [PMID: 23941285 DOI: 10.1111/den.12155] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2013] [Accepted: 07/05/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIM A double-balloon (DB) endoscope can be selectively inserted into the afferent loop to carry out endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy, allowing various types of endoscopic treatments for pancreaticobiliary diseases to be successfully carried out. In order to make such a lengthy procedure more comfortable and safe, sedatives and carbon dioxide (CO2 ) insufflation are widely used for gastrointestinal endoscopy. However, these techniques can increase the risk of CO2 retention. Recently, a new sensor for transcutaneous measurement of partial pressure of carbon dioxide (PCO2 ) has been introduced. The aim of the present study was to evaluate the changes in transcutaneous PCO2 (PtcCO2 ) during DB-ERCP with CO2 insufflation under conscious sedation and assess any complications related to sedation and CO2 insufflation. METHODS A total of 312 patients underwent DB-ERCP with CO2 insufflation at our hospital between March 2009 and December 2012. The patients were moderately sedated using midazolam with or without pentazocine. PtcCO2 was measured by a non-invasive sensor throughout DB-ERCP in all patients. RESULTS The mean peak PtcCO2 during the procedure was significantly higher than the mean PtcCO2 value before and after DB-ERCP. Body mass index, procedure time and dose of pentazocine were significantly higher in the CO2 retention group (peak PtcCO2 ≥ 50 mmHg). CO2 narcosis was observed in one case. CONCLUSIONS DB-ERCP with CO2 insufflation under conscious sedation might have the potential to increase the risk of CO2 retention. Hence, non-invasive and continuous PtcCO2 measurement is useful for early detection of hypercapnia.
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Affiliation(s)
- Hideaki Miyoshi
- Division of Gastroenterology and Hepatology, Kansai Medical University, Osaka, Japan
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Lord AC, Riss S. Is the type of insufflation a key issue in gastro-intestinal endoscopy? World J Gastroenterol 2014; 20:2193-9. [PMID: 24605018 PMCID: PMC3942824 DOI: 10.3748/wjg.v20.i9.2193] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 12/18/2013] [Accepted: 01/19/2014] [Indexed: 02/06/2023] Open
Abstract
Endoscopic procedures continue to play an emerging role in diagnosing and treating upper and lower gastrointestinal (GI) disorders. In particular, the introduction of colonoscopy in bowel cancer screening has underlined its promising role in decreasing the incidence of colorectal cancer and reducing tumour related mortality. To achieve these goals patients need to contemplate endoscopic examinations as painless and fearless procedures. The use of carbon dioxide (CO₂) as an alternative insufflation gas in comparison to air has been considered as an essential key to improving patients' acceptance in undergoing endoscopic procedures. CO₂ is absorbed quickly through the bowel mucosa causing less luminal distension and potentially less abdominal pain. However, its exact role has not been defined completely. In particular, the beneficial use of CO₂ in upper GI endoscopy and in sedated patients is still conflicting. In the present review, we aimed to assess the current evidence for using CO₂ in endoscopy and to evaluate its potential role in the future.
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Carbon dioxide insufflation during colorectal endoscopic submucosal dissection for patients with obstructive ventilatory disturbance. Int J Colorectal Dis 2014; 29:365-71. [PMID: 24297038 DOI: 10.1007/s00384-013-1806-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/20/2013] [Indexed: 02/08/2023]
Abstract
PURPOSE Carbon dioxide (CO(2)) insufflation reduces abdominal pain and discomfort after endoscopic procedures; however, there is no previous study focusing the safety of CO(2) insufflation for patients with obstructive ventilatory disturbance. Here, we investigated the safety of CO(2) insufflation during colorectal endoscopic submucosal dissection (ESD) for patients with obstructive disturbance. METHODS Between January 2010 and January 2013, colorectal ESD was performed using CO(2) insufflation for 385 consecutive patients. End-tidal CO(2) (EtCO(2)) and transcutaneous oxygen saturation (SpO(2)) were consecutively measured from the time before insertion of the colonoscope to the end of ESD. Patients were monitored by two nurses during the procedure and controlled for clinical symptoms of hypercapnia such as apnea or a depressed level of consciousness. According to their respiratory function, patients were stratified into a normal group and an obstructive disturbance group. We retrospectively compared EtCO(2) and SpO(2) during the procedures and the incidence of symptoms related to CO(2) retention between the two groups. RESULTS The obstructive disturbance group consisted of 77 patients. There were similar changes of EtCO(2) in the obstructive disturbance group and normal group and no significant rise in EtCO(2). The maximum EtCO(2) level in any patient was <60 mmHg. In the obstructive disturbance group, there were no symptoms associated with CO(2) retention. There were no significant differences in the median SpO(2) between both groups and no prolonged drop of SpO(2). CONCLUSIONS CO(2) insufflation during colorectal ESD is safe for patients with obstructive ventilatory disturbance.
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Suzuki T, Ikeda H, Iwamoto T, Sano H, Hashimoto M, Oe K, Inoue H, Serada K. Elective use of an uncuffed small-bore cricothyrotomy tube with balloon occlusion of the subglottic airway. Can J Anaesth 2013; 61:39-45. [PMID: 24158854 DOI: 10.1007/s12630-013-0057-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2013] [Accepted: 10/10/2013] [Indexed: 10/26/2022] Open
Abstract
PURPOSE To conduct a qualitative observational study on positive pressure ventilation through a percutaneous uncuffed small-bore cricothyrotomy tube with balloon occlusion of the subglottic airway to minimize supraglottic leak. CLINICAL FEATURES Ten consecutive procedures were performed in the nine men enrolled in this study. The demographics of the participants were: aged 50-73 yr, weight 48-87 kg, American Society of Anesthesiologists class I-II, and scheduled for endoscopic submucosal dissection via flexible endoscopy for en bloc resection of superficial meso- and hypopharyngeal cancer. The airway was initially secured with a supraglottic airway (SGA) under sevoflurane-based anesthesia, and a cricothyrotomy was then performed using a Portex(®) Minitrach II uncuffed cricothyrotomy tube (4-mm internal diameter). Following SGA removal, a Coopdech(®) bronchial blocker was orally or nasally inserted, and the balloon was inflated to occlude the trachea immediately beneath the glottis. The ventilator setting was initially based on observation of chest motion and end-tidal carbon dioxide tension and then readjusted according to arterial blood gas levels. All procedures were completed within a median time of 149 min. Effective ventilation was achieved in all patients despite mild hypercapnia (PaCO2 of 58 mmHg at maximum) in some patients. SpO2 levels were maintained at ≥ 98%. CONCLUSION This technique provides effective intraoperative ventilation and easy endoscopic access, and it countermeasures against the likely complication of postoperative laryngeal edema. Moreover, there is no need for conventional tracheostomy or prolonged intubation. This approach establishes a curative and less invasive pharyngeal cancer therapy. Certain adverse outcomes can be avoided, including impaired speech and swallowing, possible delayed closure of the stoma, or a compromised cosmetic outcome.
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Affiliation(s)
- Takashi Suzuki
- Department of Anesthesia, Showa University Northern Yokohama Hospital, 35-1 Chigasaki-Chuo, Tsuzuki-ku, Yokohama, 224-8503, Japan,
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Tomasko JM, Mathew A, Moyer MT, Haluck RS, Pauli EM. An intestinal occlusion device for prevention of small bowel distention during transgastric natural orifice transluminal endoscopic surgery. JSLS 2013; 17:306-11. [PMID: 23925026 PMCID: PMC3771799 DOI: 10.4293/108680813x13693422521197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
An intestinal occlusion catheter that maintains duodenal occlusion significantly improves intra-abdominal visualization during a NOTES procedure. Background and Objectives: Bowel distention from luminal gas insufflation reduces the peritoneal operative domain during natural orifice transluminal endoscopic surgery (NOTES) procedures, increases the risk for iatrogenic injury, and leads to postoperative patient discomfort. Methods: A prototype duodenal occlusion device was placed in the duodenum before NOTES in 28 female pigs. The occlusion balloon was inflated and left in place during the procedure, and small bowel distension was subjectively graded. One animal had no balloon occlusion, and 4 animals had a noncompliant balloon placed. Results: The balloon maintained its position and duodenal occlusion in 22 animals (79%) in which the bowel distention was rated as none (15), minor (4), moderate (3), or severe (0). The intestinal occlusion catheter failed in 6 animals (21%) because of balloon leak (5) or back-migration into the stomach (1), with distention rated as severe in 5 of these 6 cases. Conclusion: The intestinal occlusion catheter that maintains duodenal occlusion significantly improves the intra-abdominal working domain with enhanced visualization of the viscera during the NOTES procedure while requiring minimal time and expense.
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Affiliation(s)
- Jonathan M Tomasko
- Division of Minimally Invasive Surgery, Penn State Hershey Medical Center, Hershey, PA, USA
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Lewis JR, Cohen LB. Update on colonoscopy preparation, premedication and sedation. Expert Rev Gastroenterol Hepatol 2013; 7:77-87. [PMID: 23265152 DOI: 10.1586/egh.12.68] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
The advent of optical colonoscopy has enabled gastroenterologists to visualize the colonic mucosa. This procedure has since become the cornerstone of colon cancer screening programs. Clinicians and scientists have made great strides to fine-tune the technical aspects of this procedure and have also made important advances that allow for a more effective and safer colonoscopy. This article focuses on current research and expert opinion regarding colonoscopy preparation, premedication and sedation.
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Affiliation(s)
- Jeffrey R Lewis
- The Department of Medicine (Gastroenterology), The Mount Sinai School of Medicine, New York, NY 10029, USA
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Nishiwaki S, Araki H, Hayashi M, Takada J, Iwashita M, Tagami A, Hatakeyama H, Hayashi T, Maeda T, Saito K. Inhibitory effects of carbon dioxide insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy. World J Gastroenterol 2012; 18:3565-70. [PMID: 22826621 PMCID: PMC3400858 DOI: 10.3748/wjg.v18.i27.3565] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2011] [Revised: 03/16/2012] [Accepted: 03/20/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the inhibitory effects of carbon dioxide (CO2) insufflation on pneumoperitoneum and bowel distension after percutaneous endoscopic gastrostomy (PEG).
METHODS: A total of 73 consecutive patients who were undergoing PEG were enrolled in our study. After eliminating 13 patients who fitted our exclusion criteria, 60 patients were randomly assigned to either CO2 (30 patients) or air insufflation (30 patients) groups. PEG was performed by pull-through technique after three-point fixation of the gastric wall to the abdominal wall using a gastropexy device. Arterial blood gas analysis was performed immediately before and after the procedure. Abdominal X-ray was performed at 10 min and at 24 h after PEG to assess the extent of bowel distension. Abdominal computed tomography was performed at 24 h after the procedure to detect the presence of pneumoperitoneum. The outcomes of PEG for 7 d post-procedure were also investigated.
RESULTS: Among 30 patients each for the air and the CO2 groups, PEG could not be conducted in 2 patients of the CO2 group, thus they were excluded. Analyses of the remaining 58 patients showed that the patients’ backgrounds were not significantly different between the two groups. The elevation values of arterial partial pressure of CO2 in the air group and the CO2 group were 2.67 mmHg and 3.32 mmHg, respectively (P = 0.408). The evaluation of bowel distension on abdominal X ray revealed a significant decrease of small bowel distension in the CO2 group compared to the air group (P < 0.001) at 10 min and 24 h after PEG, whereas there was no significant difference in large bowel distension between the two groups. Pneumoperitoneum was observed only in the air group but not in the CO2 group (P = 0.003). There were no obvious differences in the laboratory data and clinical outcomes after PEG between the two groups.
CONCLUSION: There was no adverse event associated with CO2 insufflation. CO2 insufflation is considered to be safer and more comfortable for PEG patients because of the lower incidence of pneumoperitoneum and less distension of the small bowel.
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Fujimoto H, Shigemasa Y, Suzuki H. Carbon dioxide-induced inhibition of mechanical activity in gastrointestinal smooth muscle preparations isolated from the guinea-pig. J Smooth Muscle Res 2012; 47:167-82. [PMID: 22374469 DOI: 10.1540/jsmr.47.167] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Mechanical responses of smooth muscle elicited by application of CO2-gas bubbled physiological salt solution (CO2-gas solution) were investigated in isolated stomach antrum and colon preparations of the guinea-pig. Circular smooth muscle preparations of both colon and stomach were spontaneously active with periodic generation of phasic contractions. In colonic preparations, the CO2-gas solution produced a biphasic response, with an initial small transient contraction followed by a sustained inhibition of phasic contractions. Removal of the CO2-gas solution allowed a slow recovery of the spontaneous contractions over a period of about 40 min. The recovery developed with a similar time course irrespective of the length of time exposed to CO2-gas solution. The inhibitory responses elicited by CO2-gas solution were not modulated by atropine, Nω-nitro-L-arginine or neostigmine. Atropine-sensitive excitatory responses of smooth muscle elicited by transmural nerve stimulation or exogenously applied acetylcholine were attenuated or abolished in the presence of CO2-gas solution. In stomach preparations, the CO2-gas solution elicited a tri-phasic response, with an initial transient relaxation followed by a transient contraction and then a sustained inhibition of the rhythmic contractions. The peak amplitude of the transient contraction was about 2.5 times larger than the spontaneous phasic contractions. The pH of the CO2-gas solution was reduced to about 6. Application of pH 6 solution again produced a tri-phasic response, as was the case for the CO2-gas solution, however the amplitude of the transient contraction was only about 0.4 times that of the spontaneous contractions. The re-appearance of the abolished phasic contraction was quicker with the pH 6 solution (about 1.8 min) than it was for the CO2-gas solution (about 6 min). The inhibitory responses elicited by the CO2-gas solution could be simulated only partly by the acidified solution, and a possible involvement of additional factors in the inhibition elicited by CO2-gas solution was considered.
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Affiliation(s)
- Hiroyuki Fujimoto
- Department of Cell Physiology, Nagoya City University Medical School, Nagoya, Japan
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[Iatrogenic gas embolism during upper gastroscopy in a patient with a multiperforated biliary drain placed by radiological way]. ACTA ACUST UNITED AC 2012; 31:724-7. [PMID: 22749549 DOI: 10.1016/j.annfar.2012.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 04/03/2012] [Indexed: 11/21/2022]
Abstract
The authors report the first case of gas embolism arising during an upper gastrointestinal endoscopy to a patient carrier of a biliary drain placed by radiological way. The hypothesis of a biliary-vascular fistula with abnormal connection between the biliary tree and the hepatic vascular system and finally an arteriovenous intrapulmonary shunt was retained to explain the physiopathology. The immediate stop of the endoscopic procedure and the implementation of symptomatic treatment allowed a favorable neurological outcome without sequelas. The realization of an upper gastrointestinal endoscopy to a patient carrier of a biliary drain has to lead the anaesthesiologists and the gastroenterologists to take care given the incurred risk of gas embolism.
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Abstract
This article reviews the principal aspects related to sedation in endoscopy and to the prevention of adverse events in some of the most frequently performed therapeutic upper gastrointestinal (GI) endoscopic procedures (esophageal dilation and stenting, endoscopic resection of upper GI early neoplasia, hemostasis of upper GI bleeding and percutaneous endoscopic gastrostomy insertion). These procedures have an inherent risk of negative outcomes that cannot be entirely avoided. Endoscopic procedures are best performed by well-trained, competent and thoughtful endoscopists in facilities suited to provide for patient safety. Attention to clinical risk management may effectively reduce the frequency and intensity of adverse events, enhance recognition and early detection, and improve responsiveness.
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Affiliation(s)
- Gianluca Rotondano
- Division of Gastroenterology and Digestive Endoscopy, Hospital Maresca, Torre del Greco, Italy.
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