Carbon Dioxide versus Air Insuffation in Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

다국어 초록 (Multilingual 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 post-procedural 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.

참고문헌 (Reference)

1 Kikuchi T, "Transcutaneous monitoring of partial pressure of carbon dioxide during endoscopic submucosal dissection of early colorectal neoplasia with carbon dioxide insufflation: a prospective study" 24 : 2231-2235, 2010

2 Wong JC, "Towards painless colonoscopy: a randomized controlled trial on carbon dioxide-insufflating colonoscopy" 78 : 871-874, 2008

3 Lo SK, "The use of carbon dioxide in gastrointestinal endoscopy" 83 : 857-865, 2016

4 Dellon ES, "The use of carbon dioxide for insufflation during GI endoscopy: a systematic review" 69 : 843-849, 2009

5 Verhagen AP, "The Delphi list: a criteria list for quality assessment of randomized clinical trials for conducting systematic reviews developed by Delphi consensus" 51 : 1235-1241, 1998

6 Rai A, "Tension pneumothorax complicating diagnostic upper endoscopy: a case report" 94 : 845-847, 1999

7 Nonaka S, "Safety of carbon dioxide insufflation for upper gastrointestinal tract endoscopic treatment of patients under deep sedation" 24 : 1638-1645, 2010

8 Takada J, "Safety of carbon dioxide insufflation during gastric endoscopic submucosal dissection in patients with pulmonary dysfunction under conscious sedation" 29 : 1963-1969, 2015

9 Takada J, "Safety and efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection" 21 : 8195-8202, 2015

10 Tanioka D, "Safety and efficacy of carbon dioxide (CO2) insufflation during endoscopic submucosal dissection (ESD) for gastric cancer under propofol sedation: a randomized, controlled trial" 67 : AB279-, 2008

11 Church J, "Randomized, controlled trial of carbon dioxide insufflation during colonoscopy" 46 : 322-326, 2003

12 Suzuki T, "Prolonged carbon dioxide insufflation under general anesthesia for endoscopic submucosal dissection" 42 : 1021-1029, 2010

13 Stevenson GW, "Pain following colonoscopy: elimination with carbon dioxide" 38 : 564-567, 1992

14 Beller EM, "PRISMA for abstracts: reporting systematic reviews in journal and conference abstracts" 10 : e1001419-, 2013

15 Bretthauer M, "NORCCAP (Norwegian colorectal cancer prevention): a randomised trial to assess the safety and efficacy of carbon dioxide versus air insufflation in colonoscopy" 50 : 604-607, 2002

16 Sumanac K, "Minimizing postcolonoscopy abdominal pain by using CO2 insufflation: a prospective, randomized, double blind, controlled trial evaluating a new commercially available CO2 delivery system" 56 : 190-194, 2002

17 Wang WL, "Meta-analysis: the use of carbon dioxide insufflation vs. room air insufflation for gastrointestinal endoscopy" 35 : 1145-1154, 2012

18 Hawker GA, "Measures of adult pain:visual analog scale for pain (VAS Pain), numeric rating scale for pain (NRS Pain), McGill pain questionnaire (MPQ), short-form McGill pain questionnaire (SF-MPQ), chronic pain grade scale (CPGS), short form-36 bodily pain scale (SF-36 BPS), and measure of intermittent and constant osteoarthritis pain (ICOAP)" 63 (63): S240-S252, 2011

19 Noguchi Y, "Is gastric carcinoma different between Japan and the United States?" 89 : 2237-2246, 2000

20 Saltzman HA, "Intestinal response to changing gaseous environments:normobaric and hyperbaric observations" 150 : 31-39, 1968

21 Wright RW, "How to write a systematic review" 455 : 23-29, 2007

22 Hozo SP, "Estimating the mean and variance from the median, range, and the size of a sample" 5 : 13-, 2005

23 Gotoda T, "Endoscopic submucosal dissection of early gastric cancer" 41 : 929-942, 2006

24 Fujishiro M., "Endoscopic submucosal dissection for stomach neoplasms" 12 : 5108-5112, 2006

25 Onozato Y, "Endoscopic submucosal dissection for early gastric cancers and large flat adenomas" 38 : 980-986, 2006

26 Gotoda T, "Endoscopic resection (endoscopic mucosal resection/endoscopic submucosal dissection) for early gastric cancer" 25 (25): 55-63, 2013

27 Kim SY, "Efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection: a randomized, double-blind, controlled, prospective study" 82 : 1018-1024, 2015

28 Mori H, "Comparison of postoperative complications after endoscopic submucosal dissection: differences of insufflations and anesthesias" 2011 : 709237-, 2011

29 Watanabe K, "Clinical outcomes of EMR for gastric tumors: historical pilot evaluation between endoscopic submucosal dissection and conventional mucosal resection" 63 : 776-782, 2006

30 Green BT, "Cerebral air embolism during upper endoscopy:case report and review" 61 : 620-623, 2005

31 Bretthauer M, "Carbon dioxide insufflation reduces discomfort due to flexible sigmoidoscopy in colorectal cancer screening" 37 : 1103-1107, 2002

32 Maeda Y, "Carbon dioxide insufflation in esophageal endoscopic submucosal dissection reduces mediastinal emphysema:a randomized, double-blind, controlled trial" 22 : 7373-7382, 2016

33 Bretthauer M, "Carbon dioxide insufflation for more comfortable endoscopic retrograde cholangiopancreatography:a randomized, controlled, double-blind trial" 39 : 58-64, 2007

34 Shi H, "Carbon dioxide insufflation during endoscopic retrograde cholangiopancreatography: a review and meta-analysis" 42 : 1093-1100, 2013

35 Yoshida M, "Carbon dioxide insufflation during colorectal endoscopic submucosal dissection for patients with obstructive ventilatory disturbance" 29 : 365-371, 2014

36 Maple JT, "Carbon dioxide insufflation during ERCP for reduction of postprocedure pain: a randomized, double-blind, controlled trial" 70 : 278-283, 2009

37 Takano A, "Capnographic monitoring during endoscopic submucosal dissection with patients under deep sedation: a prospective, crossover trial of air and carbon dioxide insufflations" 84 : 193-198, 2011

38 National Cancer Institute, "Cancer stat facts: stomach cancer" National Cancer Institute

39 World Health Organization, "Cancer" World Health Organization

40 Oka S, "Advantage of endoscopic submucosal dissection compared with EMR for early gastric cancer" 64 : 877-883, 2006

41 Hayakawa M, "Abdominal compartment syndrome and intrahepatic portal venous gas: a possible complication of endoscopy" 28 : 1680-1681, 2002

42 Kontopantelis E, "A re-analysis of the cochrane library data: the dangers of unobserved heterogeneity in meta-analyses" 8 : e69930-, 2013

43 Maeda Y, "A prospective, randomized, double-blind, controlled trial on the efficacy of carbon dioxide insufflation in gastric endoscopic submucosal dissection" 45 : 335-341, 2013

44 Saito Y, "A pilot study to assess the safety and efficacy of carbon dioxide insufflation during colorectal endoscopic submucosal dissection with the patient under conscious sedation" 65 : 537-542, 2007

45 Maeda Y, "A pilot study to assess mediastinal emphysema after esophageal endoscopic submucosal dissection with carbon dioxide insufflation" 44 : 565-571, 2012

46 Oda I, "A multicenter retrospective study of endoscopic resection for early gastric cancer" 9 : 262-270, 2006