• Aged
• Aged, 80 and over
• Female
• Humans
• Male
• Middle Aged
• Colonoscopy/methods
• Colorectal Neoplasms/surgery
• Colorectal Neoplasms/pathology
• Endoscopic Mucosal Resection/methods
• Endoscopic Mucosal Resection/adverse effects
• Operative Time
• Prospective Studies
• Treatment Outcome
• Water

• Endoscopic ultrasonography
• Endoscopic visualization
• Endoscopy
• Gastrointestinal endoscopy
• Gel immersion

• Humans
• Endoscopy, Gastrointestinal/methods
• Endoscopy, Gastrointestinal/instrumentation
• Gels/chemistry
• Gastrointestinal Tract/diagnostic imaging
• Gastrointestinal Tract/pathology
• Artifacts

• Humans
• Colonoscopy
• Colorectal Neoplasms
• Endoscopic Mucosal Resection/methods
• Endoscopy, Gastrointestinal/methods
• Hemostasis, Endoscopic

• Japan Endoscopy Database
• colonoscopy
• colorectal cancer
• fecal immunochemical test
• magnifying endoscopy

• Adenoma
• Colonic Polyps
• Colonoscopy
• Colorectal Neoplasms
• Humans
• Japan/epidemiology
• Occult Blood

• Japan Agency for Medical Research and Development
• 29-A-13 The National Cancer Center Research and Development Fund
• 2020-A-12 The National Cancer Center Research and Development Fund

• Conservative management
• Gastroduodenal perforation
• Urgent endoscopy

• Endo-knife
• Endoscopic submucosal dissection
• Ex vivo
• Porcine model
• Scissor-type

• Animals
• Dissection/adverse effects
• Dissection/instrumentation
• Endoscopic Mucosal Resection/methods
• Endoscopy/instrumentation
• Endoscopy/methods
• Microsurgery
• Mucous Membrane/surgery
• Stomach Neoplasms/surgery
• Surgical Instruments
• Swine

• EMR
• Risk factor
• clipping closure
• colorectal ESD
• perforation

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.

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).

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).

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.

• Anesthesia
• carbon dioxide
• chronic obstructive pulmonary disease
• endoscopy
• humans

• Large colorectal sessile polyp
• Pre-cut
• Recurrence
• Tip-in endoscopic mucosal resection

• Aged
• Case-Control Studies
• Colonic Polyps/surgery
• Colorectal Neoplasms/surgery
• Endoscopic Mucosal Resection
• Female
• Follow-Up Studies
• Humans
• Intestinal Mucosa/surgery
• Japan
• Male
• Neoplasm Recurrence, Local/surgery
• Retrospective Studies
• Treatment Outcome

• Colorectal neoplasm
• Colorectal polyp
• Endoscopic resection
• Endoscopic submucosal dissection
• Therapeutic endoscopy

• Anal canal
• Endoscopic submucosal dissection
• Postoperative stricture
• Rectal cancer

• Adult
• Aged
• Aged, 80 and over
• Anal Canal/surgery
• Constriction, Pathologic/surgery
• Endoscopic Mucosal Resection/adverse effects
• Female
• Humans
• Male
• Middle Aged
• Postoperative Complications/surgery
• Rectal Neoplasms/surgery
• Retrospective Studies
• Risk Factors
• Treatment Outcome

• Anastomotic site
• Colorectal lesions
• Endoscopic submucosal dissection

• Aged
• Anastomosis, Surgical/methods
• Colorectal Neoplasms/pathology
• Colorectal Neoplasms/surgery
• Endoscopic Mucosal Resection/methods
• Feasibility Studies
• Female
• Humans
• Male
• Retrospective Studies
• Treatment Outcome

• colorectal tumor
• early colorectal carcinoma
• endoscopic mucosal resection
• endoscopic submucosal dissection
• guidelines

• Carbon dioxide
• EUS
• peripancreatic fluid collections
• transcutaneous partial pressure of carbon dioxide monitoring

• Aged
• Aged, 80 and over
• Colorectal Neoplasms/pathology
• Colorectal Neoplasms/surgery
• Dissection/methods
• Endoscopic Mucosal Resection/methods
• Female
• Humans
• Male
• Middle Aged
• Prospective Studies
• Saline Solution/administration & dosage

A recent achalasia guideline suggests that peroral endoscopic myotomy (POEM) is a safe option for achalasia that is as effective as Heller myotomy. It is recommended that POEM should be performed under general anesthesia. The incidence of adverse events such as bleeding, perforation, and carbon dioxide insufflation-related complications was lower in POEM under endotracheal general anesthesia than in POEM under sedation. Subcutaneous emphysema, pneumothorax, pneumomediastinum, pneumoperitoneum, and accompanying hemodynamic instability can be caused by carbon dioxide insufflation. Treatment of possible physiological changes and adverse events during the POEM procedure from the point of view of anesthesiologists may give endoscopists a new perspective on improving patient safety. The territory of therapeutic endoscopy can be expanded through cooperation with other departments, including anesthesia services. Efforts to understand different perspectives will certainly help not only secure patient safety but also expand the area of treatment.

• Complication
• General endotracheal anesthesia
• Peroral endoscopic myotomy

• LST-NG [PD], lateral spreading tumor
• NBI, narrow-band imaging
• SM, submucosal
• nongranular, pseudodepressed type

• adenoma extending above the dentate line
• adenoma with hemorrhoids
• case report
• combined esd and tamis

• Adenoma/diagnostic imaging
• Adenoma/pathology
• Adenoma/surgery
• Aged
• Diagnosis, Differential
• Endoscopic Mucosal Resection/methods
• Humans
• Male
• Rectal Neoplasms/diagnostic imaging
• Rectal Neoplasms/pathology
• Rectal Neoplasms/surgery
• Transanal Endoscopic Surgery/methods

• Endoscopic closure
• Oral feeding
• Over-the-scope system
• Perforated peptic ulcer

• Emphysema
• Pneumomediastinum
• Pneumothoraces
• Retropneumoperitoneum
• Transanal surgery

• Adult
• Aged
• Aged, 80 and over
• Female
• Humans
• Incidence
• Male
• Mediastinal Emphysema/diagnostic imaging
• Mediastinal Emphysema/epidemiology
• Mediastinal Emphysema/etiology
• Middle Aged
• Postoperative Complications/diagnostic imaging
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Radiography
• Retropneumoperitoneum/diagnostic imaging
• Retropneumoperitoneum/epidemiology
• Retropneumoperitoneum/etiology
• Subcutaneous Emphysema/diagnostic imaging
• Subcutaneous Emphysema/epidemiology
• Subcutaneous Emphysema/etiology
• Transanal Endoscopic Surgery/adverse effects

• Carbon dioxide
• colonoscopy
• colorectal polyp
• endoscopic mucosal resection
• endoscopic submucosal dissection

• ESD
• Master and Slave Transluminal Endoscopic Robot (MASTER)
• robot assisted tumor resection devices
• robotic
• traction

Transanal endoscopic microsurgery is considered a safe, appropriate, and minimally invasive approach, and complications after endoscopic microsurgery are rare. We report a case of sepsis and pneumoretroperitoneum after resection of a rectal lateral spreading tumor. The patient presented with rectal mucous discharge. Colonoscopy revealed a rectal lateral spreading tumor. The patient underwent an endoscopic transanal resection of the lesion. He presented with sepsis of the abdominal focus, and imaging tests revealed pneumoretroperitoneum. A new surgical intervention was performed with a loop colostomy. Despite the existence of other reports on pneumoretroperitoneum after transanal endoscopic microsurgery, what draws attention to this case is the association with sepsis.

• Retropneumoperitoneum
• Sepsis
• Transanal endoscopic microsurgery

• Appendiceal orifice
• ESD strategy
• Endoscopic submucosal dissection (ESD)
• Laterally spreading tumor (LST)
• Preoperative endoscopic diagnosis

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.

This meta-analysis is aimed to assess the efficacy and safety of use of CO₂ insufflation for ESD.

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).

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.

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.

• Air
• Carbon Dioxide/administration & dosage
• Endoscopic Mucosal Resection/methods
• Female
• Humans
• Insufflation/adverse effects
• Insufflation/methods
• Male
• Pain/prevention & control
• Randomized Controlled Trials as Topic
• Treatment Outcome

• Science and technology development projects of Suzhou
• the National Natural Science Foundation of China
• Jiangsu Standard Diagnosis and Treatment Research for Key Diseases
• the Priority Academic Program Development of Jiangsu Higher Education Institutions

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.

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.

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).

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.

• Air insufflation
• Carbon dioxide insufflation
• Early gastric carcinoma
• Endoscopic submucosal dissection
• Post-procedural pain

• Fundic gland adenoma
• colon adenoma
• diminutive colon polyps
• duodenal adenoma
• endoscopic mucosal resection (EMR)
• endoscopic submucosal dissection (ESD)
• gastric adenoma
• snare polypectomy

• Early colorectal cancer
• Endoscopic mucosal resection
• Endoscopic submucosal dissection
• Laterally spreading tumor

• CO2 insufflation
• colonoscopy
• propofol

Condyloma acuminatum (CA) is a common sexually transmitted disease caused by human papilloma virus infection. Not all individuals develop persistent, progressive disease, but careful follow up is required with moderate-to-severe dysplasia to prevent progression to malignancy. Standard therapies include surgical treatments (trans-anal resection and trans-anal endoscopic microsurgery) and immunotherapeutic and topical methods (topical imiquimod); however, local recurrence remains a considerable problem. Here, we report a case with superficial CA of the anal canal, treated with endoscopic submucosal dissection (ESD). A 28-year-old man presented with a chief complaint of hematochezia. Digital exam did not detect a tumor. Screening colonoscopy revealed 10-mm long, whitish condyles extending from the anal canal to the lower rectum. The lesion covered almost the whole circumference, and only a small amount of normal mucosa remained. Magnifying endoscopy with narrow band imaging showed brownish hairpin-shaped, coiled capillaries. Although histopathological diagnosis by biopsy revealed CA, accurate histological differentiation between CA, papilloma, and squamous cell carcinoma can be difficult with a small specimen. Therefore, we performed diagnostic ESD, which provides a complete specimen for precise histopathological evaluation. The pathological diagnosis was CA, with moderate dysplasia (anal intraepithelial neoplasia 2). There was no recurrence at 16 mo after the initial ESD. Compared to surgical treatment, endoscopic diagnosis and resection could be performed simultaneously and the tumor margin observed clearly with a magnifying chromocolonoscopy, resulting in less recurrence. These findings suggest that endoscopic resection may be an alternative method for CA that prevents recurrence.

• Condylomata acuminate
• Recurrence
• Endoscopy
• Dissection
• Carcinoma in situ

• Adult
• Anal Canal/surgery
• Anal Canal/virology
• Anus Diseases/diagnosis
• Anus Diseases/surgery
• Anus Diseases/virology
• Biopsy
• Colonoscopy
• Condylomata Acuminata/diagnosis
• Condylomata Acuminata/surgery
• Condylomata Acuminata/virology
• Diagnosis, Differential
• Dissection/methods
• Humans
• Male
• Narrow Band Imaging
• Predictive Value of Tests
• Treatment Outcome

• Colorectal tumors
• Endoscopic mucosal resection
• Endoscopic submucosal dissection
• Meta-analysis

• abdominal circumference
• abdominal distention
• carbon dioxide
• colonoscopy
• salivary amylase

• Endoscopic full-thickness resection
• Gastrointestinal stromal tumors
• Laparoscopic-assisted surgery

• colorectal cancer
• endoscopic en bloc resection
• endoscopic mucosal resection
• endoscopic submucosal dissection

Endoscopic submucosal dissection (ESD) is very useful in en bloc resection of large superficial colorectal tumors but is a technically difficult procedure because the colonic wall is thin and endoscopic maneuverability is poor because of colonic flexure and extensibility. A high risk of perforation has been reported in colorectal ESD. To prevent complications such as perforation and unexpected bleeding, it is crucial to ensure good visualization of the submucosal layer by creating a mucosal flap, which is an exfoliated mucosa for inserting the tip of the endoscope under it. The creation of a mucosal flap is often technically difficult; however, various types of equipment, appropriate strategy, and novel procedures including our clip-flap method, appear to facilitate mucosal flap creation, improving the safety and success rate of ESD. Favorable treatment outcomes with colorectal ESD have already been reported in many advanced institutions, and appropriate understanding of techniques and development of training systems are required for world-wide standardization of colorectal ESD. Here, we describe recent technical advances for safe and successful colorectal ESD.

• Endoscopic submucosal dissection
• Colorectal tumors
• Mucosal flap
• Clip-flap method

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.