• carbon dioxide (CO2)
• endoscopic submucosal dissection (ESD)
• safety

• CO2 insufflation
• abdominal distention
• abdominal pain
• carbon dioxide
• health check
• transnasal endoscopy

• aspiration pneumonia
• endoscopic submucosal dissection
• incidence
• outcome
• risk factors

Submucosal tunneling endoscopic resection (STER) is a new method for treating submucosal tumor in recent years, which is minimally invasive, with few complications and rapid recovery for patients. This study analyzed the data of patients who underwent this surgery at our hospital and explored the feasibility, effectiveness, and safety of this procedure for submucosal tumors.

To evaluate the efficacy, safety, and clinical value of STER in the treatment of submucosal tumors of the esophagus and cardia derived from the muscularis propria.

Sixty patients who underwent STER for submucosal tumors of the esophagus and cardia derived from the muscularis propria were included. The results of endoscopic ultrasonography, procedure success rate, postoperative complications, postoperative pathological results, and postoperative follow-up data were recorded and analyzed statistically.

All of the cases completed the STER, with a success rate of 100%. The diameter of submucosal tumors was 1-5 cm. The operation took 31 to 123 min, and the average operation time was 81.73 min ± 23.23 min. The length of submucosal tunnel was 4-8 cm, with an average value of 5.88 cm ± 1.17 cm. Postoperative pathology confirmed that there were 42 cases of leiomyoma and 18 cases of stromal tumor. Two patients developed subcutaneous emphysema and right-side pneumothorax post operation, who were cured with conservative treatment. All cases were followed for 3 mo without any residual or recurrence of the lesion and no complications such as esophageal stenosis.

STER is effective in the treatment of submucosal tumors of the esophagus and cardia derived from the muscularis propria, with few complications and high safety.

• Submucosal tumor
• Submucosal tunneling endoscopic resection
• Muscularis propria

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

• abdominal pain
• bupivacaine
• endoscopic submucosal dissection
• local anesthesia
• submucosal injection

• Aged
• Anesthetics, Local/administration & dosage
• Bupivacaine/administration & dosage
• Double-Blind Method
• Endoscopic Mucosal Resection
• Female
• Humans
• Male
• Middle Aged
• Pain Management
• Pain, Postoperative/drug therapy
• Time Factors
• Treatment Outcome

• Endoscopy
• Mucous Membrane
• Myotomy

• Mallory-Weiss tear
• complication
• endoscopic submucosal dissection

In Brazil, an increasing number of people are submitted to colonoscopy, either for screening or for therapeutic purposes.

To evaluate whether there are advantages of using carbon dioxide (CO₂) over air for insufflation.

Two hundred and ten of 219 patients were considered eligible for this study and were randomized into two groups according to the gas insufflation used: Air Group (n=104) and CO₂ Group (n=97). The study employed a double-blind design.

The Air and CO₂ Groups were similar in respect to bowel preparation evaluated using the Boston scale, age, gender, previous surgery, maneuvers necessary for the advancement of the device, and presence of polyps, tumors or signs of diverticulitis. However, “waking up with pain” and “pain at discharge” were more prevalent in the Air Group, albeit not statistically significant, with post-exam bloating seen only in the Air Group. The responses to a questionnaire, applied to analyze the late post-exam period, showed more comfort with the use of CO₂.

The use of CO₂ is better than air as it avoids post-examination bloating, thereby providing greater comfort to patients.

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

• Safety
• colorectal cancer
• colorectal polyp
• difficult factors
• endoscopic submucosal dissection (ESD)
• tips

• Early gastric cancer
• Early gastric neoplasm
• Endoscopic mucosal resection
• Endoscopic submucosal dissection
• Endoscopic treatment
• Polypectomy

• Adverse events (AEs)
• Bleeding
• Complications
• Endoscopic mucosal resection (EMR)
• Endoscopic submucosal dissection (ESD)
• Endoscopy
• Haemorrhage
• Perforation

• Algorithms
• Constriction, Pathologic/etiology
• Constriction, Pathologic/prevention & control
• Dissection/adverse effects
• Duodenal Neoplasms/surgery
• Endoscopic Mucosal Resection/adverse effects
• Endoscopy, Gastrointestinal
• Esophageal Neoplasms/surgery
• Esophageal Perforation/etiology
• Esophageal Perforation/prevention & control
• Esophageal Stenosis/etiology
• Esophageal Stenosis/prevention & control
• Gastrointestinal Hemorrhage/etiology
• Gastrointestinal Hemorrhage/prevention & control
• Humans
• Intestinal Perforation/etiology
• Intestinal Perforation/prevention & control
• Mucous Membrane/surgery
• Stomach Neoplasms/surgery

To assess the efficacy of CO₂ insufflation for reduction of mediastinal emphysema (ME) immediately after endoscopic submucosal dissection (ESD).

A total of 46 patients who were to undergo esophageal ESD were randomly assigned to receive either CO₂ insufflation (CO₂ group, n = 24) or air insufflation (Air group, n = 22). Computed tomography (CT) was carried out immediately after ESD and the next morning. Pain and abdominal distention were chronologically recorded using a 100-mm visual analogue scale (VAS). The volume of residual gas in the digestive tract was measured using CT imaging.

The incidence of ME immediately after ESD in the CO₂ group was significantly lower than that in the Air group (17% vs 55%, P = 0.012). The incidence of ME the next morning was 8.3% vs 32% respectively (P = 0.066). There were no differences in pain scores or distention scores at any post-procedure time points. The volume of residual gas in the digestive tract immediately after ESD was significantly smaller in the CO₂ group than that in the Air group (808 mL vs 1173 mL, P = 0.013).

CO₂ insufflation during esophageal ESD significantly reduced postprocedural ME. CO₂ insufflation also reduced the volume of residual gas in the digestive tract immediately after ESD, but not the VAS scores of pain and distention.

• Endoscopic submucosal dissection
• Carbon dioxide insufflation
• Mediastinal emphysema
• Superficial esophageal cancer
• Complication

• Aged
• Carbon Dioxide/administration & dosage
• Double-Blind Method
• Endoscopic Mucosal Resection/methods
• Female
• Humans
• Insufflation/methods
• Male
• Mediastinal Emphysema/diagnostic imaging
• Mediastinal Emphysema/prevention & control
• Middle Aged
• Postoperative Complications/prevention & control
• Prospective Studies
• Tomography, X-Ray Computed

AIM: To evaluate efficacy and safety of clip-and-snare method using pre-looping technique (CSM-PLT) for gastric endoscopic submucosal dissection (ESD).

METHODS: In the CSM-PLT method, a clip attached to the lesion side was strangulated with a snare, followed by application of an appropriate tension to the lesion independent of an endoscope. Twenty consecutive lesions were resected by ESD using CSM-PLT (CSM-PLT group) and compared with a control group, including 20 lesions that were resected by conventional ESD. The control group was matched based on the size and location of the lesion, presence of pathologic fibrosis, and experience of endoscopists. Total procedure time of ESD, proportion of en bloc resection, and complications were analyzed.

RESULTS: The total procedure time for the CSM-PLT group was significantly shorter than that for the control group (38.5 min vs 59.5 min, P = 0.023); all lesions were resected en bloc by ESD. There was no significant difference in complications between the two groups. Moreover, there was no complication in the CSM-PLT group. In one large lesion (size: 74 mm) that underwent extensive CSM-PLT during ESD, we used an additional CSM-PLT on another edge of the lesion after achieving submucosal resection to the maximum extent possible during initial CSM-PLT. In two lesions, the snare came off the lesion together with the clip after a sudden pull; nevertheless, ESD was successful in all lesions.

CONCLUSION: CSM-PLT was an effective and safe method for gastric ESD.

• Endoscopic submucosal dissection
• Clip-and-snare method
• Pre-looping technique
• Endoscope
• Dissection

• Endoscopic submucosal dissection
• Outcomes
• Perforation

• Carbon dioxide
• Percutaneous endoscopic gastrostomy
• Steady pressure automatically controlled endoscopy

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.

• Carbon dioxide
• Gastric endoscopic submucosal dissection
• Insufflation
• Mallory-Weiss tear
• Randomized controlled trial

• Aged
• Aged, 80 and over
• Air
• Blood Gas Analysis
• Carbon Dioxide/administration & dosage
• Carbon Dioxide/adverse effects
• Dissection/adverse effects
• Dissection/methods
• Female
• Gastrectomy/adverse effects
• Gastrectomy/methods
• Gastric Mucosa/pathology
• Gastric Mucosa/surgery
• Gastroscopy/adverse effects
• Gastroscopy/methods
• Humans
• Insufflation/adverse effects
• Insufflation/methods
• Japan
• Male
• Middle Aged
• Postoperative Complications/prevention & control
• Prospective Studies
• Stomach Neoplasms/blood
• Stomach Neoplasms/pathology
• Stomach Neoplasms/surgery
• Time Factors
• Treatment Outcome

• colorectal cancer
• endoscopic gastrointestinal surgery
• fatty tissue
• lens
• surfactant

• Adult
• Aged
• Aged, 80 and over
• Colonoscopes
• Colonoscopy/methods
• Colorectal Neoplasms/surgery
• Dissection/methods
• Equipment Design
• Equipment Failure
• Female
• Humans
• Incidence
• Intestinal Mucosa/surgery
• Japan/epidemiology
• Lenses/adverse effects
• Male
• Middle Aged
• Postoperative Complications/epidemiology
• Postoperative Complications/etiology
• Prospective Studies
• Risk Factors
• Solutions

• Adenoma
• Cancer
• Complication
• Duodenal tumor
• Endoscopic mucosal resection
• Endoscopic submucosal dissection
• Neuroendocrine tumor
• Technical know-how

The technique of endoscopic submucosal dissection (ESD) is now a well-known endoscopic therapy for early gastric cancer. ESD was introduced to resect large specimens of early gastric cancer in a single piece. ESD can provide precision of histologic diagnosis and can also reduce the recurrence rate. However, the drawback of ESD is its technical difficulty, and, consequently, it is associated with a high rate of complications, the need for advanced endoscopic techniques, and a lengthy procedure time. Various advances in the devices and techniques used for ESD have contributed to overcoming these drawbacks.

• Endoscopic submucosal dissection
• Early gastric cancer
• Standard techniques
• Recent advances
• Complications
• Indications

• Dissection/methods
• Endoscopes
• Endoscopy/instrumentation
• Endoscopy/methods
• Fibrinolytic Agents/adverse effects
• Gastric Mucosa/surgery
• Humans
• Postoperative Complications
• Risk Factors
• Stomach Neoplasms/surgery
• Surgical Instruments
• Treatment Outcome
• Venous Thrombosis/complications

• Carbon dioxide
• Colonoscopy
• Endoscopic retrograde cholangiopancreatography
• Gastrointestinal endoscopy
• Insufflation gas

• Carbon Dioxide/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/adverse effects
• Cholangiopancreatography, Endoscopic Retrograde/methods
• Conscious Sedation
• Endoscopy, Gastrointestinal/adverse effects
• Endoscopy, Gastrointestinal/methods
• Gastrointestinal Diseases/diagnosis
• Gastrointestinal Diseases/pathology
• Gastrointestinal Diseases/surgery
• Gastrointestinal Tract/pathology
• Gastrointestinal Tract/surgery
• Humans
• Insufflation/adverse effects
• Insufflation/methods
• Predictive Value of Tests
• Treatment Outcome