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.
Carbon Dioxide* ; Carbon* ; Hemorrhage ; Humans ; Incidence ; Insufflation* ; Methods ; Odds Ratio

Colon capsule endoscopy (CCE) is a relatively new diagnostic procedure for patients with suspected colonic diseases. This convenient, noninvasive method enables the physician to explore the entire colon without significant discomfort to the patient. However, while CCE can be performed painlessly without bowel air insufflation, the need for vigorous bowel preparation and other technical limitations exist. Due to such limitations, CCE has not replaced conventional colonoscopy. In this review, we discuss historical and recent advances in CCE including technical issues, ideal bowel preparation, indications and contraindications and highlight further technical advancements and clinical studies which are needed to develop CCE as a potential diagnostic tool.
Capsule Endoscopy* ; Colon* ; Colonic Diseases ; Colonoscopy ; Humans ; Insufflation ; Methods

During colonoscopy, air insufflation to distend the lumen and facilitate careful inspection and scope insertion can induce pain and cause discomfort. Carbon dioxide (CO₂) insufflation can decrease abdominal pain and discomfort during and after colonoscopy. The advantage of CO₂ insufflation is the rapid absorption of the gas across the intestine. Another painless option is water-assisted colonoscopy. Two methods for water-assisted colonoscopy are available: water immersion and water exchange. In a recent direct comparison, the water exchange method was superior to water immersion, CO₂ insufflation, and air insufflation with respect to pain during colonoscopy, although it still had the disadvantage of being a time-consuming procedure. Cap-assisted colonoscopy is a simple technique involving the use of a small transparent cap attached to the tip of the scope. Three studies showed an advantage of this technique in terms of reduced patient discomfort compared with the conventional method. Three robotic colonoscopy systems (Endotics System [Era Endoscopy], NeoGuide [NeoGuide Systems Inc.], and Invendoscope [Invendo Medical]) have been introduced to evaluate pain reduction during colonoscopy, but none has been widely adopted and used in practice. In this review, clinical trials of several techniques and new devices for painless colonoscopy are described and summarized.
Abdominal Pain ; Absorption ; Carbon Dioxide ; Colonoscopy* ; Humans ; Immersion ; Insufflation ; Intestines ; Methods ; Water

BACKGROUND AND OBJECTIVES: There have been various approaches introduced for endoscopic thyroidectomy. This study evaluates and compares the surgical outcomes of two such approaches: the unilateral axillo-breast approach (UABA) with gas and the gasless transaxillary approach (TA). SUBJECTS AND METHOD: We retrospectively analyzed 279 patients who underwent endoscopic thyroidectomy via UABA with gas or gasless TA from March 2008 to August 2012. Studied variables were clinicopathologic data, surgical outcomes, complications, and cosmetic satisfactions. RESULTS: Of the 279 patients, 195 (69.9%) underwent UABA with gas and 84 (30.1%) underwent gasless TA. All of the variables related to clinicopathologic characteristics showed no significant differences between the two groups. The mean operation time was significantly shorter in the UABA with gas group (131.76±44.37 min) than in the gasless TA group (191.01±55.90 min) (p<0.001). The mean postoperative pain Visual Analogue Scale scores in the UABA with gas group were 2.61±0.96 and 1.85±0.79, respectively, and those in the gasless TA group were 3.12±1.02 and 2.17±0.76, respectively, at 1 and 3 days after surgery. Incidences of postoperative complications were similar except for the higher rate of seroma in the gasless TA group. Cosmetic satisfaction scores of UABA with gas were higher than those of the gasless TA. CONCLUSION: UABA with gas may be a good option for endoscopic thyroidectomy because this approach is less invasive than the gasless TA is.
Endoscopy ; Humans ; Incidence ; Insufflation* ; Methods ; Pain, Postoperative ; Postoperative Complications ; Retrospective Studies ; Seroma ; Thyroidectomy*

Obscure gastrointestinal bleeding is defined as an intermittent or continuous loss of blood in which the source has not been identified after an upper endoscopy and colonoscopy. Small bowel bleeding is one of the most common causes of obscure gastrointestinal bleeding and constitutes 2~10% of all gastrointestinal bleeding. As the small intestine lies in the mid-portion of the intestine and has a long length, it is difficult to diagnose and treat small bowel bleeding using conventional endoscopy. Although the development of wireless capsule endoscopy has increased the diagnosis rate of small bowel disease, the use of capsule endoscopy has some limitations. The use of capsule endoscopy depends on intestinal peristalsis, and while visual diagnosis is possible, obtaining a biopsy or providing treatment is not possible with the use of the procedure. Capsule endoscopy has a few other limitations, such as the lack of air insufflation and the unavailability of rinsing. The use of the new double balloon enteroscopy procedure has advantages over the use of capsule endoscopy. With this method, it is possible to obtain biopsies and it is possible to perform therapeutic procedures, rinsing and air insufflation. We report a case of a vascular mass of the small bowel with recurrent bleeding, which was treated with endoscopic sclerotherapy.
Biopsy ; Capsule Endoscopy ; Colonoscopy ; Diagnosis ; Double-Balloon Enteroscopy* ; Endoscopy ; Hemorrhage ; Insufflation ; Intestine, Small ; Intestines ; Methods ; Peristalsis ; Sclerotherapy

OBJECTIVE: The study was aimed to investigate the effects of different levels of pressure and duration of carbon dioxide and saline in the neck of rabbits on metabolic, hemodynamic, serum sodium concentrations and hematocrit changes. METHOD: Twenty-one New Zealand rabbits were randomly divided into 7 groups according to the following pressure of CO2 or saline: 0 kPa, 0.67 kPa CO2, 1.33 kPa CO2, 2.00 kPa CO2, 0.67 kPa saline, 1.33 kPa saline, and 2.00 kPa saline. In order to make a space for the endoscopic thyroidectomy, we filled the neck of rabbits with carbon dioxide and saline. Arterial partial pressure of CO2 (PaCO2), pH, heart rate (HR), mean arterial pressure (MAP), central venous pressure (CVP), serum sodium concentration and hematocrit were measured at baseline, 45 min and 90 min after filling with gas or saline and 30 min post-filling. RESULT: Insufflation of CO2 at 0.67 kPa did not have any significant effect on the parameters, PaCO2 increased significantly 45 min and 90 min after insufflation of 1.33 kPa CO2 (P < 0.01). Marked changes in PaCO2, pH and CVP occurred 45 min and 90 min after insufflation of 2.00 kPa CO2 (P < 0.01), and the parameters did not return to baseline in 30 min after desufflation (P < 0.05). In animals receiving saline irrigation no significant changes occurred in PaCO2, pH and serum sodium concentrations at any time point. There was a tendency of decrease in HCT, but no statistically significant changes were found (P > 0.05). CVP increased significantly 90 min after saline irrigation at 1.33 kPa (P < 0.05). A significant increase in CVP occurred 45 min and 90 min after saline irrigation at 2.00 kPa (P < 0.05). No significant changes in HR and MAP occurred in all animals. CONCLUSION Filling with saline which does not cause hypercapnia, acidosis or dilutional hyponatremia can be used in endoscopic neck surgery to create and maintain a working space.
Animals ; Carbon Dioxide ; administration & dosage ; therapeutic use ; Endoscopy ; Insufflation ; Rabbits ; Sodium Chloride ; administration & dosage ; therapeutic use ; Thyroidectomy ; methods

There are many factors affecting the successful performance of CT colonography (CTC). Adequate colonic cleansing and distention, the optimal CT technique and interpretation with using the newest CTC software by a trained reader will help ensure high accuracy for lesion detection. Fecal and fluid tagging may improve the diagnostic accuracy and allow for reduced bowel preparation. Automated carbon dioxide insufflation is more efficient and may be safer for colonic distention as compared to manual room air insufflation. CT scanning should use thin collimation of < or =3 mm with a reconstruction interval of < or =1.5 mm and a low radiation dose. There is not any one correct method for the interpretation of CTC; therefore, readers should be well-versed with both the primary 3D and 2D reviews. Polyps detected at CTC should be measured accurately and reported following the "polyp size-based" patient management system. The time-intensive nature of CTC and the limited resources for training radiologists appear to be the major barriers for implementing CTC in Korea.
Carbon Dioxide/administration & dosage ; Cathartics/therapeutic use ; Colonic Polyps/radiography ; Colonography, Computed Tomographic/*methods ; Contrast Media/administration & dosage ; Diagnosis, Computer-Assisted ; Feces ; Humans ; Imaging, Three-Dimensional ; Insufflation/methods

PURPOSE: For patients with neuromuscular disease, air stacking, which inflates the lungs to deep volumes, is important for many reasons. However, neuromuscular patients with severe glottic dysfunction or indwelling tracheostomy tubes cannot air stack effectively. For these patients, we developed a device that permits deep lung insufflations substituting for glottic function. MATERIALS AND METHODS: Thirty-seven patients with bulbar-innervated muscle weakness and/or tracheostomies were recruited. Twenty-three had amyotrophic lateral sclerosis, and 14 were tetraplegic patients due to cervical spinal cord injury. An artificial external glottic device (AEGD) was used to permit passive deep lung insufflation. In order to confirm the utility of AEGD, vital capacity, maximum insufflation capacity (MIC), and lung insufflation capacity (LIC) with AEGD (LICA) were measured. RESULTS: For 30 patients, MICs were initially zero. However, with the use of the AEGD, LICA was measurable for all patients. The mean LICA was 1,622.7+/-526.8 mL. Although MIC was measurable for the remaining 7 patients without utilizing the AEGD, it was significantly less than LICA, which was 1,084.3+/-259.9 mL and 1,862.9+/-248 mL, respectively (p<0.05). CONCLUSION: The AEGD permits lung insufflation by providing deeper lung volumes than possible by air stacking.
Adult ; Aged ; Female ; Forced Expiratory Flow Rates/physiology ; Humans ; Insufflation/*instrumentation/methods ; Male ; Middle Aged ; Neuromuscular Diseases/*physiopathology/therapy ; *Ventilators, Mechanical ; Vital Capacity/physiology ; Young Adult

BACKGROUNDPulmonary surfactant dysfunction may contribute to the development of ventilator induced lung injury (VILI). Tracheal gas insufflation (TGI) is a technique in which fresh gas is introduced into the trachea and augment ventilation by reducing the dead space of ventilatory system, reducing ventilatory pressures and tidal volume (V(T)) while maintaining constant partial arterial CO2 pressure (PaCO(2)). We hypothesised that TGI limited peak inspiratory pressure (PIP) and V(T) and would minimize conventional mechanical ventilation (CMV) induced pulmonary surfactant dysfunction and thereby attenuate VILI in rabbits with acute lung injury (ALI).

METHODSALI was induced by intratracheal administration of lipopolysaccharide in anaesthetized, ventilated healthy adult rabbits randomly assigned to continuous TGI at 0.5 L/min (TGI group) or CMV group (n = 8 for each group), and subsequently ventilated with limited PIP and V(T) to maintain PaCO(2) within 35 to 45 mmHg for 4 hours. Physiological dead space to V(T) ratio (V(D)/V(T)), dynamic respiratory compliance (Cdyn) and partial arterial O(2) pressure (PaO(2)) were monitored. After ventilation, lungs were analysed for total phospholipids (TPL), total proteins (TP), pulmonary surfactant small to large aggregates ratio (SA/LA) in bronchoalveolar lavage fluid (BALF) and for determination of alveolar volume density (V(V)), myeloperoxidase and interleukin (IL)-8.

RESULTSTGI resulted in significant (P < 0.05 or P < 0.01) decrease in PIP [(22.4 +/- 1.8) cmH2O vs (29.5 +/- 1.1) cmH2O], V(T) [(6.9 +/- 1.3) ml/kg vs (9.8 +/- 1.11) ml/kg], V(D)/V(T) [(32 +/- 5)% vs (46 +/- 2)%], TP [(109 +/- 22) mg/kg vs (187 +/- 25) mg/kg], SA/LA (2.5 +/- 0.4 vs 5.4 +/- 0.7), myeloperoxidase [(6.2 +/- 0.5) U/g tissue vs (12.3 +/- 0.8) U/g tissue] and IL-8 [(987 +/- 106) ng/g tissue vs (24 +/- 3) mN/m] of BALF, and significant (P < 0.05) increase in Cdyn [(0.47 +/- 0.02) ml.cmH2O(-1).kg(-1) vs (0.31 +/- 0.02) ml.cmH2O(-1).kg(-1)], PaO(2) [(175 +/- 24) mmHg vs (135 +/- 26) mmHg], TPL/TP (52 +/- 8 vs 33 +/- 11) and Vv (0.65 +/- 0.05 vs 0.44 +/- 0.07) as compared with CMV.

CONCLUSIONSIn this animal model of ALI, TGI decreased ventilatory requirements (PIP, V(T) and V(D)/V(T)), resulted in more favourable alveolar pulmonary surfactant composition and function and less severity of lung injury than CMV. TGI in combination with pressure limited ventilation may be a lung protective strategy for ALI.

Animals ; Insufflation ; Intubation, Intratracheal ; instrumentation ; Lung ; pathology ; Pressure ; Pulmonary Surfactants ; analysis ; Rabbits ; Respiration, Artificial ; methods ; Respiratory Distress Syndrome, Adult ; therapy ; Tidal Volume ; Trachea ; physiopathology

BACKGROUND: Surgical correction needs to be considered when diaphragm eventration leads to impaired ventilation and respiratory muscle fatigue. Plication to sufficiently tense the diaphragm by VATS is not as easy to achieve as plication by open surgery. We used pneumatic compression with carbon dioxide (CO2) gas in thoracoscopic diaphragmatic plication and evaluated feasibility and efficacy. METHODS: Eleven patients underwent thoracoscopic diaphragmatic plication between January 2008 and December 2013 in Pusan National University Hospital. Medical records were retrospectively reviewed, and compared between the group using CO₂ gas and group without using CO2 gas, for operative time, plication technique, duration of hospital stay, postoperative chest tube drainage, pulmonary spirometry, dyspnea score pre- and postoperation, and postoperative recurrence. RESULTS: The improvement of forced expiratory volume at 1 second in the group using CO₂ gas and the group not using CO₂ gas was 22.46±11.27 and 21.08±5.39 (p=0.84). The improvement of forced vital capacity 3 months after surgery was 16.74±10.18 (with CO₂) and 15.6±0.89 (without CO₂) (p=0.03). During follow-up (17±17 months), there was no dehiscence in plication site and relapse. No complications or hospital mortalities occurred. CONCLUSION: Thoracoscopic plication under single lung ventilation using CO₂ insufflation could be an effective, safe option to flatten the diaphragm.
Busan ; Carbon Dioxide* ; Carbon* ; Chest Tubes ; Diaphragm ; Diaphragmatic Eventration ; Drainage ; Dyspnea ; Fatigue ; Follow-Up Studies ; Forced Expiratory Volume ; Hospital Mortality ; Humans ; Insufflation ; Length of Stay ; Medical Records ; Methods ; One-Lung Ventilation ; Operative Time ; Recurrence ; Respiratory Muscles ; Retrospective Studies ; Spirometry ; Thoracic Surgery, Video-Assisted ; Thoracoscopy ; Transcutaneous Electric Nerve Stimulation ; Ventilation ; Vital Capacity