Safety and Efficacy of Carbon Dioxide (CO2) Insufflation During Endoscopic Submucosal Dissection (ESD) for Gastric Cancer Under Propofol Sedation: A Randomized, Controlled Trial

Abstract

Background/Aims: Endoscopic submucosal dissection (ESD) procedure become popular rapidly, because it enables to remove en bloc large lesion. However, there are a lot of problems in this method (e.g. difficult procedure, many complications, high cost, and etc…). One of the most important problems is time-consuming. Thus, appropriate method of sedation and pain control are needed. We have already reported the utility of propofol sedation for ESD procedure. In addition, several studies have shown that CO2 insufflation instead of air during endoscopy can reduce post procedural pain and discomfort. We applied this CO2 insufflation method for ESD procedure under propofol sedation. We investigated the safety and efficacy of using CO2 insufflation under propofol sedation method for ESD procedure. Patients and Methods: A total of one hundred consecutive gastric cancer patients who treated by ESD procedure in our hospital were randomized to CO2 insufflation or air insufflation. Patients were sedated by propofol under oxygen inhalation (2-3 L/min) by nasotrachial airway. Sedation was provided by a doctor with prior experiences in anesthesia or a specialist anesthetist. In CO2 insufflation group we connected a CO2 cylinder to an endoscopic supply of air device and discharged it in 1.5 L/min. Using a transcutaneous partial pressure of carbon dioxide measuring system (TOSCA500; Radiometer Basel AG, Switzerland), we measured partial pressure of CO2 continuously for all patients. One hour after ESD we evaluated abdominal discomfort of the patients by using visual analogue scale (VAS) (range: 0-100 mm). Results: We carried out fifty ESD procedures using CO2 insafflation and fifty procedures using air insufflation. We excluded one patient in CO2 group and four patients in air group because of perforation. The mean operation times were 119 ± 58 min and 107 ± 46 min, mean partial pressures of CO2 during procedure were 48.8 ± 4.8 mmHg and 50.0 ± 5.5 mmHg in CO2 group and air group, respectively (not significant for each comparison). Average VAS score after ESD in CO2 group was significantly lower than that in air group (14.3 ± 20.5 mm vs. 24.3 ± 25.3 mm, P = 0.04). We did not experienced complication except of perforation in perioperatively and postoperatively. Conclusion: CO2 insufflation during ESD for gastric cancer under propofol sedation is safety and reduces patient's abdominal discomfort after procedure.