Air Insufflation Research Articles

Major perioperative adverse events of peroral endoscopic myotomy: a systematic 5-year analysis.

Background and study aims: Peroral endoscopic myotomy (POEM) is now a widely used treatment for esophageal achalasia, supported by several large cohort studies. Although major perioperative adverse events (mAE) are rare, in-depth investigations of related risks and preventive measures are lacking. The aim of this study was to systematically assess mAEs during POEM by analyzing their incidence, risks, prevention, and management. Patients and methods: This retrospective single-center analysis included all patients (n = 1680) undergoing POEM between August 2010 and July 2015 at Zhongshan Hospital. Major adverse events were defined as: vital-sign instability, intensive care unit (ICU) stay, hospital readmission, conversion to open surgery, invasive postoperative procedure, blood transfusion, or prolonged (> 5 days) hospitalization for functional impairment. Results: A total of 55 patients (3.3 %, 95 % confidence interval [CI] 2.5 % - 4.2 %) experienced mAEs: delayed mucosal barrier failure (n = 13, 0.8 %; 95 %CI 0.4 % - 1.3 %), delayed bleeding (n = 3, 0.2 %; 95 %CI 0.04 % - 0.5 %), hydrothorax (n = 8, 0.5 %; 95 %CI 0.2 % - 0.9 %), pneumothorax (n = 25, 1.5 %; 95 %CI 1.0 % - 2.2 %), and miscellaneous (n = 6, 0.4 %; 95 %CI 0.1 % - 0.8 %). Four patients (0.2 %) required ICU admission. No surgical conversion occurred, and 30-day mortality was zero. In stepwise multivariate regression, institution experience of < 1 year (odds ratio [OR] 3.85, 95 %CI 1.49 - 9.95), air insufflation (OR 3.41, 95 %CI 1.37 - 8.50), and mucosal edema (OR 2.01, 95 %CI 1.14 - 3.53) were identified as related risk factors. After introducing CO2 insufflation, the mAE rate declined to 1.9 % (95 %CI 1.2 % - 2.7 %) and seemed to plateau after 3.5 years at ~ 1 %. Conclusion: In general, POEM appears to be a safe procedure. Major adverse events were rare and could usually be prevented or anticipated, and were all managed effectively.

Population-Based Colonoscopy Screening for Colorectal Cancer

Although some countries have implemented widespread colonoscopy screening, most European countries have not introduced it because of uncertainty regarding participation rates, procedure-related pain and discomfort, endoscopist performance, and effectiveness. To our knowledge, no randomized trials on colonoscopy screening currently exist. To investigate participation rate, adenoma yield, performance, and adverse events of population-based colonoscopy screening in several European countries. A population-based randomized clinical trial was conducted among 94 959 men and women aged 55 to 64 years of average risk for colon cancer in Poland, Norway, the Netherlands, and Sweden from June 8, 2009, to June 23, 2014. Colonoscopy screening or no screening. Participation in colonoscopy screening, cancer and adenoma yield, and participant experience. Study outcomes were compared by country and endoscopist. Of 31 420 eligible participants randomized to the colonoscopy group, 12 574 (40.0%) underwent screening. Participation rates were 60.7% in Norway (5354 of 8816), 39.8% in Sweden (486 of 1222), 33.0% in Poland (6004 of 18 188), and 22.9% in the Netherlands (730 of 3194) (P < .001). The cecum intubation rate was 97.2% (12 217 of 12 574), with 9726 participants (77.4%) not receiving sedation. Of the 12 574 participants undergoing colonoscopy screening, we observed 1 perforation (0.01%), 2 postpolypectomy serosal burns (0.02%), and 18 cases of bleeding owing to polypectomy (0.14%). Sixty-two individuals (0.5%) were diagnosed with colorectal cancer and 3861 (30.7%) had adenomas, of which 1304 (10.4%) were high-risk adenomas. Detection rates were similar in the proximal and distal colon. Performance differed significantly between endoscopists; recommended benchmarks for cecal intubation (95%) and adenoma detection (25%) were not met by 6 (17.1%) and 10 of 35 endoscopists (28.6%), respectively. Moderate or severe abdominal pain after colonoscopy was reported by 601 of 3611 participants (16.7%) examined with standard air insufflation vs 214 of 5144 participants (4.2%) examined with carbon dioxide (CO2) insufflation (P < .001). Colonoscopy screening entails high detection rates in the proximal and distal colon. Participation rates and endoscopist performance vary significantly. Postprocedure abdominal pain is common with standard air insufflation and can be significantly reduced by using CO2. clinicaltrials.gov Identifier: NCT00883792.

PTH-001 Underwater Endoscopic Mucosal Resection: The Experience of Two UK Centres

Introduction Underwater Endoscopic Mucosal Resection (UEMR) is a relatively new technique, which has been developed for endoscopic resection of colonic lesions. In this technique submucosal injection is not required for many of the lesions. We present here the experience of two UK centres. Methods All of the UEMR procedures were performed by two experienced interventional endoscopists: NS performed 16 cases at St Mark’s hospital in London, and SI performed 18 cases at Russells Hall Hospital in Dudley. Patient data was collected prospectively. A Hybrid technique, i.e. injection of lifting solution or use of Argon Plasma Coagulation (APC) together with UEMR, was employed if the lesion was traversing a fold/removed in retroflexed position or if there was remnant tissue post resection, respectively. Results From May 2015 to February 2016, a total of 34 patients (mean age 64 years, range 35–85, males n = 21) have had UEMR of 35 lesions performed by the two operators. The lesions (mean size 33 mm, range 7–160 mm) were located in right colon (n = 5), transverse colon (n = 2), left colon (n = 9), and rectum (n = 19). Seven of the lesions (20%) were recurrence post previous traditional EMR. The morphology of the lesions were either flat (n = 21) or sessile (n = 14). Hybrid technique was employed as follows: Lifting (n = 14), APC (n = 4), and a combination of lifting and APC (n = 2). Histopathology of the lesions demonstrated low grade dysplasia (n = 29), high grade dysplasia (n = 4), and other (n = 2; One hyperplastic polyp, and one sessile serrated lesion). Complete endoscopic resection (at index procedure) was achieved in 34 out of the 35 lesions (97.1%); a large lesion (160 mm in size), which was crossing over two folds, was resected at two planned sessions. There was no immediate bleeding or perforation, but there was one case of delayed bleeding (2.8%). The procedures, which were performed either with no sedation or analgesia (n = 9), with light sedation and analgesia (n = 18), or with Entonox inhalation as required (n = 7), were well-tolerated with a pain score of zero or one (zero = no pain; one = minimal pain). Conclusion In our experience, underwater endoscopic mucosal resection seems to be a safe and a well-tolerated procedure. It can be an alternative to the traditional EMR, which requires either air or CO2 insufflation, and submucosal injection in all lesions. However, the air or CO2 insufflation significantly thins the bowel wall during the EMR, and submucosal injection does not only create a potential risk of seeding neoplastic cells into deeper wall layers,1 but it also prolongs the procedure time. Follow-up data is required to assess the short- and long-term recurrence rate associated with UEMR. Reference 1 Binmoeller, KF. J Interv Gastroenterol4:4:113–116. Disclosure of Interest None Declared

Schinus terebinthifolius raddi (Aroeira) and Orbignya phalerata mart. (Babassu) effect in cecorrahphy healing in rats.

To evaluate the effect of Schinus terebinthifolius Raddi (aroeira) and Orbignya phalerata Mart. (babassu) in the healing process of cecorrhaphy in rats. : Fifty four rats were used, distributed into three groups randomly: aroeira, babassu and control, which were divided into three subgroups (six animals) according to the time of the deaths (7, 14, 21 days). All underwent the same surgical procedure, cecotomy and cecorrhaphy. The animals in group aroeira and babassu received daily dose of 100 mg/kg of hydroalcoholic extract and 50 mg/kg of aquous extract respectively, by gavage. The control group received only saline solution. The parameters evaluated were: macroscopic changes, ,resistance test to air insufflations and histological changes. : All animals showed good healing without infection. All groups presented adhesions between cecum and neighboring organs. The resistance test insufflating of atmospheric air showed progressive increase of pressure according to the days in the aroeira group, and decrease in babassu group, without significant difference. Microscopy showed significant difference in the polymorphonuclear, hyperemia, angiogenesis, fibroblast proliferation and collagen histological variables in the 14th day. : Hydroalcoholic extract of aroeira and the aqueous extract of babassu favored the healing process in cecorrhaphy in rats.

Who Is for CO2? Slow Adoption of Carbon Dioxide Insufflation in Colonoscopy.

Most colonoscopies worldwide still use air insufflation, even though carbon dioxide reduces postprocedure discomfort. The authors speculate about why adoption of this effective, inexpensive, “low-t...

Accuracy of First- and Second-Generation Colon Capsules in Endoscopic Detection of Colorectal Polyps: A Systematic Review and Meta-analysis.

Colon capsule endoscopy (CCE) is a noninvasive technique used to explore the colon without sedation or air insufflation. A second-generation capsule was recently developed to improve accuracy of detection, and clinical use has expanded globally. We performed a systematic review and meta-analysis to assess the accuracy of CCE in detecting colorectal polyps. We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and other databases from 1966 through 2015 for studies that compared accuracy of colonoscopy with histologic evaluation with CCE. The risk of bias within each study was ascertained according to Quality Assessment of Diagnostic Accuracy in Systematic Reviews recommendations. Per-patient accuracy values were calculated for polyps, overall and for first-generation (CCE-1) and second-generation (CCE-2) capsules. We analyzed data by using forest plots, the I2 statistic to calculate heterogeneity, and meta-regression analyses. Fourteen studies provided data from 2420 patients (1128 for CCE-1 and 1292 for CCE-2). CCE-2 and CCE-1 detected polyps >6 mm with 86% sensitivity (95% confidence interval [CI], 82%-89%) and 58% sensitivity (95% CI, 44%-70%), respectively, and 88.1% specificity (95% CI, 74.2%-95.0%) and 85.7% specificity (95% CI, 80.2%-90.0%), respectively. CCE-2 and CCE-1 detected polyps >10 mm with 87% sensitivity (95% CI, 81%-91%) and 54% sensitivity (95% CI, 29%-77%), respectively, and 95.3% specificity (95% CI, 91.5%-97.5%) and 97.4% specificity (95% CI, 96.0%-98.3%), respectively. CCE-2 identified all 11 invasive cancers detected by colonoscopy. The sensitivity in detection of polyps >6 mm and >10 mm increased substantially between development of first-generation and second-generation colon capsules. High specificity values for detection of polyps by CCE-2 seem to be achievable with a 10-mm cutoff and in a screening setting.

1010 Prospective Multicenter Randomized Controlled Trial Demonstrating Water Exchange (WE), But Not Water Immersion (WI), Significantly Increases Adenoma Detection Compared With Air Insufflation (AI) Even in Propofol Sedated Patients

1010 Prospective Multicenter Randomized Controlled Trial Demonstrating Water Exchange (WE), But Not Water Immersion (WI), Significantly Increases Adenoma Detection Compared With Air Insufflation (AI) Even in Propofol Sedated Patients

404 The Efficacy of Carbon Dioxide Insufflation During Consecutive Upper and Lower Gastrointestinal Endoscopy: A Randomized, Double-Blind, Controlled Prospective Study

Endoscopy is performed with using air insufflations, and is associated with abdominal discomfort. It is well recognized that carbon dioxide (CO2) is absorbed quickly in the body than air. CO2 insufflation is expected to be reduces abdominal discomfort and pain after consecutive upper and lower gastrointestinal endoscopy.

The variations of the middle colic vein tributaries: depiction by three-dimensional CT angiography.

Laparoscopic transverse colectomy is challenging owing to technical difficulties in identifying an adequate dissection plane, ligating and dissecting lymph nodes around the middle colic vessels. One of the reasons for the technical difficulties is the complex relationship between the middle colic vein (MCV) and its tributary. So, defining the venous anatomy around the MCV before laparoscopic surgery seems important to avoid massive bleeding. The purpose of this study was to evaluate the depiction rate and variation of the MCV and its tributaries on three-dimensional CT angiography (3DCTA). This study included 331 patients (203 males and 128 females) scheduled for laparoscopic surgery between June 2010 and April 2012. Most of the patients had gastric or colorectal cancer. Patients who needed emergency surgeries for obstruction or perforation were excluded. 3DCTA with an i.v. contrast medium was performed immediately following the administration of effervescent granules or room air insufflation. We assessed variations of the MCV tributaries using transaxial, multiplanar reconstructed images and volume-rendering images. The MCV could be identified in all patients. The MCVs drained into the superior mesenteric vein in 62.5% of patients, gastrocolic trunk of Henle in 29.3% of patients, inferior mesenteric vein in 4.8% of patients, splenic vein in 2.7% of patients and jejunal vein in 0.6% of patients. 3DCTA is useful in evaluating the anatomic variants of the MCV in pre-operative planning for laparoscopic surgery. Use of 3DCTA for the recognition of the anatomic complexity around the MCV and its tributary plays an important role in pre-operative planning for optimal patient outcome.

Evaluation of PaO2 /FiO2 and SaO2 /FiO2 ratios in postoperative dogs recovering on room air or nasal oxygen insufflation.

To evaluate partial pressure of oxygen in arterial blood/fractional percentage of inspired oxygen (PaO2 /FiO2 ) and SaO2 /FiO2 ratios (where SaO2 is percentage of oxyhemoglobin saturation in arterial blood), and the correlation between PaO2 /FiO2 and SaO2 /FiO2 , in healthy dogs recovering postoperatively on room air versus nasal oxygen insufflation. Retrospective study. University veterinary teaching hospital. Nineteen dogs. Medical records were retrospectively evaluated for data from a previous prospective study of dogs undergoing ovariohysterectomy, subsequently randomized to receive 100 mL/kg/min of nasal oxygen insufflation (estimated 37% FiO2 , n = 9) or room air (estimated 21% FiO2 , n = 10) for 2 hours postoperatively. Baseline information was obtained 1 hour intraoperatively, followed by three postoperative time points (10, 60, and 120 min). Data recorded for each time point included FiO2 , PaO2 , SaO2 , PaO2 /FiO2 , SaO2 /FiO2 , partial pressure of carbon dioxide in arterial blood (PaCO2 ), rectal temperature, and arterial blood pH. The PaO2 /FiO2 in dogs recovering on supplemental oxygen was significantly higher compared to dogs recovering on room air (516 ± 28 vs. 359 ± 10, P < 0.0001), whereas the SaO2 /FiO2 ratio in dogs recovering on supplemental oxygen was significantly lower compared to dogs recovering on room air (268 ± 0.5 versus 448 ± 1.4, P < 0.0001). The PaO2 /FiO2 and SaO2 /FiO2 ratios demonstrated excellent correlation for both groups at each postoperative time point. In dogs breathing room air, PaO2 /FiO2 and SaO2 /FiO2 correlation coefficients were 0.90, 0.95, and 0.93 (P < 0.001). In dogs receiving supplemental oxygen, PaO2 /FiO2 and SaO2 /FiO2 correlation coefficients were 0.94, 0.93, and 0.90 (P < 0.001). In this population of postoperative dogs breathing either room air or with nasal oxygen insufflation, PaO2 /FiO2 and SaO2 /FiO2 had excellent correlation. Further evaluation into the correlation between SaO2 /FiO2 or pulse oximeter oxygen saturation (SpO2 )/FiO2 with PaO2 /FiO2 in both healthy dogs, and dogs with pulmonary dysfunction is warranted.

Eficacia de la insuflación con dióxido de carbono en enteroscopia de un solo balón para determinar profundidad de intubación y dolor posprocedimiento en pacientes referidos para evaluación del intestino delgado

IntroductionThe intubation depth of the small bowel is limited by distention due to air insufflation during the procedure. Carbon dioxide (CO2) is rapidly absorbed from the bowel lumen and prevents distention of abdomen. ObjectiveA comparison was made between the effects of CO2 and air insufflations on the intubation depth during single balloon enteroscopy (SBE), as well as post-procedure pain. DesignDescriptive case series study and comparison of the results in a tertiary care hospital. Patients and methodsA total of 147 SBE procedures were performed on 130 patients with suspected small bowel disease using CO2 insufflation in 65 procedures, and air insufflation in 82. Enteroscopy was performed using an Olympus SIF 180-Q and a UCR CO2 pump. Intubation depth was recorded using a validated form, and pos-procedure pain immediately after SBE and 12 hours later were evaluated. ResultsA total of 147 SBE procedures were performed on 130 patients with a mean small bowel intubation depth in the CO2 group significantly larger than the air group (p=.008). An oral approach was used in 95 procedures, and anal in 52 procedureswith a mean intubation depth significantly larger in the CO2 group (p=.035 and p=.004, respectively). Patient pain was significantly reduced in the CO2 group. LimitationsDescriptive study of two case series. ConclusionCO2 insufflation significantly improves intubation depth in SBE and reduces abdominal pain.

Carbon Dioxide Versus Air Insufflation for Elective Colonoscopy: A Meta-Analysis and Systematic Review of Randomized Controlled Trials.

The aim of this study was to conduct a meta-analysis and systematic review of randomized controlled trials (RCTs) comparing 2 methods of colonic insufflation for elective colonoscopy, that is, carbon dioxide (CO2) or air, and to evaluate their efficiency, safety, and side effects. Prospective RCTs comparing CO2 versus air insufflation for colonic distension during colonoscopy were selected by searching PubMed, Medline, Embase, Science Citation Index, Current Contents, and the Cochrane Central Register of Controlled Trials published between January 1980 and October 2014. The outcome variables analyzed included procedural and immediate postprocedural pain (during, end, or within 15 min after procedure), early postprocedural pain (between 30 and 120 min), intermediate postprocedural pain (360 min) and late postprocedural pain (720 to 1140 min), cecal/ileal intubation rate, cecal/ileal intubation time, and total colonoscopy examination time. These outcomes were unanimously decided to be important as they influence the practical approach toward patient management within and outside of hospital. Random effects model was used to calculate the effect size of both binary and continuous data. Heterogeneity among the outcome variables of these trials was determined by the Cochran Q statistic and I2 index. The meta-analysis was prepared in accordance with PRISMA guidelines. Twenty-four RCTs totaling 3996 patients (CO2=2017, Air=1979) were analyzed. Statistically significant differences for the pooled effect size were observed for procedural and immediate postprocedural pain [weighted mean difference (WMD)=0.49; 95% confidence interval (CI), 0.32, 0.73; P=0.0005], early postprocedural pain between 30 and 120 minutes (WMD=0.25; 95% CI, 0.12, 0.49; P<0.0001), intermediate postprocedural pain, that is, 360 minutes after completion (WMD=0.35; 95% CI, 0.23, 0.52; P<0.0001), and late postprocedural pain between 720 and 1440 minutes (WMD=0.53; 95% CI, 0.34, 0.84; P=0.0061). Comparable effects were noted for cecal/ileal intubation rate (WMD=0.86; 95% CI, 0.61, 1.22; P=0.3975), cecal/ileal intubation time (WMD=-0.64; 95% CI, -1.38, 0.09; P=0.0860), and total examination time (WMD=-0.20; 95% CI, -0.96, 0.57; P=0.6133). On the basis of our meta-analysis and systematic review, we conclude that CO2 insufflation significantly reduces abdominal pain during and following the procedure lasting up to 24 hours. There is no difference in the cecal/ileal intubation rate and time and total examination time between the 2 methods. CO2 retention with CO2 insufflation during and after the colonoscopy shows inconsequential variation compared with air insufflation and has no adverse effect on patients. CO2 instead of air should be routinely utilized for colonoscopy.

Carbon dioxide insufflation during colonoscopy can significantly decrease post-interventional abdominal discomfort in deeply sedated patients: A prospective, randomized, double-blinded, controlled trial.

CO2 has been reported to be absorbed from the bowel more rapidly than air, resulting in a discomfort reduction after colonoscopy. Its role in deeply sedated patients is limited. This study was designed to investigate the efficacy and safety of CO2 insufflation during colonoscopy in patients deeply sedated with propofol. A total of 125 continuous patients were randomly assigned to receive either CO2 (n = 63) or air (n = 62) insufflation during propofol-sedated colonoscopy. Postcolonoscopy abdominal pain, distention, and satisfaction were assessed at 1, 3, and 24 h after the procedure, and the proportions of pain-free and distention-free patients were compared. Residual bowel gas in the colon and small bowel was evaluated at 1 h after colonoscopy. End-tidal CO2 and O2 saturation was measured for safety analysis. There was a significant difference between the two groups regarding the postcolonoscopy abdominal pain, distention, and subjective satisfaction at 1 h (P < 0.001) and 3 h (P < 0.01) after the procedure. Patients' pain and distention at 1 and 3 h after the procedure were significantly lower in the CO2 group (P < 0.01). Residual bowel gas in the colon and small bowel was significantly less in the CO2 group (P < 0.001). There was no significant difference in end-tidal CO2 levels between two groups before, during, and after the procedure. Compared with air, CO2 insufflation during colonoscopy reduced postcolonoscopy abdominal discomfort and improved patients' satisfaction. It was safe to use CO2 insufflation in deeply sedated colonoscopy.

Does Bedside Sonography Effectively Identify Nasogastric Tube Placements in Pediatric Critical Care Patients?

A nasogastric tube (NGT) insertion is a common procedure in intensive care units, with some serious complications that result from the malposition of the NGT tip. This pilot study was designed to investigate the efficiency of ultrasound in verifying correct NGT placement and to compare these results with radiographic findings. This was a single-center, double-blind prospective study of patients who had received an NGT in the pediatric critical care unit. Twenty-one patients aged 1 month to 18 years were included in this study. All NGTs were inserted by the same critical care physician. After insertion, the physician first confirmed NGT placement by the auscultation of the epigastrium following the insufflation of air. Confirmation was supplemented with an abdominal radiograph. A radiologist who was unaware of the radiographic findings performed bedside sonography on all patients and verified the location of the NGTs. The findings from these 2 physicians were then compared. NGTs were inserted without any complications, and none of the NGTs were positioned in the respiratory tract in any of the patients. All NGT tips were visualized by radiography and sonography with a sensitivity of 100%. Bedside sonography performed by a radiologist is an effective and sensitive diagnostic procedure for confirming the correct NGT position in patients in the pediatric critical care unit.

Adult Female With Abdominal Pain

A 34-year-old woman with a history of fibroids presented to the emergency department with 4 days of intermittent abdominal pain. She described 1 episode of emesis and 1 loose watery stool. She denied fevers, urinary symptoms, or vaginal complaints. Her physical examination result was notable for mild periumbilical tenderness to palpation without rebound or guarding. Her pelvic examination result was unremarkable. Blood work, urinalysis, and pregnancy test results were negative. The emergency physician initially performed bedside ultrasonography (Figure 1), and computed tomography (CT) was subsequently obtained (Figure 2).Figure 2Coronal (left panel) and sagittal (right panel) CT images demonstrate intussusceptum (short arrow) and surrounding intussuscipiens (long arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT) Intussusception. Bedside ultrasonography demonstrated a hypoechoic external ring with a hyperechoic crescent, which was confirmed by the CT. Air insufflation was unsuccessful and a hemicolectomy was ultimately performed. Biopsies revealed adenocarcinoma of the colon. Intussusception is an emergent abdominal condition that is characterized by the telescoping of one part of the intestine into an adjacent part during peristalsis. If left untreated, intussusception can lead to bowel obstruction, bowel necrosis, perforation, or infection. Most cases (95%) are diagnosed in children.1Choi S.H. Han J.K. Kim S.H. et al.Intussusception in adults: from stomach to rectum.AJR Am J Roentgenol. 2004; 183: 691-698Crossref PubMed Scopus (66) Google Scholar The majority of adult patients who receive a diagnosis of intussusception require operative intervention because they usually present late in the course of the disease.2Marinis A. Yiallourou A. Samanides L. et al.Intussusception of the bowel in adults: a review.World J Gastroenterol. 2009; 15: 407-411Crossref PubMed Scopus (394) Google Scholar The most common cause of intussusception in adults is a primary neoplasm of the colon. Ideally, the emergency physician uses the curvilinear transducer to evaluate the loops of bowel where the patient is most tender. The “crescent in a doughnut sign,” characterized by a hypoechoic external ring with a hyperechoic crescent, is the most common sonographic appearance of intussusception.3Tiao M.M. Wan Y.L. Ng S.H. et al.Sonographic features of small-bowel intussusception in pediatric patients.Acad Emerg Med. 2001; 8: 368-373Crossref PubMed Scopus (50) Google Scholar

Glove Perforation Rate in Surgery: A Randomized, Controlled Study To Evaluate the Efficacy of Double Gloving.

The risk of exposure of either the patient or the surgeon to communicable disease when the surgical glove is perforated is important. Both patients and the surgical team need to be protected from this risk. Therefore, we intended to determine the efficacy of double gloving in our center. This was a prospective cohort study, involving (randomly selected) surgeons, who wore single or double latex surgical gloves during procedures. Gloves were collected and evaluated for perforations (using air insufflation and water leak methods). A total of 1,536 gloves were collected (512 single gloves and 1,024 double gloves), with 78 of 512 gloves perforated, giving a rate of 15.2%. Perforation rate was 15.2% in single gloves, 14.4% in double gloves, 15.5% in emergency operations, and 14.3% in elective surgery. It was highest (30.8%) among registrars in training, particularly when doing any deep (16.0%) surgery. Glove perforation rate was highest (17.4%) among general surgery procedures as opposed to pediatric surgery (14.6%), urology (13.9%), neurosurgery (11.7%), and plastic surgery (10.6%), with (42.1%) index finger injury. In unused (control group) gloves, the rate of perforation was (0.8%). There was a substantial difference in the overall perforation rate between single and double glove sets (15.2% versus 14.4%) (X(2) = 1748, p < 0.0001). However, among the double set, total gloves [outer and inner set] analysis revealed a perforation rate of 27.5% (141 of 512). Of this set, the number of inner gloves that perforated as a result of a through and through puncture from outer to the inner gloves gave a rate of 1.17% (six of 512). Thus, the protection offered by double gloves was 98.83% (X(2) = 280.9, p < 0.0001) even if the outer gloves were perforated. The use of double gloves has more than 90% protection to patient and the surgeon. Therefore, wearing double gloves should be encouraged in surgery.

To characterize the incidence of airway misplacement of nasogastric tubes in anesthetized intubated patients by using a manometer technique.

This study characterized the incidence of airway misplacement of nasogastric (NG) tubes in surgical patients, and the benefit of using a manometer to discriminate gastric placement from airway placement of NG tubes. Subjects included adult patients scheduled for abdominal surgery. After tracheal intubation, a 16 Fr. NG tube was inserted blindly through the nostril, and its position was assessed using the auscultation (10-ml air insufflation) or manometer (attached to NG tubes) techniques. Briefly, a biphasic pressure change synchronous with airway pressure during mechanical ventilation indicated airway misplacement. The presence of a notable pressure change while compressing the epigastric area indicated a gastric placement. A surgeon made the final confirmation of NG tube placement within the stomach using manual palpation of the tube immediately after laparotomy. The first-attempt success rate was 82.7% in 104 patients. There were 29 misplacements of 130 attempted insertions (oral cavity, n=23; trachea, n=3; distal esophagus, n=3). The incidence of airway misplacement was 2.9% (3 of 104 cases). For confirmation of gastric placement, the auscultation technique had a sensitivity of 100.0% and a specificity of 79.3%. In contrast, the manometer technique had a sensitivity of 100.0% and a specificity of 100.0% in the discrimination of gastric placement from airway placement of NG tubes. Airway misplacement of NG tubes is not uncommon in surgical patients, and the manometer technique may be a reliable and safe method to discriminate gastric placement from airway placement of NG tubes.

3:36 PMAbstract No. 401 - Is preprocedure barium necessary? Complication rate for percutaneous fluoroscopic-guided gastrostomy with and without barium

To compare complication rates between percutaneous fluoroscopic-guided gastrostomy tube (PFG) placement with and without the presence of enteric barium. From September 2004 through July 2014, 539 patients at a public teaching hospital underwent PFG for nutrition. Images acquired during PFG placement were evaluated for presence of small or large bowel contrast. In all cases, the procedure was performed with maximal gastric air insufflation and multiple fluoroscopic projections to ensure absence of bowel interposition between the stomach and anterior abdominal wall. The medical records were evaluated for SIR-defined major and minor complications within 90 days of the procedure. Major complications included hemorrhage, necrotizing fasciitis, peritonitis, aspiration, tumor implantation, and death. Minor complications included ileus, peri-stomal infection, stomal leakage, buried bumper, gastric ulcer, and inadvertent removal of tube. Deaths occurring during the 90-day period were also evaluated separately. Of 539 patients, complete data were available on 515 (96%); 77 (15%) received barium and 438 (85%) did not. The overall 90-day major and minor complication rates were 4.3% and 10.7% respectively. The major complication risk difference was 0.4%; 3.9% with barium vs. 4.3% without (95% CI -4.3% to 5.2%). The minor complication risk difference was 4.9%; 6.5% with barium and 11.4% without (95% CI -1.3% to 11.2%). There were no bowel perforations in either group. One death (counted as a major complication) occurred in the no-barium group. There was minimal difference in the major complication rate of PFG with and without barium. There were no bowel perforations in either group. Our study suggests pre-procedure barium is not necessary to protect against inadvertent bowel injury during PFG.

Insufflation with carbon dioxide reduces pneumoperitoneum after percutaneous endoscopic gastrostomy (PEG): a randomized controlled trial.

Background and study aims: Pneumoperitoneum following PEG placement has been reported in up to 60 % of cases, and while usually benign and self-limited, it can lead to evaluation for suspected perforation. This study was designed to determine whether using CO2 compared to ambient air for insufflation during PEG reduces post-procedure pneumoperitoneum. Patients and Methods: Prospective, double-blind, randomized trial of 35 consecutive patients undergoing PEG at a single academic medical center. Patients were randomized to insufflation with CO2 or ambient air. The primary outcome was pneumoperitoneum determined by left-lateral decubitus abdominal x-rays 30 minutes after PEG placement. Secondary endpoints included abdominal distention, pain, and bloating. Results: PEG was successfully placed in 17 patients using CO2 and 18 patients using ambient air. Three patients in each arm were unable or declined to have x-rays completed and were excluded. Pneumoperitoneum was identified in 2/14 (14.3 %) using CO2 and 8/15 (53.3 %) using ambient air (P = 0.05). There was no significant difference in abdominal distention, visual analog scale (VAS) scores for pain or bloating between CO2 and ambient air. Conclusion: Utilizing CO2 significantly reduces the frequency of post-procedural pneumoperitoneum compared to use of ambient air during PEG placement, with no difference in waist circumference, pain or bloating between CO2 and ambient air. CO2 appears to be safe and effective for use and may be the insufflation agent of choice during PEG.

Impact of Colonoscopy Insertion Techniques on Adenoma Detection.

Low adenoma detection rate (ADR) predicts development of interval cancers, found mainly in the right (cecum-ascending) colon, where poor bowel preparation is an associated factor. Single-site studies reported increased detection of adenomas in the proximal colon segments by water exchange (WE). Data about colon cleansing revealed that WE had the greatest impact in the right colon. To test the hypothesis that WE had the greatest impact on ADR in colon segments with the most favorable bowel cleanliness scores, namely the right colon. We pooled right colon and overall ADR data of three similarly designed colonoscopy trials that compared WE, water immersion (WI) and insufflation of air or carbon dioxide (AICD) in a mixed gender European population. In this study, 1200 (704 males) subjects and were included. 288 were screening cases. Demographic and procedural data were comparable. Water exchange achieved significantly higher right colon <10mm ADR (11.9%, vs WI 6.9%, p=0.016; vs AICD 7.2%, p=0.025). Water exchange achieved the lowest proportions of poor bowel preparation and the highest right colon and overall Boston bowel preparation scale scores (p range 0.003, <0.0005). In patients with right colon excellent bowel cleanliness, water exchange was the only method significantly associated with right colon adenoma detection. One of the limitations is unblinded colonoscopists. In a mixed gender European population, water exchange is confirmed to be a superior insertion technique showing a significant increase in <10mm right colon adenoma detection, achieving the cleanest colon and lowest proportions of poor bowel preparation requiring repeat procedures. CLINICALTRIALS. NCT01781650, 01954862, 01780818.