Manual Insufflation Research Articles

Making intussusception reductions easier: use of medical air in lieu of manual pump.

Pneumatic reduction of ileocolic intussusception is commonly performed with manual insufflators. The challenge of operating a handheld device while controlling the fluoroscope and monitoring the reduction could be obviated if the manual insufflation could be eliminated. The aim in this retrospective study was to describe and evaluate the use of medical wall air in intussusception reduction. We retrospectively reviewed all intussusception reductions over a period of years: from 2015 to 2018 using the manual insufflator and from 2018 to 2021 using medical air. We compared success rates, complication rates and time to reduction as documented on fluoroscopic image time stamps. Demographic data were obtained from the medical record. Attending radiologists and fluoroscopic technologists indicated their preference between methods, ease of use, perceived duration of reduction and perceived difference in success rates through an anonymous internal survey. There were 179 first reduction attempts in 167 patients (93 attempts during the period using the manual insufflator and 86 after converting to wall air). There was no difference in reduction duration (8:23 min for insufflation, 8:22 min for wall air, P=0.99) and no statistically significant difference in success rate (66.8% for insufflation and 79.1% for wall air, P=0.165). All survey respondents preferred the wall air method. The vast majority (93%) perceived that the wall air method was faster. Hospital wall air can be used to successfully reduce intussusceptions without incurring time burden or loss of effectiveness. The method leads to a perception of increased efficiency.

Translation from manual to automatic endoscopic insufflation enhanced by a pressure limiter.

Optimal visualization and safety have always been essential in performing any type of endoscopic surgery. However, the safety of automatic gastrointestinal (GI) insufflation has yet to be thoroughly studied, especially when combined with manual insufflation. The current study aimed to verify whether the pressure limiter could lower GI endoluminal pressure during endoscopic procedures and affect the behavioral patterns of endoscopists. A preclinical blinded trial was conducted on endoscopists who had no knowledge regarding the presence of the pressure limiter that prevents a GI endoluminal pressure above 25mmHg. Endoscopists in group A performed esophageal endoscopic submucosal dissection (ESD) with our insufflation device equipped with the pressure limiter, whereas those in group B performed the same procedure without the pressure limiter. During all procedures, endoluminal pressure was continuously monitored. The primary endpoint of the current study was to measure the endoluminal pressure with or without the pressure limiter during esophageal ESD, while the secondary endpoint was to evaluate the effect of the pressure limiter on intraesophageal pressure and perioperative outcomes during esophageal ESD. A questionnaire survey was conducted after each session. A total of 79 endoscopists were included in this randomized control study. Group A had significantly lower endoluminal pressure than group B (10.6 ± 4.61 vs. 16.25 ± 7.51mmHg, respectively; p < 0.05). Although two pigs in group B died from tension pneumothorax, none in group A died. Evaluation of lumen expansion, ease of aspiration, and visual field reproducibility were poorer in group A than in group B, although all fell within the acceptable range. Subjective evaluation of usability was divided into two categories, Excellent/Good and Poor/Bad, with no significant differences in any of the items. This preclinical study showed that endoscopic treatment with an automatic insufflation system could be performed at lower endoluminal pressure with a pressure limiter, which had no adverse effects on the endoscopist's feels on endoscopic procedures with the device.

Optimization of insufflation and pressure control in third-space endoscopy.

Third-space endoscopy requires a delicate and accurate insufflation technique to secure the endoscopic visualization and maintain the working space. However, optimal third-space insufflation parameters have yet to be determined. The aim of this study was to assess: (1) the diversity of endoluminal third-space pressure by manual insufflation, and (2) the performance of the insufflation settings for third-space endoscopy. A submucosal tunnel was created in the upper posterior wall of the porcine stomach. Using two-channel esophagogastroduodenoscopy, one channel was used for insufflation and the other was used for pressure measurement. Experiment 1 Endoluminal submucosal tunnel pressure was measured in a 10-cm submucosal tunnel of a single porcine. Six board-certified endoscopists in turn maintained what they considered sufficient exposure under manual insufflation. Experiment 2 Endoluminal submucosal tunnel pressure and number of insufflations were measured using the pressure-regulated insufflation device; the differences in the submucosal tunnel length (long: 10-cm, short: 4-cm) and the insufflation route diameter (large: 3.8-mm, small: 2.2-mm) were compared. Experiment 1 The endoluminal submucosal tunnel pressure profiles during third-space endoscopy varied between endoscopists. Experiment 2 Longer submucosal tunnels and larger insufflation route diameters lead to stable endoluminal submucosal tunnel pressure. The gap with the preset pressure of the insufflator and endoluminal pressure narrowed, and the required number of insufflations decreased with longer tunnel length and larger route diameter. The pressure dynamics in third-space endoscopy differed among endoscopists. Longer submucosal tunnels and larger insufflation route diameters lead to stable endoluminal submucosal tunnel pressure.

Intra-abdominal pressure during endoscopic full-thickness resection comparing manual and automatic control insufflation: a block-randomized porcine study.

An automatic carbon dioxide (CO2) insufflating system (SPACE) was developed to stabilize intra-lumenal pressure (ILP) during endoscopic interventions. This study investigated whether SPACE could improve the control and monitoring of extra-lumenal intra-abdominal pressure (IAP) after establishing a perforation during endoscopic full-thickness resection (EFTR) of the gastric wall in porcine models. After first establishing the optimal preset pressure for gastric EFTR in four pigs, we compared IAP dynamics during EFTR between manual insufflation and SPACE using a block-randomized study (n = 10). IAP was percutaneously monitored and plotted on a timeline graph every 5s. The maximal IAP and the area under the IAP curve exceeding 10mmHg (AUC≥10mmHg) were compared between groups, with the agreement between IAP and endolumenally monitored ILP also analyzed for animals in the SPACE group. In the first study, 8mmHg was identified as the most preferable preset pressure after establishment of the perforation. In the randomized study, the mean maximal IAP in the SPACE group was significantly lower than that in the manual insufflation group (11.0 ± 2.0mmHg vs. 17.0 ± 3.5mmHg; P = 0.03). The mean AUC≥10mmHg was also significantly smaller in the SPACE group. Bland-Altman analysis demonstrated agreement between IAP and ILP within a range of ± 1.0mmHg. SPACE could be used to control and safely monitor IAP during gastric EFTR by measuring ILP during perforation of the gastric wall.

Sigmoid Perforation during CT Colonography in a Patient with an Inguinal Hernia and Concomitant Finding of a Right-Sided Colon Cancer

The use of computed tomography colonography or virtual colonography (VC) is gaining acceptance as a screening modality for colon cancer. A comprehensive understanding of VC complications is limited. We report a case of colon perforation in a patient where a colon cancer was diagnosed using VC colonography with manual insufflation. A 79-year-old patient underwent a VC after a failed screening optical colonoscopy (OC). The initial radiological findings included a large amount of mesoperitoneum and retroperitoneal air near the proximal sigmoid and a left inguinal hernia containing the distal sigmoid colon suggesting a colonic perforation caused by colonic obstruction. Subsequent radiological interpretation revealed a 1.5 cm lesion in the posterior cecum. The patient underwent repair of the hernia, sigmoid resection for sigmoid perforation, followed by intra-operative colonoscopy (which confirmed the radiographic findings of a cecal lesion) and right colectomy. Pathologic examination confirmed the T3, N0, MX adenocarcinoma.

Gastric endoscopic submucosal dissection under steady pressure automatically controlled endoscopy (SPACE); a multicenter randomized preclinical trial.

Steady pressure automatically controlled endoscopy (SPACE) is a new modality that eliminates on-demand insufflation but enables automatic insufflation in the gastrointestinal tract. Though its use in porcine esophageal ESD was reported to be promising, its applicability and potential effectiveness to gastric procedures have not been evaluated. The aims were (1) to evaluate feasibility and safety of SPACE in the stomach, and (2) to assess its potential advantages over conventional endoscopy in preventing "blind insufflation"-related complications. A multicenter randomized preclinical animal study. Laboratories at three universities. Experiment 1: Gastric ESD was attempted in the swine (n=17), under either SPACE or manual insufflation. Experiment 2: Gastroscopy was performed for 10min in the perforated stomach (n=10) under either SPACE or manual insufflation. Experiment 1: ESD time, energy device activation time, number of forceps exchanges, specimen size, en block resection rate, vital signs and any intraoperative adverse events. Experiment 2: Intra-gastric and intra-abdominal pressures, vital signs, and any adverse events. Experiment 1: Gastric ESD was completed in all animals. ESD time tended to be shorter in SPACE than in the control, though the difference was not significant (p=0.18). Experiment 2: Although both intra-gastric and intra-abdominal pressures remained within preset values in SPACE, they showed excessive elevation in control. An animal study with small sample size. SPACE is feasible and safe for complicated and lengthy procedures such as gastric ESD, and is potentially effective in preventing serious consequences related to excessive blind insufflation.

A comparative study of degree of colorectal distention with manual air insufflation or automated CO2 insufflation at CT colonography as a preoperative examination

The purpose of this study was to compare the degree of colorectal distention between manual insufflation using room air and automatic insufflation using carbon dioxide for computed tomography colonography performed as a preoperative examination for patients with colon cancer. Participants comprised 200 patients who underwent computed tomography colonography immediately after colonoscopy from October 2011-2012. The first 100 patients were examined using manual insufflation, and the remaining 100 patients were examined using automated insufflation. Two radiologists independently assessed colorectal distention using a 4-point scale in six segments: cecum, ascending colon, transverse colon, descending colon, sigmoid colon, and rectum. Mean scores of the two radiologists were used to analyze whether any differences existed between techniques in terms of the degree of distention per segment. Mean distention values for the colonic lumen were better using the automated technique than with the manual technique in both positions (p<0.05). In segments, distention was significantly better using the automated technique than using the manual technique in the sigmoid and descending colon for prone patients, and in all segments for supine patients. Automated carbon dioxide insufflation offered significantly improved colorectal distention scores compared to manual room air insufflation.

Severe hemodynamic deterioration caused by cardiac herniation during endoscopic thoracic sympathicotomy in a patient with previously undiagnosed congenital pericardial defect.

Severe hemodynamic deterioration caused by cardiac herniation during endoscopic thoracic sympathicotomy in a patient with previously undiagnosed congenital pericardial defect.

大腸3D─CT検査用自動炭酸ガス送気装置の有用性─腸管拡張程度と受診者の受容性に関する無作為比較試験─

大腸3D─CT検査用自動炭酸ガス送気装置の有用性─腸管拡張程度と受診者の受容性に関する無作為比較試験─

Adverse events of computed tomography colonography: An Italian National Survey

To retrospectively study the frequency and magnitude of complications associated with computed tomography (CT) colonography in clinical practice. A questionnaire on complications of CT colonography was sent to Italian public radiology departments identified as practicing CT colonography with a reasonable level of training. The frequency of complications and possible risk factors were retrospectively determined. Responses were collated and row frequencies determined. A multivariate analysis of the factors causing adverse events was also performed. 40,121 examinations were performed in13 centers during the study period. No deaths were reported. Bowel perforations occurred in 0.02% (7 exams). All perforations were asymptomatic and occurred in patients undergoing manual insufflation. Five perforations (71%) occurred in procedures performed following a recent colonoscopy. There was no significant difference between perforations associated with rectal balloon (0.017%) and those that were not (0.02%). Complications related to vasovagal reaction (either with or without spasmolytic) occurred in 0.16% (63 exams). All vasovagal reactions resolved in less than 3h, without any sequelae. Perforation rate at CT colonography in Italy is comparable with elsewhere in the world, occurring regardless of the experience of radiology centers. Although the risk is very small, it may not be negligible when compared with the risk of diagnostic colonoscopy.

Use of Venturi effect for effective and uniform talc pleurodesis

Dear Editor,We read with interest Makhija et al’s [1] article aboutthe use of Venturi effect for the effective and rapid tech-nique to ensure uniform talc pleurodesis. In our centre wealso use the Venturi effect of the jet ventilator, and it doesproduce more uniform and fine distribution of the talccompared to the conventional method of manual insuffla-tion. The difference between our technique and thatreported is that while the authors use negative suctionpressure to insufflate the talc, we use positive pressure. Wetake the conventional insufflator, disconnect the rubbercomponent, and in its place connect the tubing whichcomes directly from the jet ventilator (Fig. 1). The airscatters the talc in the insufflator cavity and carries it on itsway into the chest, much as a nebulizer does. We place apiece of gauze around the tip of the insufflator as it entersthe port to prevent talc from escaping outside the chest,while at the same time it is not airtight so as to cause atension in the pneumothorax. An unscrubbed assistant thengives repeated bursts of the jet ventilator. In our experi-ence, a pressure of 5 psi (about 35 kPa) is sufficient tocause uniform distribution while at the same time safelylow to prevent tension or shift of mediastinum to theopposite side. We believe that this method is quicker andcheaper, as it needs no further pieces in the circuit, which isthe case with the authors, where the talc is placed in aseparate chamber to be sucked away by the negativepressure created by the air as it passes by. There has beenno comparative trials to determine if spreading the talc isbetter with positive than with negative pressure, though webelieve that positive pressure may result in a more effectiveand uniform spreading of the talc.Reference

Optimizing the degree of distension and reducing discomfort in CT colonography by means of a microprocessor interface system for air insufflation

Abstract The patients’ discomfort during CT colonography determines which method is used and its frequency of use. The discomfort is largely associated with the colon’s insufflation with gas. A system for an automatic room-air insufflation has been developed that ensures a continuous and steady air insufflation and an increase in colonic pressure and enables a relatively fast decompression. This system provides constant pressure monitoring and can alert the operator, if necessary. The degree of discomfort was evaluated for 36 patients, who were subjected to manual and automated air insufflation. The degree of the colonic distension achieved by the two methods was compared. The data analysis showed a significantly lower level of discomfort in patients with automated air insufflation. The degree of colonic distension was evaluated by comparing the diameters of similar segments of the colon, as well as by the subjective opinion of the operator. The distension with automated air insufflation was higher than that with manual air insufflation. In some cases there was a significant difference (P&lt;0,05). In conclusion, the results show that the automatic insufflation of air at room temperature can be used to optimize CT colonography.

Standards for Gastroenterologists for Performing and Interpreting Diagnostic Computed Tomographic Colonography

Standards for Gastroenterologists for Performing and Interpreting Diagnostic Computed Tomographic Colonography

Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery

The peroral transgastric endoscopic approach for intraabdominal procedures appears to be feasible, although multiple aspects of this approach remain unclear. This study aimed to measure intraperitoneal pressure in a porcine model during the peroral transgastric endoscopic approach, comparing an endoscopic on-demand insufflator/light source with a standard autoregulated laparoscopic insufflator. All experiments were performed with 50-kg female pigs under general anesthesia. A standard upper endoscope was advanced perorally through a gastric wall incision into the peritoneal cavity. The peritoneal cavity was insufflated with operating room air from an endoscopic light source/insufflator. Intraperitoneal pressure was measured by three routes: (1) through the endoscope biopsy channel, (2) through a 5-mm transabdominal laparoscopic port, and (3) through a 16-gauge Veress needle inserted into the peritoneal cavity through the anterior abdominal wall. The source of insufflation alternated between on-demand manual insufflation through the endoscopic light source/insufflator using room air and a standard autoregulated laparoscopic insufflator using carbon dioxide (CO(2)). Six acute experiments were performed. Intraperitoneal pressure measurements showed good correlation regardless of measurement route and were independent of the type of insufflation gas, whether room air or CO(2). On-demand insufflation with the endoscopic light source/insufflator resulted in a wide variation in pressures (range, 4-32 mmHg; mean, 16.0 +/- 11.7). Intraabdominal pressures using a standard autoregulated laparoscopic insufflator demonstrated minimal fluctuation (range, 8-15 mmHg; mean, 11.0 +/- 2.2 mmHg) around a predetermined value. Use of an on-demand unregulated endoscopic light source/insufflator for translumenal surgery can cause large variation in intraperitoneal pressures and intraabdominal hypertension, leading to the risk of hemodynamic and respiratory compromise. Safety may favor well-controlled intraabdominal pressures achieved with a standard autoregulated laparoscopic insufflator.

Making sense of CT colonography–related complication rates

Making sense of CT colonography–related complication rates

Automated Insufflation of Carbon Dioxide for MDCT Colonography: Distension and Patient Experience Compared with Manual Insufflation

The purpose of our study was to compare the effects of automated and manual carbon dioxide insufflation before CT colonography on distention and patient acceptance. One hundred forty-one symptomatic subjects underwent CT colonography using either an automated device (n = 47) or a manual method (n = 94) for carbon dioxide insufflation. CT data sets were assessed retrospectively in consensus by two blinded observers who graded distention for six colonic segments using a 4-point scale. An additional assessment of the overall clinical adequacy of distention (yes/no) was also made, and any learning curve was sought. Each patient completed a validated 24-point patient questionnaire reflecting patient satisfaction and discomfort. Distention scores, clinical adequacy, and questionnaire responses were analyzed using ordered logistic regression, Fisher's exact test, and the Mann-Whitney test statistic, respectively. Automated insufflation significantly improved distention overall (p = 0.001). For individual segments, distention was significantly improved in the sigmoid (p = 0.007) and descending (p < 0.001) colons when the patient was supine; and in the sigmoid (p = 0.02), descending (p = 0.001), and transverse (p = 0.02) colons when supine and prone positions were combined. No significant difference was seen in the clinical adequacy of distention, nor was there evidence of any learning curve for either insufflation method. Subjects were more weary after automated insufflation (p = 0.03), but no significant difference was seen for the remaining 23 questionnaire items or for feelings of bloating or discomfort. Automated carbon dioxide insufflation significantly improves colonic distention compared with manual insufflation. Benefit is greatest in the left colon, particularly when the patient is supine. Patient acceptance is similar to that for manual insufflation.

Intracolonic pressure measurements during hydrostatic and air contrast barium enema studies in children.

To prospectively evaluate intraluminal pressure changes in the colon of children undergoing conventional hydrostatic (barium and water-soluble contrast material) and air contrast barium enema studies. Dynamic intracolonic pressure was measured in 26 children undergoing hydrostatic barium (23% wt/vol) enema studies, air contrast barium enema studies, or water-soluble contrast material enema examinations. Measurements were obtained with a measuring device capable of recording rapid changes in pressure. Pressure measurements were obtained with the contrast reservoir system open (contrast material was free to run through the tubing into the patient's colon) and closed (tube was clamped). The colonic pressures during the filling phase with liquid contrast material were equal to those elsewhere at the same level with the hydrostatic system. Mean pressure ranged from 30 to 50 mm Hg with peaks of more than 100 mm Hg during Valsalva maneuvers. During air contrast barium enema studies, sharp pressure increases and rapid swings in the intracolonic pressure occurred during and after manual insufflation of air. During conventional hydrostatic barium enema studies, intracolonic pressures remain low. During air insufflation, there were intermittent high, sharp pressure peaks.