Use Of Carbon Dioxide Insufflation Research Articles

Evaluation of hepatic and renal functional changes in patients undergoing laparoscopic cholecystectomy

Background: In this era of laparoscopic surgery, with the use of carbon dioxide insufflation in creating pneumoperitoneum for ease of trocar insertion and visualization of anatomy, it comes certain systemic changes in the patient due to the compression effect of the gas as well as resorption of it through peritoneum. Aims and Objectives: The aim of the study was to assess baseline standards of hepatic and renal functional status in pre-operative patients in comparison with post-operative patients undergoing laparoscopic cholecystectomy (LC). Materials and Methods: Cases were chosen among the persons who presented with chronic calculus cholecystitis to the surgical out-patient department of Ramakrishna Mission Seva Pratishthan, Vivekananda Institute of Medical Sciences, Kolkata. Pre-operative liver function tests (LFT) and renal function tests (RFT) values were recorded. Again, LFT and RFT values were evaluated on post-operative day 1 (POD1) and POD12. Results: Serum conjugated and unconjugated bilirubin, aspartate amino transaminase, alanine amino transaminase, urea, estimated glomerular filtration rate values increases immediate postoperatively on POD1 but returns to normal pre-operative levels on POD 12. Serum alkaline phosphatase, albumin, and creatinine values decrease on POD1 and return to normal pre-operative values in POD 12. Conclusion: Hepatic and renal function changes in the immediate post-operative period of 24 h following LC. This change is transient and returns to normal levels within POD 12.

Training residents in robotic thoracic surgery

With growing integration of robotic technology in thoracic surgery, the need for structured training has never been greater with trainees expressing desire for additional experience. Determining the ideal education program is challenging as the collective experience is still relatively early and growing with many experienced surgeons still becoming facile with the platform. Understanding differences between robotic and thoracoscopic approaches including lung retraction and dissection, use of carbon dioxide insufflation, and lack of tactile feedback serves as the foundation for building a skillset. Currently, there is no standard accepted curriculum for residents. Inclusion of these trainees in structured programs has been shown to be safe with equivalent patient outcomes. There are multiple curricula under development, all of which incorporate use of simulation technology, dual console, and clear, graduated responsibilities within operations. These include introduction to the robotic system prior to progressing to bedside assistance and finally to time as console surgeon. The importance of clear definition of training milestones with deliberate graduation to more complex tasks once competency has been demonstrated cannot be overstated. It is crucial for surgeons practicing robotic surgery to make efforts to further the training of residents, but there has not been any perfect and suitable program identified yet.

Endoscopic submucosal dissection–induced incarcerated diaphragmatic hernia

A 66-year-old man underwent endoscopic submucosal dissection (ESD) with the use of carbon dioxide insufflation to resect a gastric adenoma (A, before ESD; B, after ESD). His history included surgical reconstruction of a choledochojejunostomy performed because of bile duct stricture after living donor liver transplantation. Although the ESD was uneventful, the patient had severe epigastric pain with a high fever the next day. Laboratory tests revealed elevated leukocytes and hepatobiliary enzymes.

Iatrogenic Bilateral Lower Extremity Subcutaneous Emphysema after Robotic-Assisted Laparoscopic Hysterectomy with Bilateral Salpingo-Oophorectomy and Sacrocolpopexy

As minimally invasive surgery becomes more prevalent, it is important to keep in mind the unique complications that can be associated with the use of carbon dioxide insufflation. Postoperative patients presenting with lower extremity pain and swelling should have the diagnosis of iatrogenic subcutaneous emphysema on the differential, alongside deep venous thrombosis and necrotizing fasciitis.

A Case of Thymic MALT Lymphoma Removed under Thoracoscopy with a Combined Use of Carbon Dioxide Insufflation

症例は41歳，女性．検診の胸部X線で異常を指摘され，精査の結果，縦隔腫瘍と診断され当科紹介となった．胸部CTでは，前縦隔の広範囲に境界明瞭で内部がやや不均一な腫瘤を認めた．MRIでは嚢胞成分と充実成分の混在する腫瘤と考えられた．既往歴にSjögren症候群を認めることから，多房性胸腺嚢腫を疑い，診断および治療のため手術を施行した．手術は，両側からのアプローチで胸腔鏡下に行う方針とし，右胸腔から炭酸ガス送気下に摘出を行った．結果的に右側からのアプローチにより完全切除が可能であった．病理組織検査の結果，腫瘍は胸腺MALTリンパ腫と診断された．術後経過は良好で術後4日目に退院となった．

The use of carbon dioxide insufflation to facilitate identification of intestinal injuries in patients undergoing cytoreductive surgery and intraperitoneal chemotherapy.

The use of carbon dioxide insufflation to facilitate identification of intestinal injuries in patients undergoing cytoreductive surgery and intraperitoneal chemotherapy.

Carbon Dioxide Insufflation During Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials

Despite the widespread use of carbon dioxide insufflation (CDI) in cardiac surgery, there is still paucity of evidence to prove its benefit in terms of neurologic protection. Therefore, we conducted a meta-analysis of available randomized controlled trials comparing CDI vs standard de-airing maneuvers. Electronic searches were performed to identify relevant randomized controlled trials. Primary outcomes investigated were postoperative stroke, neurocognitive deterioration, and in-hospital mortality. Risk difference (RD) was used as summary statistic. Pooled estimates were obtained by means of random-effects model to account for possible clinical diversity and methodological variation between studies. Eight studies were identified with 668 patients randomized to CDI (n = 332) vs standard de-airing maneuvers (n = 336). In-hospital mortality was 2.1% vs 3.0% in the CDI and control group, respectively (RD 0%; 95% confidence interval [CI] -2% to 2%; P = 0.87; I2 = 0%). Incidence of stroke was similar between the 2 groups (1.0% vs 1.2% in the CDI and control group, respectively; RD 0%; 95% CI -1% to 2%; P = 0.62; I2 = 0%). Neurocognitive deterioration rate was 12% vs 21% in the CDI and control group, respectively, but this difference was not statistically significant (RD: -7%; 95% CI -0.22% to 8%; P = 0.35; I2 = 0%). The present meta-analysis did not find any significant protective effect from the use of CDI when compared with manual de-airing maneuvers in terms of clinical outcomes, including postoperative neurocognitive decline.

Clinical evidence in support of use of carbon dioxide insufflation in colonoscopy: a narrative review

Insufflation of the colon is necessary to distend the lumen for exploration. Carbon dioxide (CO2) insufflation instead of air insufflation (AI) has shown conflicting results about decreasing pain or discomfort during the procedure, even when coupled with water immersion or water exchange method of insertion. CO2 insufflation is associated with a reasonably consistent decrease in bloating and pain scores in the post-procedure period. Other advantages are a decrease in toilet use, less incontinence and less flatulence after colonoscopy. No definitive results are available about the effect of CO2 on the need and dosage of sedation medication(s). Association with water-aided methods appears to show promise in decreasing pain during and after the procedure, achieve higher rates of minimally sedated or unsedated colonoscopy, with less postprocedure bloating and flatulence. Further studies are needed to investigate the impact of combining water-aided methods with CO2 on clinically relevant parameters.

Carbon dioxide insufflation versus air insufflation during endoscopic retrograde cholangiopancreatography: a meta-analysis

Background and aims: Adequate visualization during endoscopic retrograde cholangiopancreatography (ERCP) procedure requires distention of the bowel lumen, usually insufflated with room air. Patients often complain of abdominal pain post-procedure. The use of carbon dioxide insufflation in colonoscopy has been shownto result in less post-procedure abdominal pain and distension. Recently, it has been reported the use of carbon dioxide (CO2) insufflation during ERCP procedure is similarly helpful. The purpose of this study was to evaluate the efficiency, safety and comfort of ERCP involving carbon dioxide insufflation through a meta-analysis of published randomized control trials. Methods: Databases including PubMed, EMBASE, the Cochrane Library, the Science Citation Index and momentous meeting abstracts were searched and evaluated by two reviewers independently. Results: Five randomized control trials involving 446 patients were analyzed. Meta-analysis showed that patientsin the CO2 insufflation group had lower pain score (VAS) at 1-hour [MD -12.37, 95%CI(-20.96,-3.78)], 3-hours [MD -9.81, 95%CI (-17.05, -2.57)) and 6-hours [MD -8.78, 95%CI (-13.71, -3.85)] compared with air insufflation group after procedure. However, there were no significant differences between the two groups regardingtotal procedure time and procedure complication. Conclusions: Insufflation with carbon dioxide during ERCP may decrease post-procedure abdominal discomfort without any additional adverse reactions. Thus, CO2 insufflation seems appropriate to use during ERCP procedure. Large trials are required to prove any additional advantages to carbon dioxide insufflation during ERCP.

Meta‐analysis: the use of carbon dioxide insufflation vs. room air insufflation for gastrointestinal endoscopy

Carbon dioxide (CO(2)) insufflation has been proposed as an alternative to air insufflation to distend the lumen in gastrointestinal (GI) endoscopy. To perform a systematic review with meta-analysis of randomised controlled trials (RCTs) in which CO(2) insufflation was compared with room air insufflation in GI endoscopy. Electronic and manual searches were combined to search RCTs. After methodological quality assessment and data extraction, the efficacy and safety of CO(2) insufflation were systematically assessed. Twenty-one RCTs [13 on colonoscopy, four on endoscopic retrograde cholangiopancreatography (ERCP), two on double-balloon enteroscopy (DBE), one on oesophagogastroduodenoscopy, and one on flexible sigmoidoscopy] were identified. For colonoscopy, CO(2) insufflation resulted lower postprocedural pain intensity, and increased the proportion of patient without pain at 1 h (RR: 1.84, 95% CI: 1.37-2.47) and 6 h (RR: 1.28; 95% CI: 1.14-1.44) postprocedure. For ERCP, the pain-releasing effect of CO(2) insufflation was not obvious (SMD: -1.48, 95% CI: -3.56, 0.59). CO(2) insufflation revealed no consistent advantages in the RCTs of DBE, but was shown as safe as air insufflation in oesophagus/stomach endoscopic submucosal dissection in one study. pCO(2) level showed no significant variation during these procedures. Compared with air insufflation, CO(2) insufflation during colonoscopy causes lower postprocedural pain and bowel distension without significant pCO(2) variation. More RCTs are needed to assess its advantages in other GI endoscopic procedures.

Protective Effects of Zinc, Pentoxifylline, and N-Acetylcysteine in an Animal Model of Laparoscopy-Induced Ischemia/Reperfusion Injury of the Small Intestine

Pneumoperitoneum induced to facilitate laparoscopy is associated with splanchnic hypoperfusion, ischemia/reperfusion (I/R) injury, and oxidative stress. This study investigated the effects of pre- and postlaparoscopic conditioning, zinc, pentoxifylline, and N-acetylcysteine on markers of I/R injury of the small intestine in an animal model. Male Sprague-Dawley rats (n=56) were randomized to 1 of 7 treatment groups. Except for group 7 (control group that underwent sham surgery without pneumoperitoneum), pneumoperitoneum was induced in all by use of carbondioxide insufflation under a pressure of 15 mmHg. Group 1 (laparoscopic I/R) was subjected to 60 minutes of pneumoperitoneum. Group 2 (laparoscopic preconditioning plus laparoscopy) was subjected to 5 minutes of insufflation and 5 minutes of desufflation followed by 60 minutes of pneumoperitoneum. Group 3 (laparoscopy plus laparoscopic postconditioning) was subjected to 60 minutes of pneumoperitoneum and 60 minutes of desufflation followed by 5 minutes of insufflation and 5 minutes of desufflation. Group 4 (zinc), group 5 (pentoxifylline), and group 6 (N-acetylcysteine) received a single intraperitoneal injection of zinc (50 mg/kg), pentoxifylline (50 mg/kg), or N-acetylcysteine (150 mg/kg), respectively, 5 minutes before the desufflation period. Animals were killed at the end of the experiments, and small intestine samples were tested for malondialdehyde (MDA), catalase (CAT), glutathione peroxidase (GPX), and superoxide dismutase (SOD). There was no significant difference for MDA levels between each other in the groups 1, 2, and 3. But MDA levels were higher significantly in groups 1, 2, and 3 than those of groups 4, 5, 6, and 7. SOD and GPX levels of group 3 were significantly higher than those of groups 1, 2, 4 through 7. According to the SOD levels, there was no significant difference between each other in those of groups 1, 2, 4 through 7. GPX levels of group 3 were significantly higher than those of groups 1, 2, 4 through 7. GPX levels of group 1 were significantly lower than those of groups 5 and 7. The mean CAT level of groups 1 and 2 was significantly lower than that of groups 3, 6, and 7. The mean CAT level of group 3 was significantly higher than that of groups 1, 2, 4 through 7. In this animal model of small intestine I/R injury, laparoscopy caused small intestine ischemia as evidenced by elevated markers of tissue I/R injury. This effect was significantly attenuated by zinc, pentoxifylline, and N-acetylcysteine, but not by prelaparoscopy conditioning and postlaparoscopy conditioning.

Improved cerebral protection through replacement of residual intracavital air by carbon dioxide: a porcine model using diffusion-weighted magnetic resonance imaging

Background Major risk of central or peripheral organ damage is attributed to air embolism from incompletely de-aired cardiac chambers after cardiac operations. Replacement of air by carbon dioxide insufflation into the thoracic cavity is widely used. Diffusion-weighted magnetic resonance imaging of the brain detects ischemia within minutes after onset. The reversibility of ischemia in cerebral tissue after massive gaseous emboli has not yet been described. Methods After selective catheterization of a common carotid artery in 15 pigs, boli of 1 mL/kg body weight of air (n = 5) or carbon dioxide (n = 5, “low dose”) were applied. Five pigs received 2 mL/kg body weight of carbon dioxide (“high dose”). Diffusion-weighted magnetic resonance imaging of the brain was performed 2, 5, 10, 15, and 25 minutes after embolization. Results All animals of the “air” group showed important circulatory reactions leading to death of 2 animals. In the whole group, diffusion-weighted magnetic resonance imaging revealed irreversible hyperintense signals in both hemispheres. In the low-dose group, no change in signal intensity was observed in 2 pigs, and 3 others showed reversible changes in signal intensity, without important circulatory reactions. In 3 animals of the high-dose group, hyperintense signals were reversible, but 2 others presented with bilateral, irreversible signals in diffusion-weighted magnetic resonance imaging, accompanied by minor circulatory reactions. Conclusion In contrast to the dramatic effect of air emboli, identical quantities of carbon dioxide injected into cerebral arteries of the pigs were not associated with major clinical symptoms. The early reversibility of ischemic reactions visualized in diffusion-weighted magnetic resonance imaging encourages the use of carbon dioxide insufflation as a protective method in cardiac surgery.

Invited commentary

This paper describes a technique that has worked well for the authors in a small subset of cases that allows partial lung collapse for thoracoscopic procedures. The technique itself appears fairly simple, but in the majority of cases did require the use of carbon dioxide insufflation. This method is designed to replace the need for double lumen endotracheal tubes and single lung ventilation. Our experience has been very good with the use of double lumen endotracheal tubes. They provide optimal visualization of the surgical field for thoracoscopic procedures and, as such, expedite the rapid performance of these procedures. Although the authors suggest no delays in their surgical times by using this technique, I believe it is quite possible, particularly with more advanced surgical procedures, that using this method will increase the operative time, thereby offsetting any cost advantage from avoiding the double lumen endotracheal tubes. In addition, in the last 10 years with over 3,000 procedures using double lumen endotracheal tubes, we have had only one significant airway injury. I believe that this attests to the general safety of the placement of double lumen endotracheal tubes in experienced hands. The need for carbon dioxide insufflation changes the flow of the procedure as we perform it today. In fact, we often do not use trocars at our access sites. Instead, we use a simple skin incision with an incision between the intercostal space and then use standard instruments. Adding the need for CO2 requires keeping seals, and can be cumbersome, while making it difficult to use some of the instrumentation that we normally use. In summary, I believe that for simple procedures this technique can be utilized. However, for the majority, I am doubtful that there is any clinically significant benefit. There may be a small subset where this technique may have a role, such as those that have severely compromised pulmonary function or where the use of a double lumen endotracheal tube is not possible. For the vast majority of cases, I personally will accept the cost of a double lumen endotracheal tube so that I can achieve optimal visualization.

Arterial PCO2 and cardiovascular function during endoscopic neck surgery with carbon dioxide insufflation.

Endoscopic parathyroidectomy and thyroidectomy were introduced into clinical practice in 1995. Concerns about the use of carbon dioxide insufflation in the neck exist owing to reports of potential adverse metabolic and hemodynamic changes. Carbon dioxide insufflation in the neck may cause adverse effects on hemodynamic and blood gas levels. These adverse effects may reflect the level of pressure and duration of insufflation. Fifteen pigs, 5 per group, underwent endoscopic thyroidectomy at 10, 15, and 20 mm Hg. Partial pressure of carbon dioxide (arterial), pH, cardiac output, central venous pressure, heart rate, and mean arterial pressure (MAP) were measured at baseline, 1 and 2 hours after carbon dioxide insufflation, and 30 minutes after desufflation. At 10 mm Hg, PaCO2 increased slightly but not significantly, and neither acidosis nor adverse hemodynamic changes were observed. Hypercarbia, moderate acidosis, and a slight increase in MAP occurred in pigs undergoing surgery at 15 mm Hg (MAP increased to 88 +/- 2.4 mm Hg from a baseline value of 78 +/- 3.53 mm Hg; P<.05). Pigs undergoing surgery at 20 mm Hg experienced severe hypercarbia and acidosis, as well as a significant decrease in MAP (P<.05). Central venous pressure decreased at 1 hour (P<.05) and increased at 2 hours (P<.05) in pigs undergoing surgery at 15 and 20 mm Hg. After desufflation, PaCO2 and pH levels were normal for the 10 and 15 mm Hg groups, while pigs undergoing surgery at 20 mm Hg developed a higher degree of hypercarbia and acidosis (P =.001). Carbon dioxide neck insufflation is safe at 10 mm Hg. The use of insufflation pressures higher than 15 mm Hg should be avoided due to the potential risk for metabolic and hemodynamic complications.

7026 Double blind randomised controlled trial comparing carbon dioxide and air insufflation during colonoscopy; assessing patient bloating, discomfort and satisfaction.

Aim:To determine if the routine use of carbon dioxide, as opposed to air, insufflation during colonoscopy significantly reduces patient discomfort and bloating, thus increasing satisfaction. Method: 104 consecutive volunteers, aged 55 to 65, attending for a screening colonoscopy or for adenoma assessment as part of the MRC Flexiscope trial, were randomly allocated to receive either carbon dioxide or air insufflation. Carbon dioxide was delivered to the video-endoscopes using the Olympus Endoscopic CO₂regulator. The volunteers completed a questionnaire the morning after the colonoscopy and posted it to an independent address. Procedural and post-procedural discomfort and bloating were measured using 100mm visual analogue scales. Global measures of physical discomfort, anxiety and satisfaction were obtained using a previously validated satisfaction questionnaire. Results: 104 volunteers agreed to participate in the trial, questionnaires were received from 89 participants (86% return rate). Analyses were performed on an intention to treat basis. No significant difference was found for global discomfort, anxiety or satisfaction measured using the satisfaction questionnaire (Mann-Whitney U test). Conclusion: The routine use of carbon dioxide insufflation in colonoscopy significantly reduces bloating both during and after the procedure and post-procedural discomfort, but not procedural discomfort. There was no impact on global assessment of discomfort, anxiety or satisfaction. This research was made possible through an MRC grant to fund the Flexiscope trial.

Carbon dioxide insufflation for more comfortable colonoscopy

Forty patients examined with the use of carbon dioxide insufflation during fiberoptic colonoscopy showed no significant residual gas on plain radiographs taken 30 minutes after the procedure. By contrast, 19 of 20 patients examined with air insufflation showed excessive distension of large and/or small intestine. The rapid absorption of carbon dioxide may be a safety factor in a few patients and adds to the comfort of the procedure in many others by virtually eliminating overdistension afterwards. It also makes it technically possible to perform a barium enema immediately after colonoscopy.

Fatal colonic explosion during colonoscopic polypectomy

A patient is described who sustained the first reported colonic explosion during colonoscopic polypectomy. Mannitol solution was used for bowel preparation, and the colon was completely clean. During snare removal of a cecal polyp using highfrequency current a loud explosion occurred. In spite of emergency surgery with transfusion of 45 units of blood, uncontrollable hemorrhage persisted from multiple bleeding points, and the patient died. This occurrence seems to us to justify the routine use of carbon dioxide insufflation during polypectomy and the avoidance of mannitol for bowel preparation.

The safety of carbon dioxide insufflation during colonoscopic electrosurgical polypectomy

In order to avoid the explosion hazard at colonoscopic polypectomy, the author investigated and found safe the regular use of carbon dioxide insufflation, rather than air, during the entire diagnostic and therapeutic procedure.