A pilot study to assess mediastinal emphysema after esophageal endoscopic submucosal dissection with carbon dioxide insufflation

Background and aims: Mediastinal emphysema sometimes develops following esophageal endoscopic submucosal dissection (ESD) without perforation because the esophagus has no serosa. Carbon dioxide (CO₂) insufflation during esophageal ESD may reduce the incidence of mediastinal emphysema. The aim of the present study was to compare the incidence and severity of post-ESD mediastinal emphysema in patients receiving CO₂ insufflation vs. standard air insufflation during esophageal ESD.

Patients and methods: A total of 27 patients who had undergone esophageal ESD with insufflation of CO₂ between July 2009 and March 2010 were enrolled in this study (CO₂ group). Another 105 patients who had undergone esophageal ESD with air insufflation between March 2004 and May 2009 were included as historical controls (air group). Multi-detector row computed tomography (MDCT) was carried out immediately after ESD. A conventional chest radiograph was taken the next day. Mediastinal emphysema findings on MDCT and radiography were compared between the groups.

Results: Mediastinal emphysema detected by chest radiography was 0 % in the CO₂ group vs. 6.6 % in the air group (n.s.). Mediastinal emphysema on MDCT was significantly less frequent in the CO₂ group compared with the air group (30 % vs. 63 %; P = 0.002). The severity of mediastinal emphysema also tended to be lower in the CO₂ group.

Conclusions: Whereas mediastinal emphysema detected by radiography is not so common, MDCT immediately after ESD revealed a certain prevalence of post-ESD mediastinal emphysema. Insufflation of CO₂ rather than air during esophageal ESD significantly reduced postprocedural mediastinal emphysema. CO₂ can be considered as insufflating gas for esophageal ESD.

• References

• 1 Evan D, James H, Ian G et al. The use of carbon dioxide for insufflations during GI endoscopy: a systematic review. Gastrointest Endosc 2009; 69: 843-849
• 2 Saito Y, Uraoka T, Matsuda T et al. A pilot study to assess the safety and efficacy of carbon dioxide insufflations during colorectal endoscopic submucosal dissection with the patient under conscious sedation. Gastrointest Endosc 2007; 65: 537-542
• 3 Church J, Delaney C. Randomized, controlled trial of carbon dioxide insufflation during colonoscopy. Dis Colon Rectum 2003; 46: 322-326
• 4 Sumanac K, Zealley I, Fox BM et al. Minimizing postcolonoscopy abdominal pain by using CO2 insufflation: a prospective, randomized, double blind, controlled trial evaluating a new commercially available CO2 delivery system. Gastrointest Endosc 2002; 56: 190-194
• 5 Bretthauer M, Thiis-Evensen E, Huppertz-Hauss G et al. NORCCAP (Norwegian colorectal cancer prevention): a randomised trial to assess the safety and efficacy of carbon dioxide versus air insufflation in colonoscopy. Gut 2002; 50: 604-607
• 6 Yamano H, Yoshikawa K, Kimura T et al. Carbon dioxide insufflation for colonoscopy: evaluation of gas volume, abdominal pain, examination time and transcutaneous partial CO2 pressure. J Gastroenterol 2010; 45: 1235-1240
• 7 Bretthauer M, Seip B, Aasen S et al. Carbon dioxide insufflation for more comfortable endoscopic retrograde cholangiopancreatography: a randomized, controlled, double-blind trial. Endoscopy 2007; 39: 58-64
• 8 Maple JT, Keswani RN, Hovis RM et al. Carbon dioxide insufflation during ERCP for reduction of postprocedure pain: a randomized, double-blind, controlled trial. Gastrointest Endosc 2009; 70: 278-283
• 9 Bretthauer M, Lynge AB, Thiis-Evensen E et al. Carbon dioxide insufflation in colonoscopy: safe and effective in sedated patients. Endoscopy 2005; 37: 706-709
• 10 Domagk D, Bretthauer M, Lenz P et al. Carbon dioxide insufflation improves intubation depth in double-balloon enteroscopy: a randomized, controlled, double-blind trial. Endoscopy 2007; 39: 1064-1067
• 11 Uraoka T, Kato J, Kuriyama M et al. CO2 insufflation for potentially difficult colonoscopies: efficacy when used by less experienced colonoscopists. World J Gastroenterol 2009; 15: 5186-5192
• 12 Suzuki T, Minami H, Komatsu T et al. Prolonged carbon dioxide insufflation under general anesthesia for endoscopic submucosal dissection. Endoscopy 2010; 42: 1021-1029
• 13 Nonaka S, Saito Y, Takisawa H et al. Safety of carbon dioxide insufflation for upper gastrointestinal tract endoscopic treatment of patients under deep sedation. Surg Endosc 2010; 24: 1638-1645
• 14 Kuroha M, Hirasawa D, Fujita N et al. Mediastinal emphysema in endoscopic submucosal dissection for esophageal cancer-evaluation with CT. Endoscopy 2007; 39 (Suppl. 1): A353
• 15 Oyama T, Tomori A, Hotta K et al. Endoscopic submucosal dissection of early esophageal cancer. Clin Gastroenterol Hepatol 2005; 3: 67-70
• 16 Toyonaga T, Nisino E, Hirooka T et al. Use of short needle knife for esophgeal endoscopic submucosal dissection. Dig Endosc 2005; 17: 246-252
• 17 Takeuchi M, Kobayashi M, Narisawa R. Management for complications from esophageal ESD. Gastroenterological Endoscopy 2006; 48 (Suppl. 2): 2005
• 18 Ozawa T, Watanabe H. Present situation of esophageal ESD at our hospital. Gastroenterological Endoscopy 2007; 49 (Suppl. 1): 854
• 19 Tamiya Y, Nakahara K, Kominato K et al. Pnuemomediastinum is a frequent but minor complication during esophageal endoscopic submucosal dissection. Endoscopy 2010; 42: 8-14
• 20 Araki H, Nishiwaki S, Onogi F et al. Postoperative pneumomediastinum detected by computed tomography after endoscopic submucosal dissection for esophageal neoplasms in consecutive cases. Gastrointest Endosc 2009; 69: AB350
• 21 Maeda Y, Hirasawa D, Fujita N et al. Mediastinal emphysema after esophageal endoscopic submucosal dissection: its prevalence and clinical significance. Dig Endosc 2011; 23: 221-226
• 22 Hirasawa D, Fujita N, Ishida K et al. Handmade outer flashing channel for safe endoscopic submucosal dissection. Dig Endosc 2005; 17: 183-185
• 23 Faigel DO, Baron TH, Goldstein JL et al. Guidelines for the use of deep sedation and anesthesia for GI endoscopy. Gastrointest Endosc 2002; 56: 613-617
• 24 Training Committee. American Society for Gastrointestinal Endoscopy. Training guideline for use of propofol in gastrointestinal endoscopy.. Gastrointest Endosc 2004; 60: 167-172
• 25 The Japan Esophageal Society. Japanese Classification of Esophageal Cancer [article in Japanese with English abstract in part]. 10th. edition, revised version. Tokyo: Kanehara Shuppan; 2008
• 26 Bretthauer M, Hoff GS, Thiis-Evensen E et al. Air and carbon dioxide volumes insufflated during colonoscopy. Gastrointest Endosc 2003; 58: 203-206
• 27 Maeda Y, Hirasawa D, Naotaka F. Carbon dioxide insufflation reduces mediastinal emphysema after esophageal endoscopic submucosal dissection (ESD). Gastrointest Endosc 2011; 73 (Suppl.1): AB407