Safety and efficacy of carbon dioxide insufflation during gastric endoscopic submucosal dissection

AIM: To compare the safety and efficacy of carbon dioxide(CO2) and air insufflation during gastric endoscopic submucosal dissection(ESD).METHODS: This study involved 116 patients who underwent gastric ESD between January and December 2009.After eliminating 29 patients who fit the exclusion criteria,87 patients,without known pulmonary dysfunction,were randomized into the CO2 insufflation(n = 36) or air insufflation(n = 51) groups.Standard ESD was performed with a CO2 regulation unit(constant rate of 1.4 L/min) used for patients undergoing CO2 insufflation.Patients received diazepam for conscious sedation and pentazocine for analgesia.Transcutaneous CO2 tension(Ptc CO2) was recorded 15 min before,during,and after ESD with insufflation.Ptc CO2,the correlation between Ptc CO2 and procedure time,and ESD-related complications were compared between the two groups.Arterial blood gases were analyzed after ESD in the first 30 patients(12 with CO2 and 18 with air insufflation) to assess the correlation between arterial blood CO2 partial pressure(Pa CO2) and Ptc CO2.RESULTS: There were no differences in respiratoryfunctions,median sedative doses,or median procedure times between the groups.Similarly,there was no significant difference in post-ESD blood gas parameters,including Pa CO2,between the CO2 and air groups(44.6 mm Hg vs 45 mm Hg).Both groups demonstrated median p H values of 7.36,and none of the patients exhibited acidemia.No significant differences were observed between the CO2 and air groups with respect to baseline Ptc CO2(39 mm Hg vs 40 mm Hg),peak Ptc CO2 during ESD(52 mm Hg vs 51 mm Hg),or median Ptc CO2 after ESD(50 mm Hg vs 50 mm Hg).There was a strong correlation between Pa CO2 and Ptc CO2(r = 0.66; P < 0.001).The incidence of Mallory-Weiss tears was significantly lower with CO2 insufflation than with air insufflation(0% vs 15.6%,P = 0.013).CO2 insufflation did not cause any adverse events,such as CO2 narcosis or gas embolisms.CONCLUSION: CO2 insufflation during gastric ESD results in similar blood gas levels as air insufflation,and also reduces the incidence of Mallory-Weiss tears.

Diagnosis of the jejunoileal lymphoma by double-balloon endoscopy

AIM:To investigate the feasibility of double-balloon endoscopy(DBE) to detect jejunoileal lymphoma,compared with fluorodeoxyglucose positron emission tomography(FDG-PET).METHODS:Between March 2004 and January 2011,we histologically confirmed involvement of malignant lymphoma of the jejunoileum in 31 patients by DBE and biopsy.In 20 patients of them,we performed with FDGPET.We retrospectively reviewed the records of these 20 patients.Their median age was 64 years(range 50-81).In the 20 patients,the pathological diagnosis of underlying non-Hodgkin's lymphoma(NHL) comprised follicular lymphoma(FL,n = 12),diffuse large B cell lymphoma(DLBCL,n = 4),mantle cell lymphoma(MCL,n = 2),enteropathy associated T cell lymphoma(ETL,n = 1) and anaplastic large cell lymphoma(ALCL,n = 1).RESULTS:Ten cases showed accumulation by FDGPET(50%).FDG-PET was positive in 3 of 12 FL cases(25%) while in 7 of 8 non-FL cases(88%,P < 0.05).Intestinal FL showed a significantly lower rate of positive FDG-PET,in comparison with other types of lymphoma.Cases with endoscopically elevated lesions(n = 10) showed positive FDG-PET in 2(20%),but those with other type NHL did in 8 of 10(80%,P < 0.05).When the cases having elevated type was compared with those not having elevated type lesion,the number of cases that showed accumulation of FDG was significantly smaller in the former than in the latter.CONCLUSION:In a significant proportion,small intestinal involvement cannot be pointed out by FDG-PET.Especially,FL is difficult to evaluate by FDG-PET but essentially requires DBE.