Carbon dioxide versus air insufflation enteroscopy: a systematic review and meta-analysis based on randomized controlled trials

Water exchange-assisted versus carbon dioxide-insufflated single-balloon enteroscopy: a randomized controlled trial

BACKGROUND

Single-balloon enteroscopy (SBE) is a valuable but difficult modality for the diagnosis and treatment of small-bowel disease. The water exchange method has the advantage of facilitating intubation during colonoscopy. Here, we evaluated the effects of water exchange on procedure-related variables related to SBE.

METHODS

This randomized controlled trial was conducted in a tertiary-care referral center in China. Patients due for attempted total enteroscopy were randomly allocated to undergo water exchange-assisted (water exchange group) or carbon dioxide-insufflated enteroscopy (CO₂ group). All patients were planned to undergo both anterograde and retrograde procedures. The primary outcome was the total enteroscopy rate. Secondary outcomes included the maximal insertion depth, positive findings, procedural time, and adverse events.

RESULTS

In total, 110 patients were enrolled, with 55 in each group. Baseline characteristics between the two groups were comparable. Total enteroscopy was achieved in 58.2 % (32/55) of the water exchange group and 36.4 % (20/55) of the control group (P = 0.02). The mean (standard deviation) estimated intubation depth was 521.2 (101.4) cm in the water exchange group and 481.6 (95.2) cm in the CO₂ group (P = 0.04). The insertion time was prolonged in the water exchange group compared with the CO₂ group (178.9 [45.1] minutes vs. 154.2 [27.6] minutes; P < 0.001). Endoscopic findings and adverse events were comparable between the two groups.

CONCLUSIONS

The water exchange method improved the total enteroscopy rate and increased the intubation depth during SBE. The use of water exchange did not increase the complications of enteroscopy.

Insufflation of Carbon Dioxide versus Air During Colonoscopy Among Pediatric Patients: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background/Aims:

Carbon dioxide is increasingly used in insufflation during colonoscopy in adult patients; however, air insufflation remains the primary practice among pediatric gastroenterologists. This systematic review and meta-analysis aims to evaluate insufflation using CO₂ versus air in colonoscopies in pediatric patients.

Methods:

Individualized search strategies were performed using MEDLINE, Cochrane Library, EMBASE, and LILACS databases following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane working methodology. Randomized control trials (RCTs) were selected for the present meta-analysis. Pooled proportions were calculated for outcomes including procedure time and abdominal pain immediately and 24 hours post-procedure.

Results:

The initial search yielded 644 records, of which five RCTs with a total of 358 patients (CO₂: n=178 versus air: n=180) were included in the final analysis. The procedure time was not different between the CO₂ and air insufflation groups (mean difference, 10.84; 95% confidence interval [CI], -2.55 to 24.22; p=0.11). Abdominal pain immediately post-procedure was significantly lower in the CO₂ group (risk difference [RD], -0.15; 95% CI; -0.26 to -0.03; p=0.01) while abdominal pain at 24 hours post-procedure was similar (RD, -0.05; 95% CI; -0.11 to 0.01; p=0.11).

Conclusions:

Based on this systematic review and meta-analysis of RCT data, CO₂ insufflation reduced abdominal pain immediately following the procedure, while pain was similar at 24 hours post-procedure. These results suggest that CO₂ is a preferred insufflation technique when performing colonoscopy in pediatric patients.

Carbon Dioxide vs. Air Insufflation for Pediatric Gastrointestinal Endoscopy: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Background: Carbon dioxide (CO₂) insufflation during gastrointestinal (GI) endoscopic procedures has gained popularity in adults. However, its utility in pediatric patients is not known. The current review aimed to compare the efficacy of CO₂ vs. air insufflation for GI endoscopic procedures in pediatric patients. Methods: The electronic databases of PubMed, Embase, Scopus, and CENTRAL were searched from the inception of databases to 15th August 2020. Results: All randomized controlled trials (RCTs) comparing CO₂ vs. air insufflation for GI endoscopic procedures in pediatric patients were eligible for inclusion. Five RCTs were identified. Pooled analysis of data from 226 patients in the CO₂ group and 224 patients in the air group revealed that patients receiving CO₂ insufflation were at a lower odds of experiencing postoperative pain as compared to those undergoing the procedure with air (OR: 0.40; 95% CI: 0.19, 0.87; I ² = 62%; p = 0.02). Descriptive analysis indicated no difference in the two groups for abdominal distention after the procedure. Two trials reported elevated CO₂ in the study group but without any pulmonary complications. Bloating was reported by two studies and both reported significantly less bloating in the CO₂ group. Conclusion: Our study indicates that the incidence of pain may be reduced with the use of CO₂ insufflation in pediatric GI endoscopies without a significant risk of adverse events. However, current evidence is from a limited number of trials and not strong to recommend a routine of CO₂ in pediatric gastroenterology practice. Further high-quality RCTs are required to supplement current evidence.

Quality indicators in enteroscopy. Enteroscopy procedure

Within the project "Quality Indicators in Gastrointestinal Endoscopy," under the leadership of the Sociedad Española de Patología Digestiva (SEPD), our goal is to propose the procedures and the structure, process, and outcome indicators required for the application and assessment of quality in enteroscopy. To this end a search was performed for quality indicators in enteroscopy. Quality of evidence was measured by using the GRADE (Grading of Recommendations Assessment, Development and Evaluation) system, and classified as high, moderate, low, and very low. A total of 10 process indicators (one preprocedure, eight procedure, one postprocedure) were identified for enteroscopy, with appropriate indication and choice of most efficient route being most significant.

Efficacy and safety of water-exchange enteroscopy compared to carbon dioxide insufflation during enteroscopy

INTRODUCTION

carbon dioxide (CO2) insufflation during enteroscopy reduces procedure time and subsequent symptoms and increases the insertion depth compared with room air. In colonoscopy, the water-exchange (WE) technique is associated with less pain compared with CO2 insufflation. The WE technique is not well studied in enteroscopy. The aim of this study was to compare the efficacy and safety of enteroscopy with WE and CO2.

METHODS

a prospective, comparative and observational study was performed of double balloon enteroscopies (DBE) that were randomized in two groups. The first group used WE while the second group used CO2 insufflation. The data collected was evaluated via univariate analysis and multiple logistic regression (variables with p ≤ 0.10 according to the univariate analysis).

RESULTS

forty-six DBE were included; 23 in each arm. The median age of cases was 63.5 years and 37% were female. There were no statistical differences between the groups with regard to the access route, findings, therapy and complications. Four patients (20%) in the CO2 group had adverse events (abdominal distension and pain) and one in the WE group (nausea), which was not statistically significant. The median insertion depth was greater in the CO2 group; 260 cm vs 160 cm (p = 0.048). Multiple logistic regression showed a statistically significant difference in the insertion depth using CO2 insufflation (OR 1.009, 1.001-1.017; p = 0.034).

CONCLUSIONS

DBE with a CO2 insufflation technique and WE are safe with a greater insertion depth with CO2.

Performance measures for small-bowel endoscopy: A European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative

The European Society of Gastrointestinal Endoscopy (ESGE) together with the United European Gastroenterology (UEG) recently developed a short list of performance measures for small-bowel endoscopy (i.e. small-bowel capsule endoscopy and device-assisted enteroscopy) with the final goal of providing endoscopy services across Europe with a tool for quality improvement. Six key performance measures both for small-bowel capsule endoscopy and for device-assisted enteroscopy were selected for inclusion, with the intention being that practice at both a service and endoscopist level should be evaluated against them. Other performance measures were considered to be less relevant, based on an assessment of their overall importance, scientific acceptability, and feasibility. Unlike lower and upper gastrointestinal endoscopy, for which performance measures had already been identified, this is the first time small-bowel endoscopy quality measures have been proposed.

CO 2 vs. air insufflation in endoscopic ultrasonography: a prospective study

Background and study aims  Carbon dioxide (CO ₂ ) is being increasingly used for insufflation during endoscopy for safety and better tolerance. The role of CO ₂ during endoscopic ultrasonography (EUS) has not been studied yet. Our main aim was to compare the effects of CO ₂ vs. air insufflation on abdominal discomfort in patients undergoing EUS. Our secondary outcomes were to ascertain the effects of CO ₂ insufflation on image quality/visual artifacts and on the amount of sedation. Patients and methods  This was a prospective, controlled, single-blind, observational study. Abdominal discomfort was assessed before diagnostic EUS, and 1 and 3 hours post-procedure and recorded as a visual analogue scale. Image quality was also recorded as a 4-point scale from optimal to poor at four different scanning sites (esophagus, stomach, duodenal bulb and second portion). Results  A total of 198 patients were enrolled. We observed that CO ₂ resulted in less abdominal discomfort than air insufflation that was statistically significant at 3 hours ( P  = 0.048) but not at 1 hour after EUS ( P  = 0.112), probably due to the ongoing effects of sedation at the latter stage. On the other hand, no differences were found in the dose of sedation administered in the two groups. Image quality was significantly better in the CO ₂ group compared to the air group at all four different scanning sites ( P  < 0.01). Similarly, CO ₂ correlated with less visual artifacts and need of suction ( P  < 0.01). Conclusions  Similarly to previous findings with other endoscopic procedures, EUS was associated with improved scores for abdominal discomfort with CO ₂ rather than air insufflation. Moreover, overall EUS image quality was improved using CO ₂ insufflation. Future studies are warranted to ascertain whether CO ₂ insufflation should be regarded as the standard of care for diagnostic EUS.