Carbon dioxide for gut distension during digestive endoscopy: Technique and practice survey

Painless colonoscopy: fact or fiction?

Although colonoscopy is a routinely performed procedure, it is not devoid of challenges, such as the potential for perforation and considerable patient discomfort, leading to patients postponing the procedure with several healthcare risks. This review delves into preprocedural and procedural solutions, and emerging technologies aimed at addressing the drawbacks of colonoscopies. Insufflation and sedation techniques, together with various other methods, have been explored to increase patient satisfaction, and thereby, the quality of endoscopy. Recent advances in this field include the prevention of loop formation, encompassing the use of variable-stiffness endoscopes, computer-guided scopes, magnetic endoscopic imaging, robotics, and capsule endoscopy. An autonomous endoscope that relies on self-propulsion to completely avoid looping is a potentially groundbreaking technology for the next generation of endoscopes. Nevertheless, critical techniques need to be refined to ensure the development of effective and efficient endoscopes.

Carbon dioxide insufflation reduces the relapse of ulcerative colitis after colonoscopy: A randomized controlled trial

BACKGROUND AND AIM

Colonoscopy is necessary for diagnosing and surveilling patients with ulcerative colitis, though it may cause disease flares. Colonoscopy with carbon dioxide (CO2) insufflation decreases abdominal discomfort; however, its effect on exacerbation incidence in ulcerative colitis remains unclear. Therefore, this study aimed to evaluate the colonoscopy effects using CO2 insufflation in patients with ulcerative colitis.

METHODS

Overall, 96 remissive patients with ulcerative colitis (partial Mayo score ≤ 2) who underwent total colonoscopy between March 2015 and December 2019 at Osaka University Hospital were enrolled and blindly randomized to the CO2 (n = 45) and air (n = 51) insufflation group (UMIN-CTR, number: UMIN000018801). The post-procedural abdominal discomfort and the clinical relapse (partial Mayo score ≥ 3) rate within 8 weeks were evaluated.

RESULTS

Baseline backgrounds did not differ between the groups. The mean abdominal fullness and pain scores were significantly lower in the CO2 group than in the Air group immediately (p = 0.0003, p = 0.0003) and 30 min (p < 0.0001, p < 0.0001) after colonoscopy. While the overall clinical relapse rate remained unchanged between the groups, the clinical relapse rate at 8 weeks after colonoscopy was significantly lower in the CO2 group than in the Air group in patients not in complete remission (Mayo endoscopic subscore ≥ 1, p = 0.049; or partial Mayo score ≥ 1, p = 0.022).

CONCLUSIONS

CO2 insufflation can reduce abdominal discomfort in remissive patients with ulcerative colitis and decrease clinical relapse at 8 weeks after colonoscopy for those not in complete remission.

Relief Effect of Carbon Dioxide Insufflation in Transnasal Endoscopy for Health Checks-A Prospective, Double-Blind, Case-Control Trial

CO2 insufflation has proven effective in reducing patients’ pain after colonoscopies but has not been examined in esophagogastroduodenoscopies. Therefore, we examined the effect of CO2 insufflation in examinees who underwent transnasal endoscopies without sedation. This study is a single-center, prospective, double-blind, case-control trial conducted between March 2017 and August 2018. Subjects were assigned weekly to receive insufflation with either CO2 or air. The primary outcome was improvement of abdominal pain and distension at 2 h and 1-day postprocedure. In total, 336 and 338 examinees were assigned to the CO2 and air groups, respectively. Visual analog scale (VAS) scores for abdominal distension (15.4 vs. 25.5; p < 0.001) and distress from flatus (16.0 vs. 28.8; p < 0.001) at 2 h postprocedure were significantly reduced in the CO2 group. VAS scores for pain during the procedure (33.5 vs. 37.1; p = 0.059) and abdominal pain after the procedure (3.9 vs. 5.7; p = 0.052) also tended to be lower at 2 h postprocedure, but all parameters showed no significant difference at 1-day postprocedure. All procedures were safely completed through the planned program, and no apparent adverse events requiring treatment or follow-up occurred. In conclusion, CO2 insufflation may reduce postprocedural abdominal discomfort from transnasal esophagogastroduodenoscopies. (UMIN000028543).

Screening colonoscopy: The present and the future

In the United States, colorectal cancer (CRC) is the second leading cause of mortality in men and women. We are now seeing an increasing number of patients with advanced-stage diagnosis and mortality from colorectal cancer before 50 years of age, which requires earlier screening. With the increasing need for CRC screening through colonoscopy, and thus endoscopists, easier and simpler techniques are needed to train proficient endoscopists. The most widely used approach by endoscopists is air insufflation colonoscopy, where air distends the colon to allow visualization of the colonic mucosa. This technique is un-comfortable for patients and requires an anesthetist to administer sedation. In addition, patients commonly complain about discomfort post-op as air escapes into the small bowel and cannot be adequately removed. Current research into the use of water insufflation colonoscopies has proved promising in reducing the need for sedation, decreasing discomfort, and increasing the visibility of the colonic mucosa. Future direction into water insufflation colonoscopies which have shown to be simpler and easier to teach may increase the number of proficient endoscopists in training to serve our aging population.

A meta-analysis of carbon dioxide versus room air insufflation on patient comfort and key performance indicators at colonoscopy

BACKGROUND

Carbon dioxide (CO₂) has been used as an alternative to air insufflation at endoscopy with good results; however, uptake of the technique has been poor, possibly due to perceived lack of outcome equivalency. This meta-analysis evaluates the effectiveness of CO₂ versus air in reducing pain post-colonoscopy and furthermore examines other key performance indicators (KPIs) such as sedative use, procedure times and polyp detection rates.

METHODS

This meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Pubmed, Pubmed Central, Embase and Cochrane Library were searched for randomized studies from 2004 to 2019, reporting outcomes for patients undergoing colonoscopy with air or CO₂ insufflation, who reported pain on a numerical or visual analogue scale (VAS). Results were reported as mean differences (MD) or pooled odds ratios (OR) with 95% confidence intervals (95% CI).

RESULTS

Of 3586 citations, 23 studies comprising 3217 patients were analysed. Patients undergoing colonoscopy with air insufflation had 30% higher intraprocedural pain scores than those receiving CO₂ (VAS 3.4 versus 2.6, MD -0.7, 95% CI - 1.4-0.0, p = 0.05), with a sustained beneficial effect amongst those in the CO₂ group at 30 min, 1-2-h and 6-h post procedure (MD - 0.8, - 0.6 and - 0.2, respectively, p < 0.001 for all), as well as less distension, bloating and flatulence (p < 0.01 for all). There were no differences between the two groups in KPIs such as the sedation required, procedure time, caecal intubation or polyp detection rates.

CONCLUSIONS

CO₂ insufflation improves patient comfort without compromising colonoscopic performance.

Efficacy and safety of carbon dioxide insufflation versus air insufflation during endoscopic retrograde cholangiopancreatography in randomized controlled trials: a systematic review and meta-analysis

Background and study aims  Ambient air is the most commonly used gas for insufflation in endoscopic procedures worldwide. However, prolonged absorption of air during endoscopic examinations may cause pain and abdominal distension. Carbon dioxide insufflation (CO ₂ i) has been increasingly used as an alternative to ambient air insufflation (AAi) in many endoscopic procedures due to its fast diffusion properties and less abdominal distention and pain. For endoscopic retrograde cholangiopancreatography (ERCP), use of CO ₂ for insufflation is adequate because this procedure is complex and prolonged. Some randomized controlled trials (RCTs) have evaluated the efficacy and safety of CO ₂ as an insufflation method during ERCP but presented conflicting results. This systematic review and meta-analysis with only RCTs evaluated the efficacy and safety of CO ₂ i versus AAi during ERCP. Methods  A literature search was performed using online databases with no restriction regarding idiom or year of publication. Data were extracted by two authors according to a predefined data extraction form. Outcomes evaluated were abdominal pain and distension, complications, procedure duration, and CO ₂ levels. Results  Eight studies (919 patients) were included. Significant results favoring CO ₂ i were less abdominal distension after 1 h (MD: -1.41 [-1.81; -1.0], 95 % CI, I² = 15 %, P  < 0.00001) and less abdominal pain after 1 h (MD: -23.80 [-27.50; -20.10], 95 %CI, I² = 9 %, P  < 0.00001) and after 6 h (MD: -7.00 [-8.66; -5.33]; 95 % CI, I² = 0 %, P  < 0.00001). Conclusion  Use of CO ₂ i instead of AAi during ERCP is safe and associated with less abdominal distension and pain after the procedure.

COLONOSCOPY: RANDOMIZED COMPARATIVE STUDY OF INSUFFLATION WITH CARBON DIOXIDE VERSUS AIR

Background:

In Brazil, an increasing number of people are submitted to colonoscopy, either for screening or for therapeutic purposes.

Aim:

To evaluate whether there are advantages of using carbon dioxide (CO₂) over air for insufflation.

Methods:

Two hundred and ten of 219 patients were considered eligible for this study and were randomized into two groups according to the gas insufflation used: Air Group (n=104) and CO₂ Group (n=97). The study employed a double-blind design.

Results:

The Air and CO₂ Groups were similar in respect to bowel preparation evaluated using the Boston scale, age, gender, previous surgery, maneuvers necessary for the advancement of the device, and presence of polyps, tumors or signs of diverticulitis. However, “waking up with pain” and “pain at discharge” were more prevalent in the Air Group, albeit not statistically significant, with post-exam bloating seen only in the Air Group. The responses to a questionnaire, applied to analyze the late post-exam period, showed more comfort with the use of CO₂.

Conclusions:

The use of CO₂ is better than air as it avoids post-examination bloating, thereby providing greater comfort to patients.

Single-Balloon Enteroscopy

Single-balloon enteroscopy is among 3 device-assisted enteroscopy systems on the market. Compared with double-balloon enteroscopy, no significant difference in diagnostic yield was found. Additionally, no significant difference was found in oral and anal insertion depth, adverse events, or procedure times. Some studies observed lower complete enteroscopy rates, which have evidently no diagnostic impact. With a learning curve of around 30 procedures, the single-balloon endoscope is a safe endoscopic tool, which seems equally suitable for diagnostic and therapeutic interventions. Carbon dioxide should be used for single-balloon endoscopy procedures, especially in patients with a history of surgical abdominal interventions.

Preprocedural Assessment for Sedation in Gastrointestinal Endoscopy

The role of the anesthesia service in sedation for gastrointestinal endoscopy (GIE) has been steadily increasing. The goals of preprocedural assessment are determined by the specific details of the procedure, the issues related to the illness that requires the endoscopy, comorbidities, the goals for sedation, and the risk of complications from the sedation and the endoscopic procedure. Rather than consider these issues as separate entities, they should be considered as part of a continuum of preparation for GIE. This is told from the perspective of an anesthesiologist who regularly participates in the full range of sedation for GIE.

Carbon dioxide insufflation vs conventional air insufflation for colonoscopy: a systematic review and meta-analysis of published randomized controlled trials

AIM

Conventional air insufflation (AI) may cause prolonged abdominal bloating, excessive abdominal pain and discomfort during colonoscopy. Carbon dioxide may be an acceptable alternative to avoid these complications. The object of this study was to evaluate systematically the effectiveness of carbon dioxide insufflation (CI) for colonoscopy compared with AI.

METHOD

Randomized controlled trials (RCTs) comparing the effectiveness of CI with that of AI during colonoscopy were retrieved from medical electronic databases and combined analysis was performed using the RevMan statistical package. The combined outcome of dichotomous and continuous variables was expressed as an odds ratio (OR) and standardized mean difference (SMD).

RESULTS

Twenty-one RCTs comprising 3607 patients were included in the study. There was statistically significant heterogeneity among included studies. CI showed a significant trend towards reduced procedural pain [SMD -1.34; 95% confidence interval (95% CI) -2.23 to -0.45; z = 2.96; P < 0.003] and also postprocedural pain at 1 h (SMD -1.11; 95% CI -1.83 to -0.38; z = 2.97; P < 0.003), 6 and 24 h (OR 0.44; 95% CI 0.23-0.85; z = 2.44; P < 0.01). CI was associated with faster caecal intubation (SMD -0.20; 95% CI -0.37 to -0.02; z = 2.23; P < 0.03) but the caecal intubation rate was similar (P = 0.59) in both colonic insufflation techniques .

CONCLUSION

CI seems to have clinical advantages over AI for colonoscopy with regard to pain during and after the procedure.

Precise tumor size measurement under constant pressure by novel real-time micro-electro-mechanical-system hood for proper treatment (with videos)

Background

Tumor size determination is subject to the measurement method used by endoscopists and is especially dependent on the air quantity. As the intraluminal pressure must be measured objectively to obtain an accurate tumor size measurement, insufflation can affect the results. Thus, we examined the utility of a micro-electro-mechanical-system (MEMS) pressure sensor hood.

Methods

Twenty consecutive air insufflation/deflation tests were performed in vivo using a dog’s stomach. Correlations between the actual pressure measured and the signal strength of the MEMS hood were measured. We marked 2 points 20 mm on the antrum and another 3 points, with insufflation corresponding to the maximum stable distance of two markings. We performed five insufflation/deflation tests to obtain the relationship between pressure and distances to accurately measure the distance under constant pressure.

Results

In the air insufflation/deflation test performed 20 consecutive times, the MEMS hood signal strength (V) and the pressure measurement sensor values (mmHg) showed good correlation. There was good correlation between intraluminal pressures of 2.5–40 mmHg and the two marking distances on the antrum (correlation coefficient 0.952) (P < 0.05). However, once the intraluminal pressure reached a certain level (40 mmHg), expansion of the two marking distances ceased. The same measurements were conducted on the greater curvatures of the lower body and middle body and on the lesser curvature of the lower body.

Conclusions

Correct tumor size measurements using a MEMS hood enable a more accurate diagnosis, which can be used to develop suitable treatment strategies.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-014-3642-3) contains supplementary material, which is available to authorized users.

Carbon dioxide insufflation for endoscopic retrograde cholangiopancreatography: A meta-analysis and systematic review

AIM

To assess the safety and efficacy of carbon dioxide (CO(2)) insufflation during endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

The Cochrane Library, Medical Literature Analysis and Retrieval System Online, Excerpta Medica Database, Science Citation Index Expanded, Chinese Biomedical Literature Database, and references in relevant publications were searched up to December 2011 to identify randomized controlled trials (RCTs) comparing CO(2) insufflation with air insufflation during ERCP. The trials were included in the review irrespective of sample size, publication status, or language. Study selection and data extraction were performed by two independent authors. The meta-analysis was performed using Review Manager 5.1.6. A random-effects model was used to analyze various outcomes. Sensitivity and subgroup analyses were performed if necessary.

RESULTS

Seven double-blind RCTs involving a total of 818 patients were identified that compared CO(2) insufflation (n = 404) with air insufflation (n = 401) during ERCP. There were a total of 13 post-randomization dropouts in four RCTs. Six RCTs had a high risk of bias and one had a low risk of bias. None of the RCTs reported any severe gas-related adverse events in either group. A meta-analysis of 5 RCTs (n = 459) indicated that patients in the CO(2) insufflation group had less post-ERCP abdominal pain and distension for at least 1 h compared with patients in the air insufflation group. There were no significant differences in mild cardiopulmonary complications [risk ratio (RR) = 0.43, 95% CI: 0.07-2.66, P = 0.36], cardiopulmonary (e.g., blood CO(2) level) changes [standardized mean difference (SMD) = -0.97, 95% CI: -2.58-0.63, P = 0.23], cost analysis (mean difference = 3.14, 95% CI: -14.57-20.85, P = 0.73), and total procedure time (SMD = -0.05, 95% CI: -0.26-0.17, P = 0.67) between the two groups.

CONCLUSION

CO(2) insufflation during ERCP appears to be safe and reduces post-ERCP abdominal pain and discomfort.

Carbon dioxide insufflation in colonoscopy is safe: a prospective trial of 347 patients

Available evidence suggests that the use of CO₂ insufflation in endoscopy is more comfortable for the patient. The safety of CO₂ use in colonoscopy remains contentious, particularly in sedated patients. The objective of the present prospective trial was to assess the safety of CO₂ colonoscopies. Methods. 109 patients from our previous randomized CO₂ colonoscopy study and an additional 238 subsequent consecutive unselected patients who had a routine colonoscopy performed in a private practice were enrolled from April 2008 through September 2008. All but 2 patients were sedated. All patients were routinely monitored with transcutaneous CO₂ measurement. Volumes of CO₂ administered were correlated with capnographic measurements from transcutaneous monitoring. Results. Of the 347 patients examined, 57% were women; mean (SD) age of participants was of 60.2 years (12.8). Mean propofol dosage was 136 mg (64 mg). Mean CO₂ values were 34.7 mm Hg (5.3) at baseline, 38.9 mm Hg (5.5) upon reaching the ileum, and 36.9 mm Hg (5.0) at examination's end. Mean maximum increase of CO₂ was 4.5 mm Hg (3.6). No correlation was observed between volume of CO₂ administered and increase in level of CO₂ (correlation coefficient: 0.01; P value: 0.84). No complications were observed. Conclusions. The present prospective study, which was based on one of the largest sedated patient sample reported to date in this setting, provides compelling evidence that CO₂ insufflation in colonoscopy is safe and unassociated with relevant increases in transcutaneously measured levels of CO₂.

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

BACKGROUND

Carbon dioxide (CO(2)) insufflation has been proposed as an alternative to air insufflation to distend the lumen in gastrointestinal (GI) endoscopy.

AIM

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.

METHODS

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.

RESULTS

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.

CONCLUSIONS

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.

Acceptability and side-effects of colonoscopy and sigmoidoscopy in a screening setting

OBJECTIVE

Quantitative information on adverse reactions associated with colorectal cancer (CRC) screening tests is useful to estimate the balance between benefit and risk in different strategies.

SETTING

Six Italian screening centres.

METHODS

Thirty-day active follow-up (interview about side-effects and acceptability of the screening procedure and review of hospital admissions) among average-risk people undergoing flexible sigmoidoscopy (FS), total colonoscopy (TC), fecal immunochemical test (FIT) in a multicentre randomized trial of CRC screening. Multivariable logistic models were used to assess determinants of completion rate and self-reported pain.

RESULTS

The attendance rate following the first invitation and mail reminder was 28.2% (1696/6018) in the FS and 23.0% (1382/6021) in the TC arm. Response rate to the 30-day follow-up questionnaire was 88.6% (1502/1696) among people undergoing FS, and 86.7% (1198/1382) among those undergoing TC. The proportion of people complaining of serious reactions following bowel preparation (odds ratio [OR], 5.17; 95% confidence interval [CI] 3.70-7.24) or reporting severe pain immediately after the exam (OR, 1.86; 95% CI 1.47-2.34) was higher for TC than for FS. The most common post-procedural complaints were abdominal distension and pain. People mentioning pain or bowel distension following preparation were more likely to report severe pain both after FS (OR, 2.13; 95% CI 1.52-2.97) and TC (OR: 2.03; 95% CI 1.41-2.90). The 30-day hospitalization rate was similar after FS, TC and FIT.

CONCLUSIONS

Screenees reported higher pain levels after TC than FS. The proportion of people complaining of severe side effects after discharge was similar. Bowel preparation was poorly tolerated by people undergoing TC. Subjects' reactions to the bowel preparation was predictive of post-procedural discomfort. A commitment of at least 48 hours was required of people undergoing TC, compared with 3-4 for FS.

Technical issues and new devices of ESD of early gastric cancer

Endoscopic submucosal dissection (ESD) is a highly refined technique compared to conventional endoscopic mucosal resection. It enables complete resection of early gastric cancer (EGC) which has no possibility of lymph node metastasis. Indication for ESD of EGC generally entails early gastric cancer confined to the mucosa with well differentiated histology, though there are clinically suitable expanded criteria. As ESD requires specific skill and expertise, endoscopists need to be familiarized with basic methods and the use of special devices. The essence of the technique is to dissect the submucosal layer with direct vision and maintain the cutting plane above the underlying proper muscle layer. Although there are some differences in the detailed technical aspect, the cardinal method of ESD is now well established and standardized. Furthermore, research and development of new ESD devices that render more efficient, safe ESD are still in progress to improve the overall result of ESD on early gastric cancer.

Carbon dioxide insufflation in routine colonoscopy is safe and more comfortable: results of a randomized controlled double-blinded trial

Many patients experience pain and discomfort after colonoscopy. Carbon dioxide (CO₂) can reduce periprocedural pain although air insufflation remained the standard procedure. The objective of this double-blinded, randomized controlled trial was to evaluate whether CO₂ insufflation does decrease pain and bloating during and after colonoscopy compared to room air. Methods. 219 consecutive patients undergoing colonoscopy were randomized to either CO₂ or air insufflation. Propofol was used in all patients for sedation. Transcutaneous CO₂ was continuously measured with a capnograph as a safety parameter. Pain, bloating, and overall satisfaction were assessed at regular intervals before and after the procedure. Results(data are mean ±SD). 110 patients were randomized to CO₂ and 109 to room air. The baseline characteristics were similar in both groups. The mean propofol dose was not different between the treatments, as were the time to reach the ileum and the withdrawal time. pCO₂ at the end of the procedure was 35.2 ± 4.3 mmHg (CO₂ group) versus 35.6 ± 6.0 mmHg in the room air group (P > .05). No relevant complication occurred in either group. There was significantly less bloating for the CO₂ group during the postprocedural recovery period (P < .001) and over the 24-hour period (P < .001). Also, patients with CO₂ insufflation experienced significantly less pain (P = .014). Finally, a higher overall satisfaction (P = .04 ) was found in the CO₂ group. Conclusions. This trial provides compelling evidence that CO₂ insufflation significantly reduces bloating and pain after routine colonoscopy in propofol-sedated patients. The procedure is safe with no significant differences in CO₂ between the two groups.

Carbon dioxide insufflation for colonoscopy: evaluation of gas volume, abdominal pain, examination time and transcutaneous partial CO2 pressure

BACKGROUND

Insufflation with carbon dioxide (CO(2)) in colonoscopy has not been widely adopted and, consequently, limited data are available on insufflated gas volume and blood pCO(2). The aim of this study was to compare CO(2) and air as an insufflation agent in patients undergoing colonoscopy without sedation in terms of insufflated gas volume, pCO(2), pain and examination time.

METHODS

This was a randomized, double-blind, control trial. Consecutive patients presenting for colonoscopy, excluding those with lung or malignant disease, were randomized into two groups: insufflation with air or with CO(2), respectively. Insufflated gas volume, pain, pCO(2) and examination time were assessed.

RESULTS

The study cohort comprised 120 patients (66 randomized to CO(2) group). No significant difference in insufflated gas volumes was found between the CO(2) and air groups. The mean pCO(2) measured before, during (the peak value) and 30 min after colonoscopy were 40, 43 and 40 mmHg, respectively, in both groups. The pain scores in the air group were significantly greater than those in the CO(2) group until 3 h after the examination. There was a significant faster cecal intubation time and a trend toward shorter examination time in the CO(2) group.

CONCLUSIONS

The CO(2) gas volume used in our study (14.0 L) was much greater than that reported by others (8.3 L), but the pCO(2) values were still within the normal reference range, indicating the safety of CO(2) insufflation over a greater range of CO(2) gas volume. Among our patients, CO(2) insufflation was associated with relatively less pain and a shorter examination time. Based on our results, we recommend that CO(2) become the standard gas for insufflation in patients undergoing colonoscopy without sedation.

Prophylaxis of post-ERCP pancreatitis: a practice survey

BACKGROUND

Prophylactic pancreatic stenting is widely used by expert biliary endoscopists to prevent post-ERCP pancreatitis (PEP); nonsteroidal anti-inflammatory drugs (NSAIDs) are thought to prevent PEP.

OBJECTIVE

To assess the use of pancreatic stenting and NSAIDs for PEP prophylaxis among endoscopists and its determinants.

DESIGN

A survey was distributed to 467 endoscopists attending a course on therapeutic digestive endoscopy.

INTERVENTION

Completed surveys were collected from 141 endoscopists performing ERCP in 29 countries (answer rate 30.2%); practices were most often located in community hospitals with an annual hospital volume of < or = 500 ERCPs (in Belgium, Spain, Italy, and France in about half of cases). For all conditions listed, including needle-knife precut, previous PEP, suspected sphincter of Oddi dysfunction, and ampullectomy, less than half of the endoscopists reported attempting prophylactic pancreatic stenting in > or = 75% of cases. Thirty (21.3%) survey respondents did not perform prophylactic pancreatic stenting in any circumstance; this was mainly ascribed to lack of experience. Measurement of PEP incidence and an annual hospital volume of > 500 ERCPs were independently associated with the use of prophylactic pancreatic stenting (P = .005 and P = .030, respectively). Most survey respondents (n = 118, 83.7%) did not use NSAIDs for PEP prophylaxis. This was mainly ascribed to lack of scientific evidence of its benefits.

MAIN OUTCOME MEASUREMENTS

Proportion of cases in which pancreatic stenting is attempted during ERCP; reasons for not using prophylactic pancreatic stenting or NSAIDs.

LIMITATIONS

Survey, not an audit of practice.

CONCLUSIONS

Despite scientific evidence of its benefits, use of prophylactic pancreatic stenting is not as widely adopted as previously thought; use of NSAIDs for PEP prophylaxis is marginal.