Carbon Dioxide versus Air Insufflation in Gastric Endoscopic Submucosal Dissection: A Systematic Review and Meta-Analysis of Randomized Controlled Trials

Abstract

Background/AimsEndoscopic submucosal dissection (ESD) with air insufflation is commonly used for the staging and treatment of early gastric carcinoma. However, carbon dioxide (CO2) use has been shown to cause less post-procedural pain and fewer adverse events. The objective of this study was to compare the post-procedural pain and adverse events associated with CO2 and air insufflation in ESD.MethodsA systematic search was conducted for randomized control trials (RCTs) comparing the two approaches in ESD. The Mantel-Haenszel method was used to analyze the data. The mean difference (MD) and odds ratio (OR) were used for continuous and categorical variables, respectively.ResultsFour RCTs with a total of 391 patients who underwent ESD were included in our meta-analysis. The difference in maximal post-procedural pain between the two groups was statistically significant (MD, -7.41; 95% confidence interval [CI], -13.6 – -1.21; p=0.020). However, no significant differences were found in the length of procedure, end-tidal CO2, rate of perforation, and postprocedural hemorrhage between the two groups. The incidence of overall adverse events was significantly lower in the CO2 group (OR, 0.51; CI, 0.32–0.84; p=0.007).Conclusions:CO2 insufflation in gastric ESD is associated with less post-operative pain and discomfort, and a lower risk of overall adverse events compared with air insufflation.

Carbon Dioxide Insufflation in Endoscopic Submucosal Dissection: Is It an Urgent Need?

“…In a recent issue of Clinical Endoscopy , Baniya et al reported a systematic review and meta-analysis of CO 2 vs. room air insufflation in gastric ESD focusing on post-procedural abdominal pain and adverse events [ 12 ]. Unlike a recently published meta-analyses [ 11 ] about the efficacy and safety of CO 2 (vs. room air) insufflation in ESD (combining gastric, colorectal, and esophageal ESD), this study [ 12 ] focused only on gastric ESD. Therefore, readers can understand the results of this study under the scope of subgroup analysis of the study by Li et al, although this analysis was not conducted in their study [ 11 ].…”

“…Although the meta-analyses by Li et al [ 11 ] and Baniya et al [ 12 ] commonly claimed less post-procedural abdominal pain or discomfort in the CO 2 insufflation group (vs. room air insufflation) of patients with ESD [ 11 ] or those with gastric ESD [ 12 ], they could not overcome the methodological limitations. When the enrolled studies report multiple outcomes, it is difficult to select the optimal value for the meta-analysis.…”

“…In the meta-analysis by Baniya et al [ 12 ], the values of three studies (studies by Tanioka et al [ 14 ], Maeda et al [ 15 ], and Kim et al [ 16 ]) were combined (Table 3 and Fig. 2 in their study [ 12 ]), while Tanioka et al [ 14 ] presented only one value (abdominal pain after gastric ESD on a 100-mm visual analogue scale), namely 14.3±20.5 (CO 2 group) vs. 24.3±25.3 (air group). Maeda et al [ 15 ] and Kim et al [ 16 ] presented four values in each study.…”

“…Maeda et al [ 15 ] and Kim et al [ 16 ] presented four values in each study. Therefore, an optimal value should be selected for the meta-analysis in the studies by Maeda et al [ 15 ] and Kim et al [ 16 ] Baniya et al selected maximal post-procedure abdominal pain as the primary effect size to combine [ 12 ]. Therefore, the values 14.3±20.5 (CO 2 group) vs. 24.3±25.3 (air group) in the study by Tanioka et al [ 14 ] and 35.2±30.3 (CO 2 group) vs. 48.5±29 (air group) in the study by Kim et al [ 16 ] were selected for the meta-analysis (Table 3 in their study [ 12 ]).…”

“…Therefore, an optimal value should be selected for the meta-analysis in the studies by Maeda et al [ 15 ] and Kim et al [ 16 ] Baniya et al selected maximal post-procedure abdominal pain as the primary effect size to combine [ 12 ]. Therefore, the values 14.3±20.5 (CO 2 group) vs. 24.3±25.3 (air group) in the study by Tanioka et al [ 14 ] and 35.2±30.3 (CO 2 group) vs. 48.5±29 (air group) in the study by Kim et al [ 16 ] were selected for the meta-analysis (Table 3 in their study [ 12 ]). However, 1 (CO 2 group) vs. 4 (air group) in the study by Maeda et al [ 15 ] were selected instead of 4 (CO 2 group) vs. 4 (air group), which are the maximal values [ 12 ].…”