INTRODUCTION: Intraoperative endoscopy (IOE) has gained wider clinical acceptance as a useful adjunct in advanced laparoscopic surgery. One known drawback of IOE, however, is prolonged distension of downstream bowel which compromises the subsequent surgical exposure/procedure, resulted in open conversion in worst case scenario. The use of rapid absorptive carbon dioxide (CO2) instead of air, has been proven effective to reduce such distension in ambulatory settings. However, its intraoperative use, especially for upper gastrointestinal endoscopy (upper IOE), has yet to be established. The purpose of this study was to assess the feasibility, safety and efficacy of CO2-insufflation for upper IOE during laparoscopic surgery.
METHOD: A historical comparison study was performed between the initial 10 consecutive patients undergoing CO2-insufflating upper IOE (CO2 group; March 2007 to August 2007) and past 12 consecutive patients who underwent conventional air-insufflating upper IOE (AIR group; March 2002 – March 2007) during laparoscopic upper gastrointestinal surgery including partial gastrectomy, esophagocardiomyotomy, and fundoplication. The following parameters were obtained and compared between the two groups: 1) background data; 2) feasibility (completion rate of upper IOE); 3) safety (any intraoperative cardiopulmonary events, such as hypercapnia, arrhythmia, hypothermia); 4) efficacy (any difficulties in gaining surgical exposure after IOE, any residual intestinal gas, time to resume oral intake). The amounts of post-IOE residual intestinal gas on the immediate postoperative abdominal radiographs were evaluated and classified into 5 grades by independent and blinded examiners. The dedicated insufflating system (UCR, Olympus Medical Systems, Tokyo, Japan) was employed for CO2 insufflation. The Mann-Whitney U test was used to analyze any differences between the two groups.
RESULTS: 1) Both groups had comparable backgrounds. 2) Upper IOE was completed in both groups without any complications. 3) No serious cardiopulmonary complication related to upper IOE was noted in both groups. 4) One case in AIR group was converted to open because of inadequate surgical exposure due to post-IOE excessive bowel distension. CO2 group showed significantly lower grade of residual intestinal gas on postoperative abdominal radiographs compared to AIR group (p=0.025). Postoperative oral intake was resumed earlier in CO2 group (p=0.003).
CONCLUSIONS: CO2-insufflation, when used for IOE, is feasible, safe and effective in minimizing post-IOE bowel distension compared to conventional air-insufflation.
Program Number: P259