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Endoscopic submucosal dissection (ESD) is a standard treatment for patients with gastrointestinal neoplasm who have a negligible risk of lymph node metastasis. ESD enables en bloc resection of gastrointestinal neoplasm and organ preservation, thus, avoiding surgical treatment. With the advances in endoscopic skills and expertise, endoscopists have focused on ensuring the quality of recovery of patients as well as reducing procedure-related adverse events such as gastric perforation, hemorrhage, or abdominal pain. Procedure-related gastric perforation or hemorrhage might be less significant, because it is usually managed by endoscopic hemostasis or clipping without additional surgical treatments in skilled endoscopies. However, procedure-related abdominal pain or discomfort might lower the quality of recovery of patients after gastric ESD. Distension of the intestinal lumen is essential to ensure adequate visibility and to secure the space required for a safe procedure. During endoscopic procedures, a large amount of gas is insufflated (i.e., 8–18 L during diagnostic colonoscopy, which far exceeds the physiological gastrointestinal gas with a volume of 0.1–1 L). Room air is the most commonly used material during diagnostic and therapeutic endoscopic procedures. However, it can cause abdominal pain, because it is poorly absorbed in the intestines and is mostly excreted by belching or passage of flatus. Moreover, abdominal discomfort or pain due to retained gas is common. When gastric perforation occurs, the leaked air increases the intra-abdominal pressure and can induce pneumoperitoneum. Although rarely observed, air embolism is another adverse event related to ESD-induced gastric perforation. To overcome these potentially fatal adverse events, carbon dioxide (CO2) instead of room air has been proposed as the insufflating agent, because CO2 is rapidly absorbed by tissues. CO2 was proposed as the insufflating agent of the large intestine in the 1950s, and it has been used to distend the abdominal cavity for endoscopic exploration of the peritoneal cavity during laparoscopic surgery. CO2 is 160 times more rapidly absorbed than nitrogen is and 13 times more rapidly absorbed than oxygen is. It is passively absorbed through the gastrointestinal mucosa into the bloodstream and is eventually exhaled through the lungs. Therefore, rapid absorption of CO2 can minimize the barotrauma and can rapidly reduce luminal distension. The superior efficacy of CO2 (vs. room air) in reducing postoperative pain or discomfort during laparoscopic surgery has been established. However, this has not been extensively evaluated in the field of gastric ESD. In a recent issue of Clinical Endoscopy, Baniya et al. reported a systematic review and meta-analysis of CO2 vs. room air insufflation in gastric ESD focusing on post-procedural abdominal pain and adverse events. Unlike a recently published Received: August 13, 2017 Revised: September 6, 2017 Accepted: September 15, 2017 Correspondence: Chang Seok Bang Department of Internal Medicine, Hallym University College of Medicine, Chuncheon Sacred Heart Hospital, 77 Sakju-ro, Chuncheon 24253, Korea Tel: +82-33-240-5821, Fax: +82-33-241-8064, E-mail: csbang@hallym.ac.kr

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