Incisionless Gastric Sleeve
Endoscopic sleeve gastroplasty (ESG) is a new minimally invasive endoscopic intervention to treat obesity at a lower cost and higher patient acceptability. It is based on reducing the gastric reservoir by using a full-thickness endoscopic suturing device. The procedure is performed under general endotracheal anesthesia, via an upper flexible endoscope, and facilitated with CO2 insufflation into the stomach. The purpose of this letter is to familiarize anesthesiologists with potentially adverse events that may occur during this procedure.
Incision less Surgery is the next wave in minimally invasive surgery and is rapidly becoming an option demanded by patients, insurers and healthcare providers. New surgical tools enable access to the GI tract and abdominal organs through a patient’s mouth or other natural orifices, eliminating the need for external incisions into the body. Incision fewer procedures include those performed within the natural pathways (lumens) of the GI tract, called Endolumenal Surgery or NOS (Natural Orifice Surgery) or by creating an opening in the lumen to access abdominal organs, called NOTES (Natural Orifice Transluminal Endoscopic Surgery).
During ESG, capnoperitoneum, subcutaneous emphysema, and very frequently, high end-tidal CO2 and high peak inspiratory pressure (PIP) can be encountered. These events are attributed to the insufflated CO2, which can escape from the stomach to the abdomen during suture placement, and are identical to those occurring with other endoscopic procedures using CO2 insufflation. The rise in PIP during ESG can be used as a marker for increased intra-abdominal pressure due to capnoperitoneum.If ventilation is subsequently compromised, decompression of the abdomen, with a simple needle or trocar, may be necessary.
This highlights the need for open communication with the surgeon once significant changes begin to occur. Mild hypercarbia is common during ESG and is usually managed by increasing minute ventilation, although major elevations in high end-tidal CO2 can be seen when capnoperitoneum occurs. A more serious, but less frequent, the complication of CO2 insufflation during ESG is tension pneumothorax, which is managed with chest tube placement. Tension pneumothorax must always be suspected if PIP does not decrease immediately after the abdominal needle decompression.
Anesthesiologists need to be alert to the potential complications of CO2 insufflation during ESG, which is expected to become a widely practiced bariatric therapy. It is important to recognize and treat intraoperative capnoperitoneum timely in order to avoid possible clinically significant ventilatory and circulatory consequences. Additionally, to decrease the risk of potential insufflation-related complications during ESG, it is recommended to minimize CO2 insufflation during suture placement and use systems with a facility for the measurement of gas delivery pressures.
