Neoplasms

All Conditions

Symptoms and General Pathology

Digestive System Diseases

Rare Diseases

Carcinoma

Carcinoma, Ductal

Constriction, Pathologic

Bile Duct Diseases

Choledocholithiasis

Common Bile Duct Diseases

Biliary Tract Diseases

Gastrointestinal Diseases

Gallstones

Cholelithiasis

Cholecystolithiasis

Adenocarcinoma

Neoplasms, Glandular and Epithelial

Neoplasms by Histologic Type

Bile Duct Cancer

All patients will undergo endoscopic retrograde cholangiopancreatography (ERCP) that is indicated for suspected or confirmed choledocholithiasis or biliary strictures. "Air" contrast cholangiography using carbon dioxide gas will be performed with standard fluoroscopy and digital subtraction fluoroscopic image capture followed by routine cholangiography using iodinated contrast and standard fluoroscopy. Carbon dioxide (CO2) is routinely used in ERCP procedures and would flow into the biliary tree of patients at the time of ERCP, irrespective of this study's interventions. Digital subtraction image capture is a commercially available setting on certain fluoroscopy units that optimizes resolution with air or CO2 used as a contrast medium.

Carbon dioxide (CO2) will be injected into the biliary tree (which is already exposed to CO2 during routine ERCP) and images will be obtained by using fluoroscopy and digital subtraction imaging (a specific setting on certain fluoroscopy tables).

"Air" contrast cholangiography using carbon dioxide gas

Andrew Y. Wang, MD

Carbon dioxide (CO2) gas is widely used for luminal insufflation during endoscopic retrograde cholangiopancreatography (ERCP) of the biliary tract. While frequently observed during routine ERCP, there are few data on the topic of "air" or "CO2" cholangiography. Our primary aim is to compare radiographic cholangiograms in patients with biliary tract disease (from stones or strictures) during ERCP obtained by using carbon dioxide as the contrast medium vs. conventional iodinated contrast.

It has been recommended that endoscopic retrograde cholangiopancreatography (ERCP) be performed using carbon dioxide (CO2) instead of room air as the infused "air" or gas for luminal insufflation for reasons of improved patient comfort and in case of procedural adverse events (as CO2 is more quickly absorbed by the body and as it can be exhaled via the lungs). Air cholangiograms are often incidentally visible on fluoroscopy (radiographically) during ERCP prior to injection of iodinated contrast into the biliary tree. Despite the information from an air cholangiogram being readily available in many instances, biliary endoscopists and radiologists who read the fluoroscopic images taken during ERCP do not usually comment or interpret the "air" or "CO2" cholangiograms. Consequently, very little data is available on the topic of "air" or "CO2" cholangiography. As a contrast medium for cholangiography, CO2 might be safer than iodinated contrast, which is the standard contrast medium used during ERCP, as iodinated contrast cannot be easily absorbed by the body and as it can be trapped proximal to obstructing biliary stones or strictures and lead to biliary tract infection.

This is a prospective cohort study that will enroll patients undergoing ERCP for suspected choledocholithiasis and/or biliary stricture(s). If they did not participate in this study, these patients would still require an ERCP with CO2 used as the endoscopically insufflated "air" medium. Enrolled patients will undergo an initial cholangiogram with CO2 (injected into the bile ducts) utilizing both conventional fluoroscopy and digital subtraction fluoroscopic imaging, followed by conventional cholangiography using iodinated contrast (injected into the bile ducts). Digital subtraction fluoroscopic imaging is a commercially available setting on certain fluoroscopy units that optimizes resolution with air or CO2 used as a contrast medium. Findings on CO2 cholangiography will be compared to those obtained from pre-procedural abdominal imaging along with the cholangiogram done using iodinated contrast at the time of the ERCP procedures.

Cholangiography Using Carbon Dioxide Versus Iodinated Contrast in ERCP

CO2 Cholangiography as an Alternative to Iodinated Contrast in Endoscopic Retrograde Cholangiopancreatography

For choledocholithiasis: correct identification of the number and location of stones. For biliary strictures: correct identification of number and location of strictures.

Fluoroscopy/radiation usage/exposure will be measured for each imaging modality and then compared

University of Virginia

Associate Professor of Medicine

Liver Neoplasms

Gastrointestinal Neoplasms

Digestive System Neoplasms

Liver Diseases

Central Nervous System Depressants

All Drugs and Chemicals

Hematinics

Anesthetics

Liver Extracts

When using HFJV in liver tumour ablation procedures for optimizing surgical conditions, an ETT size 9 is routinely being used in our department.

In this arm an endotracheal tube of size 8 will be used. This is one size smaller than is routine when HFJV is being used for liver tumour ablation procedures in our department. Worth to note is that an endotracheal tube of size 8 is routine in all other surgical procedures, in men, during general anaesthesia.

Compare the levels of carbon dioxide and if it is related to ETT size when using size 9 (routine) or size 8 (intervention).

Entotracheal tube size

Klara Bergmark, MD

High Frequency Jet Ventilation (HFJV) can be used in liver tumour ablation to minimise breathing related movements. The jet cannula is placed freely inside an endotracheal tube (ETT) and the outflow of air is passive, moving out in the interspace between the jet cannula and the inner walls of the ETT.

This study aims to investigate whether the tube size can influence the washout of carbon dioxide using two different sizes of ETT's.

The aim of the present prospective randomised study is to compare differences in levels of carbon dioxide between two different endotracheal tube-sizes.

Background: High Frequency Jet Ventilation (HFJV) has become an important technique for ventilation during stereotactic near-diaphragm ablation to minimise breathing related movements. Thus, avoiding risks associated to movements and subsequent dislocation of the target tumour. HFJV is being increasingly used during CT-guided, percutaneous liver tumour ablation. As shown previously, breathing related movements in upper abdominal organs, are decreased significantly when compared to conventional ventilation. When HFJV is being used in the setting for tumour ablation the jet cannula is inserted into an ordinary endotracheal tube (ETT). The HFJV catheter is placed in the ETT and is during jet ventilation lying freely within the tube. Right placement is confirmed by a harmonic curve on the screen of the jet ventilator. It is of great importance that the ETT is not obstructed as this type of ventilation is dependent on passive outflow of expired air, through the tube, passing from the lungs around the catheter within the tube into the surrounding air. If the lumen around the catheter within the ETT is becoming too small, there is a risk for intrinsic PEEP built up, and subsequent risk for barotrauma, pneumothorax. The space between the catheter and the inner lumen of the ETT also governs the exhalation of gas, the passage of expired gas containing CO2 from the lung. A small inner diameter of the ETT may thus likewise increase the risk for a raise in arterial carbon dioxide. To minimise these risks, an ETT one size larger than usual can be used to lower the risk for pressure increase and improve gas exchange. One should consider the risks, even though very low, of mechanical injury in the airway when larger ETT's are being used. Previous studies on arterial blood gas in liver tumour was performed using a ETT one size larger (size 9 in men). Tadié et al showed that laryngeal injury was related to the length of intubation, the non-use of muscle relaxant drugs and the height/ETT diameter ratio. This was a study made in an ICU and all patients were intubated \>24 hrs and therefore not fully applicable to the OR-setting. Jaensson et al describe a significant lower risk for post operative sore throat (POST) using a smaller ETT size in women during elective surgery. Myles et al describe women being 1.5 times more likely to report having POST compared to men. To defend the superiority of a larger tube size further studies assessing the effect of the ETT size on the arterial CO2 tension is needed.

Methods: After written, informed consent, 26 (13 in each group) consecutive, male patients planned for liver tumour ablation with HFJV will be included in the study.

Participants will be randomized to ETT size 8 or 9. Randomisation will take place in an earlier stage with the help of a computerised randomisation generator where 26 envelopes are prepared in which the information of tube size is to be found. The envelopes are on the outside anonymous. The envelopes will be opened by the anaesthetic nurse in the operation room, who will then prepare the ETT.

An arterial line will be placed before the start of anaesthesia and a transcutaneous measuring device will be placed on the forehead of the patient. After preoxygenation, induction and ETT placement, conventional ventilation will be started and a normal tcCO2 value reached (tcCO2 4,5-5 before the start of HFJV). HFJV will have pre-set settings with the same values for all patients. Driving pressure (DP) will be 1,2 bar and frequency 220/min. Measurements from the three different methods; arterial pCO2, transcutaneous CO2 and etCO2 will then be recorded at the start of HFJV (t=0) and then every 15' until t=45 minutes of HFJV. In the case of rapidly increasing CO2, a cut off limit of 10 kPa will be used. When this level is reached, settings on the ventilator will be changed. That means increasing DP and, if needed, lower the frequency. If this does not lead to a satisfactory CO2-level HFJV has to be changed to conventional ventilation until the CO2-level is within normal limits. Any injury during intubation and post extubation stridor (PES) will be recorded. The patient will be asked for post operative sore throat (POST) and any signs of postoperative hoarseness (PH) will be noted in the protocol before leaving the post anaesthetic care unit (PACU) and also approximately 24 hrs after extubation. If symptoms still occur after 24 hrs, follow up will take place approximately 72 hrs and 96 hrs after extubation. If symptoms are still present by this point the patient will be offered a doctor's appointment.

Statistics: The power calculation was based on data from previous studies. The base-line PaCO2 among 12 male patients, at the start of HFJV, was 4.9 kPa (SD 0.5) with an increase to mean PaCO2 of 6.7 (SD 1.5) at 15 minutes with HFJV and a tube size of 9. With the hypothesis that the PaCO2 would increase to a mean of 8.0 kPa after 15 minutes of HFJV ventilation, with a tube size 8, groups of 11 patients are needed to verify the difference at a p\<0.05 with a power of 80%. To compensate for potential drop-outs, groups of 13 patients is set as the study population. Data will be presented as mean, SD, median and range where applicable. One-way ANOVA will be used on normal distributed data and ANOVA on ranks will be used on non-normal distributed data. Bonferroni's test will be used to compare differences between the different timepoints. A p-value of \<0,05 will be considered as statistically significant.

Importance of the study: This study is conducted to if the larger endotracheal tube size has benefits in gas exchange when HFJV is being used in liver tumour ablation procedures. Normally it is desirable to use as small ETT as possible as this minimises the risks for airway injury. The risks of air entrapment and even pneumothorax and raise in carbon dioxide levels are also risks that are potentially harmful for the patients and must be avoided. The small risk of using a one size larger ETT would therefore be accepted if the benefits can be shown in this study.

Patients planned for liver tumour ablation will be randomised to one of two sizes of ETT, size 8 or size 9.

The patient is not being informed what ETT-size is being used.

As men and women routinely uses two different ETT sizes and we wanted to compare two sizes within one group, this study will only focus on men.

Endotracheal Tube Size Effect on the Carbon Dioxide Washout During Jet Ventilation

Does Endotracheal Tube (ETT) Size Facilitate Carbon Dioxide Washout in Liver Tumour Ablation With High Frequency Jet Ventilation (HFJV)? - a Randomised Controlled Trial

Carbon dioxide level from an arterial line (PaCO2) in kPa will be compared from the levels at baseline to the level at 15 minutes of HFJV.

The dynamics of carbon dioxide changes obtained from an arterial line (PaCO2) in kPa, transcutaneously (tcCO2) in kPa and end tidal measurement (etCO2) in kPa registered every 15 minutes during the first 45 minutes of HFJV. That is, all values from each timepoint (15 minutes, 30 minutes and 45 minutes after the start of HFJV) will be compared to baseline.

During HFJV measure pause pressure (PP) in mbar and peak pressure in mbar .

PaO2 in kPa will also be measured and analysed during the procedure.

pH will also be measured and analysed during the procedure.

Lactate in mmol/L will also be measured and analysed during the procedure.

Saturation in percent will also be measured and analysed during the procedure.

Signs of apparent mechanical injury in the airway. Signs of apparent injury, being visible injury during intubation and post extubation stridor (PES). Post operative sore throat (POST) and any signs of postoperative hoarseness (PH)

Region Stockholm

Colonic Neoplasms

Colonic Polyps

Polyps

Pathological Conditions, Anatomical

Intestinal Polyps

Colorectal Neoplasms

Intestinal Neoplasms

Colonic Diseases

Intestinal Diseases

Herbal and Botanical

Cola

warmed carbon dioxide insufflation used in colonoscopy

room temperature air insufflation used in colonoscopy

room temperature air insufflation

warmed carbon dioxide insufflation

Lawrence Hookey, MD

Colorectal cancer is the second most common cancer in the world and the second leading cause of cancer-related mortality. Colorectal cancers arise from precursor adenomatous polyps in a well characterized adenoma to carcinoma progression. The removal of such precursor lesions reduces colorectal cancer mortality between 30 to 50%. Colonoscopy is used for detection of neoplastic polyps but significant miss rates of such lesions are reported. Methods to reduce spasm of the colon have been investigated to increase adenoma detection rates including the use of warm water irrigation and hyoscine butyl bromide. Carbon dioxide warmed to body temperature is postulated to have spasmolytic effects. Administration of warmed carbon dioxide during colonoscopy may improve polyp detection.

Objective: In this study, colonoscopy using warmed carbon dioxide insufflation will be compared to standard room temperature air insufflation to see if there is a greater detection of polyps per patient.

Methods: Patients undergoing colonoscopy for screening and surveillance indications will be included and randomized to receive either room temperature room air or warmed carbon dioxide (37 degrees Celsius). Endoscopists and patients will be blinded to the intervention. Data on indication, preparation, sedation, withdrawal time will be recorded. Polyp detection rate will be the primary outcome. Secondary outcomes will include adenoma detection rate and advanced lesion detection rates.

The Impact of Warmed Carbon Dioxide Insufflation During Colonoscopy on Polyp Detection

The Impact of Warmed Carbon Dioxide Insufflation During Colonoscopy on Polyp Detection: A Randomized Controlled Trial

Queen's University

Assistant Professor and Director of Endoscopy

Respiratory Tract (Lung and Bronchial) Diseases

Mouth and Tooth Diseases

Ear, Nose, and Throat Diseases

Respiratory Aspiration

Oropharyngeal Neoplasms

Hyperventilation

Respiration Disorders

Respiratory Tract Diseases

Signs and Symptoms, Respiratory

Pharyngeal Neoplasms

Otorhinolaryngologic Neoplasms

Head and Neck Neoplasms

Pharyngeal Diseases

Stomatognathic Diseases

Otorhinolaryngologic Diseases

Platelet Aggregation Inhibitors

Sevoflurane

Anesthetics, Inhalation

After end of surgery, hyperventilation and administration of a small, precalculated amount of CO2 into the breathing circuit will be performed.

After end of surgery, patients will be subdued to a standard weaning procedure.

Mechanical hyperventilation to enhance elimination of inahalation anesthetics. Administration of a precalculated flow of CO2 according to gender and weight into the inspiratory limb of the breathing circuit in order to avoid hypocapnia.

Isocapnic hyperventilation

Isocapnic hyperventilation (IHV) is a method that shortens time to extubation after inhalation anaesthesia by increasing airway carbon dioxide (CO2) during hyperventilation (HV). In two experimental studies (mechanical lung model and porcine model) and in a pilot study on patients undergoing sevoflurane anaesthesia for major ear-nose-throat (ENT) surgery, the investigators evaluated the feasibility of an alternative technique of IHV. By performing a prospective, randomised controlled study, the investigators want to further test this alternative method for IHV.

Isocapnic hyperventilation (IHV) provides an alternative method for weaning from inhalation anaesthesia which decreases the time to eye-opening, extubation and time spent in the PACU. The method is well known since at least 40-50 years and involves the maintenance of a stable CO2 level during hyperventilation, which increases the elimination of anaesthetic gas without producing hypocapnia. Studies have declared that the reduction in time to eye-opening is 50-60 % compared to a standard weaning procedure after inhalation anaesthesia.

There are several principally different ways to maintain the CO2 level during hyperventilation, where a number of technical solutions that add dead-space to the anaesthesia circuit and thereby produce rebreathing of CO2 during hyperventilation are the most studied methods so far. However, the original method of directly adding CO2 to the breathing circuit during hyperventilation could be considered in need of a re-evaluation, as modern anaesthesia delivery units and monitoring equipment to a great extent can eliminate the risk of hypercapnia, that was described with this procedure in the 1980ies.

An alternative IHV method is to directly infuse CO2 to the inspiratory limb of the breathing circuit through a mixing box while using mechanical hyperventilation by a standardised protocol. This technique was recently evaluated by the investigators, in a bench test, and in an in vivo model. Based on these studies, the CO2 dosage needed to achieve isocapnia during HV at various levels of alveolar ventilation, CO2 production and dead space was estimated and a gender- and weight-based nomogram for CO2 delivery during IHV was constructed. Furthermore, the investigators could show, in vivo, that the washout time of sevoflurane anaesthesia was one-third compared to normal ventilation. The feasibility of this IHV method was evaluated in a pilot study in humans, based on the results of our two previous experimental studies. To finalize the project the investigators now conduct a prospective randomized trial to evaluate the efficacy of the method, compared to a standard weaning procedure, after long-term sevoflurane anaesthesia.

Isocapnic Hyperventilation - an Alternative Method

Isocapnic Hyperventilation for Enhancing Recovery After Inhalation Anaesthesia - an Alternative Method

Postoperative quality of recovery (PQRS) scale

Sahlgrenska University Hospital, Sweden

Consultant

Lung Neoplasms

Multiple Pulmonary Nodules

Solitary Pulmonary Nodule

Respiratory Tract Neoplasms

Thoracic Neoplasms

Lung Diseases

After dividing all the targeted vascular and bronchial structures, the lung of the operating side was re-inflated with 100% oxygen.

After the targeted segment structures were successfully dissected, the collapsed intraoperative lung was completely re-expanded with carbon dioxide.

During one-lung ventilation with an open chest, the non-ventilated lung collapses initially due to the inherent elastic recoil properties of the lung. Once passive venting has ceased, further collapse will then be wholly dependent on ongoing gaseous uptake and absorption atelectasis. Improved inflation-deflation method is currently the most widely used method in clinical practice. After dividing all the targeted vascular and bronchial structures, the lung of the operating side was re-inflated with 100% oxygen. After the operative lungs is completely expanded, perform pure oxygen mechanical single lung ventilation for the healthy lung, waiting for clear presentation of the plane between the targeted segment and the other segments.

100% oxygen

During one-lung ventilation with an open chest, the non-ventilated lung collapses initially due to the inherent elastic recoil properties of the lung. Once passive venting has ceased, further collapse will then be wholly dependent on ongoing gaseous uptake and absorption atelectasis. The solubility coefficient for carbon dioxide is 0.57. The rapid diffusion properties of carbon dioxide would be expected to speed lung collapse and so facilitate surgery. After the targeted segment structures were successfully dissected, the collapsed intraoperative lung was completely re-expanded with carbon dioxide. After the operative lungs is completely expanded, perform pure oxygen mechanical single lung ventilation for the healthy lung, waiting for clear presentation of the plane between the targeted segment and the other segments.

Carbon dioxide

With the increasing acceptance of routine computed tomography (CT) screenings, early-stage lung cancer detection is becoming more frequent. For ground glass opacity predominant early-stage lung cancer, segmentectomy can get the same oncological benefits as lobectomy. In addition, lung nodules that are highly suspected to be metastases can also be performed by segmentectomy to preserve more lung function. During the surgery, the rapid and precise identification of the intersegmental plane is one of the challenges. The improved inflation-deflation method is currently the most widely used method in clinical practice. According to the dispersion coefficient of the gas, the rapid diffusion properties of carbon dioxide would be expected to speed lung collapse and so facilitate surgery. The purpose of this study was to investigate the feasibility and safety of carbon dioxide on the appearance time of satisfactory and ideal planes during segmentectomy.

This study was approved by the ethics committee of Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology. This randomized parallel group trial enrolled patients scheduled to receive thoracoscopic anatomic segmentectomy at Tongji Hospital. General anesthesia with double lumen endotracheal tube was administered to the patients. With the guidance of preoperative three-dimensional computed tomography bronchography and angiography, the targeted segment structures could be precisely dissected, and then intersegmental demarcation was confirmed by the modified inflation-deflation method in this study. In group A (100% oxygen), after dividing all the targeted vascular and bronchial structures, the lung of the operating side was re-inflated with 100% oxygen. In group B (Carbon dioxide), after the targeted segment structures were successfully dissected, the collapsed operative lung was completely re-expanded with carbon dioxide. The purpose of this study was to investigate the feasibility and safety of carbon dioxide on the appearance time of satisfactory and ideal planes during segmentectomy. The starting time point of the intersegmental plane was when the whole lungs had completely re-expanded. The end point was when the preserved segment was fully deflated, and a boundary had formed between the targeted segment and the reserved lung.

Application of Carbon Dioxide for Identifying the Intersegmental Plane in Thoracoscopic Segmentectomy

Application of Carbon Dioxide for Identifying the Intersegmental Plane in Thoracoscopic Segmentectomy: A Randomized Controlled Study

Duration of hospitalization after surgery.

Measured using the Quality of Recovery 40 (QoR-40) Score and asking patients to complete the questions 24 hours before operation, 48 hours after operation and 1 week after operation.

The starting time point of the intersegmental plane was when the whole lungs had completely re-expanded. The end point was when the preserved segment was fully deflated, and a boundary had formed between the targeted segment and the reserved lung.

Tongji Hospital

Professor

After dividing all the targeted vascular and bronchial structures, the lung of the operating side was re-inflated with 100% oxygen.

100% oxygen: During one-lung ventilation with an open chest, the non-ventilated lung collapses initially due to the inherent elastic recoil properties of the lung. Once passive venting has ceased, further collapse will then be wholly dependent on ongoing gaseous uptake and absorption atelectasis. Improved inflation-deflation method is currently the most widely used method in clinical practice. After dividing all the targeted vascular and bronchial structures, the lung of the operating side was re-inflated with 100% oxygen. After the operative lungs is completely expanded, perform pure oxygen mechanical single lung ventilation for the healthy lung, waiting for clear presentation of the plane between the targeted segment and the other segments.

Group A: 100% Oxygen

After the targeted segment structures were successfully dissected, the collapsed intraoperative lung was completely re-expanded with carbon dioxide.

Carbon dioxide: During one-lung ventilation with an open chest, the non-ventilated lung collapses initially due to the inherent elastic recoil properties of the lung. Once passive venting has ceased, further collapse will then be wholly dependent on ongoing gaseous uptake and absorption atelectasis. The solubility coefficient for carbon dioxide is 0.57. The rapid diffusion properties of carbon dioxide would be expected to speed lung collapse and so facilitate surgery. After the targeted segment structures were successfully dissected, the collapsed intraoperative lung was completely re-expanded with carbon dioxide. After the operative lungs is completely expanded, perform pure oxygen mechanical single lung ventilation for the healthy lung, waiting for clear presentation of the plane between the targeted segment and the other segments.

Study title	NCT ID	Conditions	Interventions	Eligibility	Organization
Cholangiography Using Carbon Dioxide Versus Iodinated Contrast in ERCP	NCT02611453	Choledocholithi... Bile Duct Disea... Bile Duct Carci...	"Air" contrast ...	18 Years -	University of Virginia
Endotracheal Tube Size Effect on the Carbon Dioxide Washout During Jet Ventilation	NCT05370001	Liver Tumor	Entotracheal tu...	18 Years -	Region Stockholm
The Impact of Warmed Carbon Dioxide Insufflation During Colonoscopy on Polyp Detection	NCT02065037	Colonic Polyps Colonic Neoplas...	room temperatur... warmed carbon d...	40 Years -	Queen's University
Isocapnic Hyperventilation - an Alternative Method	NCT03074110	Oropharyngeal N...	Isocapnic hyper...	18 Years -	Sahlgrenska University Hospital, Sweden
Application of Carbon Dioxide for Identifying the Intersegmental Plane in Thoracoscopic Segmentectomy	NCT05350137	Lung Cancer Pulmonary Nodul... Segmentectomy Pulmonary Nodul...	100% oxygen Carbon dioxide	18 Years - 80 Years	Tongji Hospital
Endotracheal Tube Size Effect on the Carbon Dioxide Washout During Jet Ventilation	NCT05370001	Liver Tumor	Entotracheal tu...	18 Years -	Region Stockholm
Endotracheal Tube Size Effect on the Carbon Dioxide Washout During Jet Ventilation	NCT05370001	Liver Tumor	Entotracheal tu...	18 Years -	Region Stockholm
Cholangiography Using Carbon Dioxide Versus Iodinated Contrast in ERCP	NCT02611453	Choledocholithi... Bile Duct Disea... Bile Duct Carci...	"Air" contrast ...	18 Years -	University of Virginia

Spots Global Cancer Trial Database for carbon dioxide