Upper gastrointestinal (GI) endoscopy has evolved from predominantly diagnostic examinations to a broad spectrum of therapeutic and interventional procedures. As procedural complexity, duration and patient comorbidity increase, anaesthetic management must provide dependable oxygenation and ventilation without compromising access for the endoscope. Deep sedation can be effective in selected patients, but airway obstruction, hypoventilation and hypoxaemia remain important concerns, particularly when the airway is not actively secured. Endotracheal intubation provides a definitive tracheal airway and controlled ventilation, but direct laryngoscopy and passage of a tube through the glottis can produce sympathetic stimulation and postoperative laryngeal symptoms.[1,2] The development of endoscopy-specific supraglottic devices attempts to bridge the gap between sedation-only techniques and conventional tracheal intubation. The LMA Gastro was designed with a dedicated endoscopic channel and a separate ventilation channel, permitting passage of an upper GI endoscope while maintaining a supraglottic airway. Terblanche and colleagues reported that the device could provide effective ventilation and facilitate upper GI endoscopy, supporting its feasibility as an alternative airway strategy.[1] Subsequent observational work has described successful use during interventional endoscopy, including in selected high-risk patients, while emphasizing appropriate patient selection and preparedness for conversion to tracheal intubation.[2,3] The potential advantages of a Gastro LMA are not limited to procedural access. Supraglottic airway insertion generally avoids direct passage through the vocal cords and may therefore reduce the magnitude of the cardiovascular response to airway instrumentation. A lower sympathetic response is particularly relevant in patients in whom abrupt tachycardia or hypertension is undesirable. Meta-analytic evidence comparing laryngeal mask airways with endotracheal tubes has also demonstrated lower rates of postoperative hoarseness and coughing with supraglottic airway use, although the magnitude of benefit varies with device type, procedure and patient population.[4] For upper GI endoscopy specifically, device design may influence endoscopist ergonomics. A conventional ETT secures the airway but occupies oral space and may alter the geometry of endoscope passage. The Gastro LMA is intended to maintain a stable supraglottic seal while providing a separate channel for the endoscope. Case-based and observational reports have described unobstructed endoscopic access and adequate ventilation with the device.[3,5] More recent comparative and randomized work with Gastro-specific airway devices has continued to explore insertion success, haemodynamic responses, oxygenation, airway pressure, procedural satisfaction and recovery outcomes.[6–8] Despite increasing clinical experience, direct comparisons with ETT in upper GI endoscopy remain clinically important. A dedicated airway device should not be judged solely by insertion time or postoperative comfort; it must also maintain gas exchange, provide an adequate seal for positive-pressure ventilation, permit uninterrupted endoscopy and avoid major adverse events. Therefore, a comprehensive comparison should include both physiological and patient-centred endpoints. The present study was undertaken to compare Gastro LMA and ETT in adults undergoing upper GI endoscopy under general anaesthesia. The principal focus was the cardiovascular response to airway insertion, with secondary evaluation of insertion characteristics, airway seal pressure, oxygenation, carbon dioxide elimination, endoscopist satisfaction, procedure duration, postoperative sore throat and hoarseness, recovery time and overall complications. The study hypothesis was that Gastro LMA would provide comparable respiratory performance with less haemodynamic perturbation and lower postoperative airway morbidity than ETT in appropriately selected patients.

Study design and setting This was an observational comparative study conducted in the Department of Anaesthesiology at Raipur Institute of Medical Sciences, Raipur, India, over an 18-month period. The source thesis describes routine clinical allocation of airway device according to the attending anaesthesiologist’s judgement rather than randomization. The manuscript therefore retains the observational design and does not describe the study as a randomized controlled trial. Participants Adults aged 18–70 years, ASA physical status I or II, Mallampati grade I–II, and scheduled for upper GI endoscopy under general anaesthesia were eligible after written informed consent. Patients with ASA III–IV status, Mallampati III–IV, pregnancy, restricted head and neck movement, severe or untreated respiratory disease, contraindication to general anaesthesia, or refusal to participate were excluded.[File source] Sample size The thesis reports a minimum sample size of 36 patients per group based on comparison of two independent proportions, using alpha 0.05 and 80% power. The final cohort comprised 72 patients, equally divided between Gastro LMA and ETT groups.[File source] Anaesthetic technique After intravenous access and standard monitoring, baseline SpO2, systolic and diastolic blood pressure, mean arterial pressure and pulse rate were recorded. Premedication included midazolam 0.02 mg/kg, glycopyrrolate 0.004 mg/kg and nalbuphine 0.3 mg/kg. Anaesthesia was induced with propofol 2 mg/kg and lignocaine 1.5 mg/kg, followed by atracurium 0.5 mg/kg. Gastro LMA was inserted without a laryngoscope; ETT placement was performed under direct visualization by a trained anaesthesiologist. Neuromuscular blockade was reversed with neostigmine and glycopyrrolate, and the airway device was removed after adequate spontaneous respiration and tidal volume.[File source] Outcomes and statistical analysis The study assessed haemodynamic variables at predefined perioperative time points, insertion success and insertion time, airway seal pressure, SpO2, ETCO2, endoscopist satisfaction using a Likert scale, procedure duration, postoperative sore-throat VAS, hoarseness, recovery time and adverse events. Continuous data were summarized as mean±SD and compared using an unpaired t test or Mann–Whitney U test as appropriate; categorical data were analysed using chi-square or Fisher exact tests. p<0.05 was considered statistically significant and p<0.01 highly significant.[File source]

Baseline characteristics The two groups were well matched. Mean age was 44.3±10.2 years in the Gastro LMA group and 43.8±9.8 years in the ETT group (p=0.81). Male participants comprised 61.1% and 55.6%, respectively (p=0.62). ASA I status was present in 58.3% of each group, and mean BMI was 24.1±2.5 versus 23.8±2.7 kg/m2 (p=0.57). These similarities reduce concern that demographic imbalance explains the observed differences.[File source] Haemodynamic response Heart rate was comparable at baseline but increased less after Gastro LMA insertion. HR immediately after insertion was 95.0±8.2 bpm with Gastro LMA versus 110.6±9.4 bpm with ETT (p<0.001), and remained lower at 5 minutes (86.1±7.8 versus 92.3±8.0 bpm; p=0.02). Similar attenuation was observed for blood pressure: SBP after insertion was 134.2±10.8 versus 147.8±11.2 mmHg (p<0.001), DBP was 84.0±8.3 versus 94.2±8.7 mmHg (p<0.001), and MAP was 100.9±8.5 versus 110.6±9.1 mmHg (p<0.001). By the postoperative measurement, intergroup differences were no longer significant.[File source] Insertion and airway performance First-attempt success was 91.7% for Gastro LMA and 83.3% for ETT (p=0.29). Mean insertion time was significantly shorter with Gastro LMA, 22.6±4.5 seconds versus 30.8±5.7 seconds (p<0.001). The mean airway seal pressure recorded for Gastro LMA was 40.2±3.8 cmH2O. Oxygenation remained stable, with minimum intraoperative SpO2 of 97.8±0.9% versus 97.6±1.0% (p=0.48). Mean ETCO2 was 36.2±2.1 versus 35.9±2.3 mmHg (p=0.48). No episode of desaturation below 94% was recorded.[File source] Procedural ergonomics Endoscopist satisfaction was significantly higher with Gastro LMA. The mean Likert score was 4.3±0.6 compared with 3.7±0.7 for ETT (p=0.002). Half of the Gastro LMA cases were rated 'extremely satisfied' compared with 27.8% of ETT cases. Procedure duration was similar: 38.2±8.5 minutes versus 37.6±9.1 minutes (p=0.78). Thus, the improved airway ergonomics did not translate into a longer endoscopic procedure.[File source] Postoperative morbidity and recovery Postoperative sore-throat severity was substantially lower with Gastro LMA (VAS 1.3±0.8) than ETT (3.4±1.0; p<0.001). Hoarseness occurred in 3/36 patients (8.3%) with Gastro LMA compared with 10/36 (27.8%) with ETT (p=0.04). Recovery time was shorter with Gastro LMA, 6.8±1.7 versus 8.9±2.1 minutes (p=0.001). Overall complications were reported in 8.3% of Gastro LMA patients compared with 27.8% of ETT patients (p=0.04), and no aspiration, severe desaturation or airway obstruction was documented.[File source] Table 1. Baseline characteristics Variable Gastro LMA (n=36) ETT (n=36) p value Age, years; mean±SD 44.3±10.2 43.8±9.8 0.81 Male, n (%) 22 (61.1) 20 (55.6) 0.62 ASA I, n (%) 21 (58.3) 21 (58.3) 0.84 BMI, kg/m²; mean±SD 24.1±2.5 23.8±2.7 0.57 Table 2. Haemodynamic response Time point Gastro LMA HR ETT HR Gastro LMA MAP ETT MAP Baseline 82.6±7.5 81.9±8.1 92.8±7.1 92.2±6.9 After insertion 95.0±8.2 110.6±9.4 100.9±8.5 110.6±9.1 5 min 86.1±7.8 92.3±8.0 93.4±6.7 97.1±7.5 Post-op 80.4±7.0 82.1±7.5 90.1±6.6 90.7±6.8 Table 3. Airway and procedural outcomes Outcome Gastro LMA ETT p value First-attempt success 91.7% 83.3% 0.29 Insertion time, s 22.6±4.5 30.8±5.7 <0.001 Airway seal pressure, cmH2O 40.2±3.8 — — Minimum SpO2, % 97.8±0.9 97.6±1.0 0.48 ETCO2, mmHg 36.2±2.1 35.9±2.3 0.48 Procedure duration, min 38.2±8.5 37.6±9.1 0.78 Endoscopist satisfaction 4.3±0.6 3.7±0.7 0.002 Table 4. Postoperative outcomes Outcome Gastro LMA ETT p value Sore-throat VAS 1.3±0.8 3.4±1.0 <0.001 Hoarseness 3 (8.3%) 10 (27.8%) 0.04 Recovery time, min 6.8±1.7 8.9±2.1 0.001 No overall complication 33 (91.7%) 26 (72.2%) 0.04

Principal findings This study demonstrates a consistent pattern favouring Gastro LMA for several clinically relevant endpoints while showing comparable respiratory performance with ETT. The most prominent difference was the attenuated cardiovascular response to airway insertion. Baseline HR, SBP, DBP and MAP were essentially identical, but each increased substantially more after tracheal intubation than after Gastro LMA insertion. The response was transient, with values converging postoperatively. This pattern is biologically plausible because direct laryngoscopy and passage of an ETT through the glottis provide more intense stimulation of pharyngeal, laryngeal and tracheal structures than placement of a supraglottic device.[4,9] Comparison with prior evidence The haemodynamic findings are consistent with the broader literature comparing supraglottic devices and ETT. Randomized and observational studies have repeatedly shown smaller increases in heart rate and blood pressure with LMA insertion than with laryngoscopy and tracheal intubation. In the endoscopy-specific setting, the pilot randomized trial by Zhou et al. reported reduced cardiovascular disturbance and shorter placement time with a novel gastro-laryngeal mask compared with ETT, supporting the concept that endoscopy-specific supraglottic devices can reduce instrumentation stress while preserving procedural access.[8] The present findings extend that concept to the Gastro LMA used in routine upper GI endoscopy. Insertion time and first-attempt success Gastro LMA placement was approximately eight seconds faster on average. Although an eight-second difference may appear modest, it can become operationally meaningful in high-volume endoscopy units because shorter airway establishment may reduce apnoea time and improve room turnover. Importantly, first-attempt success was not statistically different, suggesting that the shorter insertion time was not achieved at the expense of technical reliability. The result also aligns with studies of LMA Gastro and related gastro-laryngeal devices that describe high insertion success and practical feasibility.[1–3,6,8] Airway seal, oxygenation and ventilation The mean airway seal pressure of 40.2 cmH2O indicates that the device achieved a substantial seal for controlled ventilation in this selected population. This is consistent with published reports describing adequate oropharyngeal leak pressures with the LMA Gastro.[1,5] However, an important distinction should be made between an adequate ventilation seal and protection from pulmonary aspiration. A supraglottic airway does not provide the same tracheal isolation as a cuffed ETT. Therefore, the present data support effective ventilation rather than equivalence in aspiration protection. The absence of aspiration events in this small cohort is reassuring but cannot establish safety in patients with substantial aspiration risk. The SpO2 and ETCO2 findings are particularly important because a new airway device must first demonstrate non-inferior respiratory performance before comfort or workflow advantages can be considered. In this study, minimum SpO2 remained above 97% in both groups and mean ETCO2 values were almost identical. These observations are consistent with the prospective observational study by Terblanche et al., which established the feasibility of LMA Gastro for upper GI endoscopy, and with subsequent clinical experience during ERCP and other interventions.[1–3] The findings also resemble the pediatric randomized experience of Elghamry et al., although the present study was conducted in adults and should not be generalized to children.[6] Endoscopist satisfaction and procedural access The significantly higher endoscopist satisfaction score is an important practical finding. The Gastro LMA is specifically designed around the needs of upper GI endoscopy, and its integrated channel can provide a stable route for the endoscope while maintaining the airway. Terblanche et al. described the dual-channel design as a key feature, while Chiew et al. reported successful endoscopic access in clinical use.[1,5] Schmutz et al. further demonstrated feasibility during advanced interventional procedures in a high-risk population, although their study was not a direct randomized comparison with ETT.[2] The present study suggests that the ergonomic advantage is detectable even during routine upper GI endoscopy. Postoperative sore throat and hoarseness The reduction in postoperative throat symptoms was one of the clearest patient-centred benefits. Sore-throat VAS was reduced by more than two points on a 0–10 scale, and hoarseness occurred approximately three times as often with ETT. These results are biologically coherent because ETT insertion requires passage through the vocal cords and continued contact with laryngeal and tracheal mucosa. The broader evidence supports this direction: the systematic review by Xu et al. found significantly lower hoarseness and coughing with flexible LMAs than with ETT, although pooled sore-throat rates were not uniformly different across all studies.[4] Device-specific results may therefore depend on cuff design, pressure, insertion technique, procedure type and duration. Recovery and overall complications Recovery was approximately two minutes faster with Gastro LMA. In short elective endoscopic procedures, a small difference can contribute to faster turnover and reduced demand on recovery-area resources. The lower overall complication burden also supports better patient tolerance. However, the study's definition of overall complications should be interpreted carefully because the table primarily captures minor airway symptoms, especially hoarseness. The absence of aspiration, severe desaturation and airway obstruction is reassuring, but the sample of 72 patients is too small to exclude uncommon major adverse events. Clinical interpretation and patient selection The findings support Gastro LMA as a useful option for carefully selected adults undergoing elective upper GI endoscopy under general anaesthesia, particularly when airway access, rapid recovery and minimization of sympathetic stimulation are priorities. The study population was deliberately low risk: ASA I–II, Mallampati I–II, non-obese and without major respiratory disease or restricted neck movement. These criteria are important because the results should not be extrapolated to patients with full stomachs, severe reflux, active upper GI bleeding, significant aspiration risk, severe obesity, difficult airway predictors or major cardiopulmonary instability without additional evidence. Strengths and limitations Strengths include equal group size, standardized anaesthetic management, multiple haemodynamic time points, objective respiratory measurements, airway seal pressure measurement, procedural satisfaction scoring and direct patient assessment of sore throat and recovery. The principal limitation is the observational, non-randomized allocation, which introduces the possibility of selection bias and confounding by indication. The single-centre design and small sample size also restrict external validity. The study excluded high-risk patients, so the absence of aspiration or severe respiratory events should not be interpreted as evidence of universal safety. Longer-term voice outcomes, dysphagia, microaspiration and patient-reported recovery were not evaluated. Future multicentre randomized trials should compare Gastro LMA with ETT and deep sedation across diagnostic and therapeutic procedures and include higher-risk subgroups.[7,8] Physiological rationale for the insertion response The magnitude of the insertion response is clinically relevant because airway instrumentation occurs at a vulnerable transition between induction and establishment of controlled ventilation. Direct laryngoscopy requires elevation of the tongue and epiglottis, stimulation of the pharyngeal and laryngeal structures, and passage of the tube through the vocal cords. These stimuli activate sympathetic pathways and can produce transient tachycardia and hypertension. In contrast, a supraglottic device is positioned above the glottic opening and generally requires less manipulation of the airway. The present differences in HR, SBP, DBP and MAP therefore provide a coherent physiological signal rather than an isolated statistical finding. The fact that values returned toward baseline after the initial period further suggests that the observed effect was related to airway instrumentation rather than persistent differences in perioperative management. Importance of airway seal pressure Airway seal pressure deserves specific consideration when evaluating a Gastro LMA because the device must accommodate positive-pressure ventilation while allowing simultaneous endoscopic access. The recorded mean seal pressure of 40.2±3.8 cmH2O indicates a robust seal in this selected cohort. Terblanche et al. described the LMA Gastro as a dual-channel device designed specifically for endoscopy, while Chiew et al. demonstrated clinically satisfactory cuff fit and oropharyngeal leak pressure in endoscopic use.[1,5] Nevertheless, seal pressure is not synonymous with aspiration protection. A supraglottic airway leaves the larynx and trachea exposed to potential regurgitated gastric contents. Thus, the appropriate interpretation is that the measured seal was adequate for ventilation under the conditions studied; it should not be used to justify Gastro LMA in patients with a high aspiration risk. Relevance to endoscopy workflow The endoscopy suite differs from a conventional operating theatre because the airway device and endoscope must coexist in a restricted oral and pharyngeal space. A device that secures ventilation but interferes with scope passage may be clinically impractical. The higher endoscopist satisfaction score in the present study provides indirect evidence that the integrated channel of the Gastro LMA supported procedural ergonomics. Importantly, the procedure itself was not prolonged, indicating that improved satisfaction was not achieved at the cost of slower endoscopy. This is consistent with reports describing unobstructed passage of standard endoscopes through the Gastro LMA and with more recent studies of endoscopy-specific supraglottic devices.[1,5–8] Implications for difficult or prolonged procedures Although the present cohort was limited to routine elective cases, the design of the Gastro LMA may be particularly useful when the endoscopic procedure is longer or more technically demanding. Deep sedation can become unstable during prolonged therapeutic procedures, whereas ETT intubation may be unnecessarily invasive in selected patients. The dedicated endoscopic channel creates a potential middle ground in which ventilation is actively supported while the procedure proceeds through a stable access route. Published experience in ERCP and other advanced interventions suggests feasibility, but these settings involve different patient positions, aspiration risks and procedural demands; therefore, evidence should be considered supportive rather than interchangeable with routine diagnostic endoscopy.[2,3,7] Patient comfort and future research Patient comfort is increasingly recognized as an outcome of anaesthetic quality rather than a secondary consideration. The lower sore-throat VAS and reduced hoarseness in this study indicate that avoiding transglottic intubation may produce a tangible improvement in the immediate postoperative experience. Future trials should extend this assessment to dysphagia, cough, voice quality, patient-reported satisfaction and symptom persistence beyond the recovery unit. Objective assessment of cuff pressure, gastric insufflation, regurgitation and microaspiration would also clarify the safety profile of Gastro LMA more completely. Larger multicentre randomized trials should include obese patients, elderly patients, patients with obstructive sleep apnoea and selected therapeutic procedures, while maintaining explicit criteria for conversion to ETT.

In adults with ASA I–II status undergoing elective upper GI endoscopy under general anaesthesia, Gastro LMA provided effective oxygenation and ventilation comparable with ETT while producing a smaller haemodynamic response to airway insertion, faster placement, higher endoscopist satisfaction, less postoperative sore throat and hoarseness, and faster recovery. The device therefore appears to be a practical endoscopy-specific supraglottic airway for appropriately selected patients. The observational design, restricted-risk population and small sample size require that these findings be confirmed in larger randomized multicentre studies before broad recommendations are made for high-risk or aspiration-prone patients.

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