Comparison of three sedation models for same-day painless bidirectional endoscopy: A multicenter randomized controlled trial.

BACKGROUND AND AIM: We investigated the most beneficial propofol sedation model for same-day painless bidirectional endoscopy (BDE).
METHODS: Asymptomatic participants scheduled for same-day painless BDE examination from October 2020 to September 2021 were randomized to three groups: sedated esophagogastroduodenoscopy followed by unsedated colonoscopy (Group A); sedated esophagogastroduodenoscopy followed by sedated colonoscopy (Group B); and sedated esophagogastroduodenoscopy followed by sedated insertion colonoscopy (Group C). Patient discomfort, colonoscopy performance, doses of propofol, cardiovascular stress, anesthesia resuscitation, and sedation-related adverse events were evaluated.
RESULTS: A total of 3200 participants were analyzed. Baseline demographics, patient discomfort, cecal intubation rate, adenoma detection rate and sedation-related adverse events were similar in the three groups. Propofol dose was the lowest in Group A (137.65 ± 36.865 mg) compared with Group B (177.71 ± 40.112 mg, P < 0.05) and Group C (161.63 ± 31.789 mg, P < 0.05). Decline in vital signs was most obvious in Group B during the procedure (P < 0.05). Recovery time was the shortest in Group A (5.01 ± 1.404 min) compared with Group B (9.51 ± 2.870 min, P < 0.05) and Group C (5.83 ± 2.594 min, P < 0.05); discharge time was the shortest in Group A (3.53 ± 1.685 min) compared with Group B (11.29 ± 5.172 min, P < 0.05) and Group C (6.47 ± 2.338 min, P < 0.05). Adenomas per positive patient of Group A (2.29 ± 1.055) and Group C (2.28 ± 0.931) were more than that in Group B (2.11 ± 0.946, P < 0.05).
CONCLUSIONS: Sedated esophagogastroduodenoscopy followed by unsedated colonoscopy is the superior model for same-day painless BDE with the benefits of satisfactory patient comfort, reduced sedation dose, less cardiovascular stress, faster recovery, shorter discharge time and high colonoscopy quality.

Introduction

The combination of esophagogastroduodenoscopy (EGD) and colonoscopy, which is termed bidirectional endoscopy (BDE), is commonly administered for physical check‐ups in China. The benefits of same‐day BDE include a shorter hospital stay, reduced medical costs, a reduction of sedation doses and the convenience for patients. , , , , , A national survey showed that the sedation rate for gastrointestinal endoscopy in China was ~50%, and the predicted number of gastroenterological endoscopies in China could reach 51 million by 2030. The dramatic increase in sedated gastroenterological endoscopy is challenging with the shortage of anesthesiologists and anesthesia nurses, and sedation is supposed to bring patient adequate comfort during the examination as well as rapid recovery and discharge, especially in the COVID‐19 era; thus, a safe sedation model with a rapid turnover and discharge time is essential for this high‐volume practice to remain efficient.

Propofol is an ideal drug for use in the vast majority of patients who require deep sedation for endoscopic examinations, , because its unique pharmacokinetic properties make endoscopy almost painless, with a very predictable and rapid recovery process. Propofol has a narrow therapeutic window and no antidote, and higher doses are associated with increased risks of respiratory and circulatory inhibitions, which may lead to adverse events that require cardiopulmonary support. , Given the possibility of propofol‐induced adverse events, it needs to be clear why we use it and, when doing so, to give no more than necessary. The present study aimed to compare the efficacy, safety and colonoscopy performance of different propofol administration methods to determine the superior model for same‐day painless BDE.

Methods

Study design

This multicenter prospective randomized controlled study was conducted between October 2020 and September 2021 at the following seven hospitals in China: Shanxi Tumor Hospital; The Second People's Hospital of Datong; Datong Shoujia Digestive Disease Hospital; Xiaoyi Traditional Chinese Medicine Hospital; Lvliang Traditional Chinese Medicine Hospital; Erdos Kangning Physical Examination Center and The First Hospital of Shanxi Medical University, Yanhu District Branch. The study was approved by the Chinese Ethics Committee of Registering Clinical Trials (IRB number ChiECRCT20210642) and was registered in the Chinese Clinical Trial Registry (ChiCTR2200056917).

Asymptomatic population aged 35–60 years who were scheduled for same‐day painless BDE as part of routine physical examination were included. Written informed consent was obtained from all individuals prior to their inclusion in the study. Eligible participants were randomized to the following three groups with allocation ratio of 1:1:1 using the random number table algorithm made by a third‐party statistician with the SPSS software (version 24.0, Inc., Chicago, IL, USA): sedated EGD followed by unsedated colonoscopy (Group A); sedated EGD followed by sedated colonoscopy (Group B); and sedated EGD followed by sedated insertion colonoscopy (Group C). The engaged endoscopists and anesthesiologists were told the allocation results at the beginning of the BDE procedure by assistant nurses. The exclusion criteria were as follows: patients with an American Society of Anesthesiologists (ASA) classification of ≥ 4; patients with an allergy to propofol; patients without companion; patients with polyposis syndrome; patients with colorectal cancer; patients with poor bowel preparation (Boston Bowel Preparation Scale, BBPS score < 6 points or any segmental score < 2 points); failure to reach the cecum due to bowel obstruction; colonoscope withdrawal time less than 6 min; and patients who refused to participate in the study. Demographic data, including age, sex, height, weight and history of abdominal, or pelvic surgery were recorded. The examinations were performed by experienced endoscopists with an average colonoscope insertion time less than 5 min, and ADR > 40% in the past 3 years. Propofol (AstraZeneca Italy, Caponago, Italy) sedation was administered by experienced anesthesiologists.

Study procedure

Each participant underwent bowel preparation in accordance with the local practices of the hospitals. Dyclonine hydrochloride mucilage (Yangtze River Pharmaceutical Group Co., Ltd. 0.1 g/10 mL) was given 15 min before gastroscopy for oropharyngeal topical anesthesia. No antispasmodic medication was administered before or during the procedure. Before starting the procedure, nasal oxygen was given at a flow rate of 3 L/min. Vital signs were monitored throughout the procedure using standard monitors. All procedures began with the participants in the left lateral position. Examinations were performed with gastroscopes (GIF‐HQ290, GIF‐H290Z, GIF‐H260; Olympus Co. Ltd, Tokyo, Japan; BL‐7000, Fujifilm, Japan) and colonoscopes (CF‐HQ290I, CF‐H260AI, Olympus, Japan; BL‐7000, Fujifilm, Japan). Room air was used for insufflation. All examinations followed the EGD‐colonoscopy sequence. Once the EGD was finished, the subsequent colonoscopy was carried out immediately. For induction, a standard premedication of 2 mg/kg of propofol was given. Additional doses of propofol (0.5 mg/kg) were administered as per the requirement according to the changes in vital signs such as deeper in breath, increase of heart rate or even body movement. In Group A, propofol was not administered any more after the EGD examination finished; in Group B, propofol was administered until the whole procedure finished; and in Group C, propofol was not administered any more after colonoscope inserted into the cecum. Cecal intubation was confirmed by the observation of cecal landmarks. Individuals in Group A and Group C underwent dynamic position changes during colonoscope withdrawal as follows: the supine position for the cecum, ascending colon, hepatic flexure (left lateral position when necessary) and transverse colon, the right lateral position (or 30 degrees to the right) for the splenic flexure and descending colon, and the left lateral position for the sigmoid colon and rectum. Individuals in Group B were kept in the left lateral position throughout the procedure. The bowel preparation quality was rated by the endoscopist according to the BBPS. The location, size, and morphology of any polyp found during the procedure were recorded. When a polyp was detected, a biopsy was taken or the polyp was removed and placed in a separate bottle and sent for histopathological examination. No complicated therapy was carried out in outpatient service, such as complex polypectomy for polyps larger than 5 mm in diameter and endoscopic submucosal dissection. The procedure time for EGD and colonoscopy were measured with a stopwatch. During the procedure, blood pressure, heart rate and SpO2 were recorded at three periods: before propofol administration; when the vital sign reached the lowest value; and when the whole examination finished. Individuals were monitored in the recovery unit after the examination and were not discharged until their Aldrete score were 9 or higher. The total dose of propofol, Modified Gloucester Comfort Scale (MGCS) score, recovery time, discharge time and sedation‐related adverse events were recorded.

Definition

The MGCS score, as observed by the assistant, was assessed with discomfort scored on a scale of 1–5 (1, no discomfort; 5, extreme discomfort). Scores of 1–3 were considered to indicate comfort, and scores of 4 and 5 were considered to indicate significant discomfort. Adenoma detection rate (ADR) was defined as the proportion of patients with at least one adenoma detected. Adenomas per positive patient (APP) was defined as the average number of adenomas detected in positive patient. Recovery time was defined as the interval between the last time when propofol was administrated and the first response after being woken up. Discharge time was defined as the interval between the end of the whole endoscopy procedure and Aldrete score reached 9 or higher.

Study outcomes

The primary outcome was patient comfort. The secondary outcomes were colonoscopy performance, including the cecal intubation rate (CIR), ADR and APP, total doses of propofol, changes in vital signs, recovery time, discharge time, and sedation‐related adverse events.

Statistical analysis

SPSS version 24.0 (SPSS Inc., Chicago, IL, USA) was used for the data analysis. Based on clinical experience, we assume that the patient comfort rate (the proportion of patients with MGCS score of 1–3) in sedated EGD followed by sedated colonoscopy could be 99%, and the rate may be 90% in sedated EGD followed by unsedated colonoscopy. With alpha risk set at 2.5%, a statistical power of 80%, noninferiority margin set at −0.01 and 20% exclusion rate after randomization, 98 subjects in each group are needed, 294 in total.

Exploratory data analysis and Shapiro–Wilk tests were performed to determine the normality of the data distribution. Normally distributed continuous data are expressed as the mean ± standard deviation (SD). Categorical variables are presented as counts and percentages. Continuous variables were compared using Student's t test between groups and by one‐way analysis of variance among multiple groups. Comparisons between time‐based measurements within each group were performed with repeated‐measures analysis of variance. Categorical variables were compared using the Pearson χ 2 test. A probability P value of < 0.05 was considered statistically significant, and all tests were two‐sided.

Results

Baseline demographic and clinical characteristics

A total of 3200 eligible individuals (1067 in Group A, 1067 in Group B and 1066 in Group C) were finally analyzed (Fig. 1). The participants in the three groups were comparable in terms of their demographic and clinical data. As shown in Table 1, there was no significant difference among the three groups in terms of age, sex, body mass index, history of abdominal or pelvic surgery, EGD examination time, colonoscope insertion time, and colonoscope withdrawal time (P > 0.05).

Figure 1

Flow diagram illustrating the selection of study subjects.

Table 1

Demographic and clinical data of the three groups

	Group A (n = 1067)	Group B (n = 1067)	Group C (n = 1066)	F/χ 2	P
Male/female	521/546	550/517	544/522	1.779	0.411
Age (years)	47.49 ± 7.416	47.70 ± 7.542	47.17 ± 7.376	1.343	0.261
Body mass index (kg/m2)	26.43 ± 5.467	26.81 ± 5.661	26.89 ± 5.971	2.006	0.135
History of abdominal or pelvic surgery, n (%)	141(13.2)	135(12.7)	138(12.9)	0.150	0.928
EGD examination time (s)	269.33 ± 17.50	270.01 ± 17.69	269.53 ± 17.48	0.423	0.655
Colonoscope insertion time (s)	150.66 ± 17.53	151.17 ± 17.44	149.98 ± 17.58	1.251	0.286
Colonoscope withdrawal time (s)	425.01 ± 52.22	425.95 ± 53.67	424.67 ± 52.12	0.169	0.844

EGD, esophagogastroduodenoscopy.

Patient discomfort

The MGCS scores of the three groups are presented in Table 2. In Group A, 944 participants (88.5%) were scored 1 point (no discomfort), 85 participants (8.0%) were scored 2 points (minimal discomfort), and 38 participants (3.5%) scored 3 points (mild discomfort). In Group B and Group C, all participants were scored 1 point. The MGCS of the three groups were all rated as comfortable (scale 1–3). Mild discomfort rarely caused involuntary movements, and abdominal press by an assistant was taken in time when necessary.

Table 2

Comparison among patient discomfort in the three groups during the examination

	Group A (n = 1067)	Group B (n = 1067)	Group C (n = 1066)
MGCS, n (%)
1	944 (88.5)	1067 (100)	1066 (100)
2	85 (8.0)	‐	‐
3	38 (3.5)	‐	‐
4	‐	‐	‐
5	‐	‐	‐

MGCS, Modified Gloucester Comfort Scale; 1, no discomfort; 2, minimal discomfort; 3, mild discomfort; 4, obvious discomfort; 5, extreme discomfort.

Colonoscopy performance

The CIR was 100% in each group. As shown in Table 3, the ADRs of Group A, Group B, and Group C were 46.9% (500/1067), 42.6% (455/1067), and 45.0% (480/1066), respectively. There was no significant difference between the three groups (χ 2 = 3.858, P > 0.05). The APPs of Group A, Group B, and Group C were 2.29 ± 1.055, 2.11 ± 0.946, and 2.28 ± 0.931, respectively. The APP of Group B was significantly lower than those of Group A and Group C (P < 0.05), and there was no significant difference between Group A and Group C (P > 0.05).

Table 3

Comparison of ADR and APP between three groups

	Group A (n = 1067)	Group B (n = 1067)	Group C (n = 1066)	χ 2 /F	P
ADR	46.9%	42.6%	45.0%	3.858	0.145
APP	2.29 ± 1.055	2.11 ± 0.946 a	2.28 ± 0.931 b	5.059	0.006

Compared with Group A, P < 0.05.

Compared with Group B, P < 0.05.

ADR, adenoma detection rate; APP, adenomas per positive patient.

Sedation‐related indicators

As shown in Table 4, there was no significant difference in systolic blood pressure, diastolic blood pressure, heart rate or SpO2 between the three groups before propofol administration (T0) (P > 0.05). The vital signs declined to different degrees during the procedure (T1) in all groups, and the decline was most obvious in Group B (P < 0.05). These change episodes were transient, and the patients recovered soon afterward.

Table 4

Comparison among vital signs in the three groups throughout the examination

		T0	T1	T2	F	P
SBP (mmHg)	Group A	117.12 ± 26.186	109.86 ± 21.269	120.49 ± 18.881	66.202	< 0.001
	Group B	115.62 ± 19.9	96.81 ± 13.81 a	104.52 ± 14.14 a	365.314	< 0.001
	Group C	117.13 ± 27.915	102.94 ± 23.11 a , b	102.08 ± 24.031 a , b	125.839	< 0.001
	F	1.297	115.938	282.182
	P	0.274	< 0.001	< 0.001
DBP (mmHg)	Group A	69.53 ± 20.592	64.98 ± 19.537	68.67 ± 16.24	17.501	< 0.001
	Group B	70.88 ± 13.702	54.03 ± 14.354 a	66.39 ± 10.516 a	507.286	< 0.001
	Group C	70.02 ± 17.225	60.27 ± 15.676 a , b	69.67 ± 11.437 b	151.654	< 0.001
	F	1.631	115.872	17.864
	P	0.196	< 0.001	< 0.001
HR (n/min)	Group A	78.69 ± 13.059	72.7 ± 10.119	74.7 ± 12.293	71.934	< 0.001
	Group B	79.26 ± 9.578	67.98 ± 9.678 a	75.75 ± 9.022 a	388.831	< 0.001
	Group C	78.68 ± 11.957	69.86 ± 12.831 a , b	76.75 ± 12.335 a , b	152.847	< 0.001
	F	0.874	50.015	8.712
	P	0.417	< 0.001	< 0.001
SpO2(%)	Group A	97.13 ± 2.065	93.01 ± 5.747	97.6 ± 1.725	530.750	< 0.001
	Group B	97.14 ± 1.802	88.53 ± 6.032 a	98.05 ± 1.401 a	2133.726	< 0.001
	Group C	97.04 ± 2.398	91.46 ± 3.999 a , b	97.55 ± 1.752 b	1483.080	< 0.001
	F	0.705	194.159	30.336
	P	0.494	< 0.001	< 0.001

Compared with Group A, P < 0.05.

Compared with Group B, P < 0.05.

Continuous variables were compared using one‐way analysis of variance among multiple groups. Comparisons between time‐based measurements within each group were performed with repeated‐measures analysis of variance.

SBP, systolic blood pressure; DBP, diastolic blood pressure; HR, heart rate. T0, before propofol administration; T1, when the vital sign reached the lowest value; T2, when the whole examination finished.

As shown in Table 5, the total doses of propofol in Group A, Group B and Group C were 137.65 ± 36.865 mg, 177.71 ± 40.112 mg, and 161.63 ± 31.789 mg, respectively. The total doses of propofol in Group A was significantly lower than those in Group B and Group C (P < 0.001). The recovery time in Group A, Group B, and Group C were 5.01 ± 1.404 min, 9.51 ± 2.870 min, and 5.83 ± 2.594 min, respectively. The recovery time in Group A was significantly shorter than those in Group B and Group C (P < 0.001). The discharge time in Group A, Group B, and Group C were 3.53 ± 1.685 min, 11.29 ± 5.172 min, and 6.47 ± 2.338 min, respectively. The discharge time in Group A was significantly shorter than those in Group B and Group C (P < 0.001).

Table 5

Comparison of propofol doses, recovery time, and discharge time between the three groups

	Group A (n = 1067)	Group B (n = 1067)	Group C (n = 1066)	F	P
Doses of propofol (mg)	137.65 ± 36.865	177.71 ± 40.112 a	161.63 ± 31.789 a , b	326.964	0.000
Recovery time (min)	5.01 ± 1.404	9.51 ± 2.870 a	5.83 ± 2.594 a , b	1085.622	0.000
Discharge time (min)	3.53 ± 1.685	11.29 ± 5.172 a	6.47 ± 2.338 a , b	1400.152	0.000

Compared with Group A, P < 0.05.

Compared with Group B, P < 0.05.

As shown in Table 6, sedation‐related adverse events were observed in 316 individuals, such as transient apnea (lack of respiratory activity for < 15 s), coughing, and hiccup. The patients recovered soon after instant intervention such as patient stimulation, chin lift, and increasing oxygen supplementation. None of them experienced any severe adverse events such as emergent intubation, unanticipated hospitalization or death. There was no significant difference in the incidence of sedation‐related adverse events between the three groups (9.3% vs 10.3% vs 10.0%, P > 0.05).

Table 6

Comparison of sedation‐related adverse events between the three groups

	Group A (n = 1067)	Group B (n = 1067)	Group C (n = 1066)	χ 2	P
Total, n (%)	99 (9.3)	110 (10.3)	107 (10.0)	0.685	0.710
Transient apnea	24 (2.2)	36 (3.4)	31 (2.9)	2.466	0.291
Coughing	33 (3.1)	42 (3.9)	38 (3.6)	1.119	0.571
Hiccup	42 (3.9)	32 (3.0)	38 (3.6)	1.407	0.495

Discussion

The benefits of sedatives in transoral endoscopy have been relatively well described in previous studies, such as improving patient receptivity, satisfaction, and examination performance, and it is suggested that upper gastrointestinal endoscopy should be performed under sedation. , , Thus, we performed sedated EGD for all participants in this study. EGD followed by colonoscopy is believed to be the most beneficial sequence for same‐day painless BDE as a result of lower sedative doses, less cardiovascular stress, faster recovery, and less discomfort. , , The onset of the effect of propofol is 0.5–1 min, the peak effect is 2 min after intravenous injection, and the duration of the effect is 4–8 min. , Discomfort during colonoscopy varies during the procedure, most often occurring during insertion. In the EGD‐colonoscopy sequence with propofol sedation, patients are still under the influence of the initial bolus of propofol at the completion of EGD, which may alleviate the discomfort during colonoscope insertion. Consequently, a smaller or even no additional dose of propofol was needed to relieve the pain during colonoscopy. As shown in the present study, the discomfort scores in the three groups were all classified at the scale of comfortable according to the MGCS.

Besides the quality of the patient experience during and after sedation, the medical costs and recovery unit turnover should also be considered. In the present study, the recovery time and discharge time were both the shortest in the sedated EGD followed by unsedated colonoscopy group, which had the lowest propofol dose. In addition to general flow of an endoscopy unit, rapid recovery has a major impact on patient satisfaction and postprocedure education.

Changing position during colonoscopy is one of the easiest ways to improve colonoscopy quality, which removes the liquid from the area to be observed, places the bowel segment at the highest location in the abdominal cavity, opens the sharp angle at the folds, and improves the luminal distention with a small amount of air insufflation. However, deep‐sedated colonoscopy is conducted entirely in the left lateral position because it is difficult to move a deep‐sedated patient to change their position, and the supine position during deep sedation may increase respiratory movements, choking rates, and other respiratory problems. Several studies demonstrated that the use of sedation during colonoscopy increased the ADR comparing with unsedated colonoscopy, but they did not mention whether dynamic position changes were performed in unsedated colonoscopy, , , , , which may underestimate the quality of unsedated colonoscopy. As shown in the present study, the ADRs in all three groups were high and did not differ significantly from each other. Our result is in accordance with one research that showed unsedated colonoscopy had a high lesion detection rate, and the ADR was no lower than that of sedated colonoscopy. However, the ADR only ascertains whether at least one adenoma is identified, while more detected adenomas lead to higher risk stratification and shorter surveillance intervals. Dynamic position change is believed to be associated with more adenomas detected per patient, , , , , which was also verified in our results of APP. The APPs were higher in groups with position changes during withdrawal (P < 0.05).

A nationwide population‐based study showed that sedation during endoscopy was significantly associated with minor, but not major, cardiocerebrovascular disease adverse events, and no severe adverse events were reported in our study. The major adverse effects of propofol are respiratory depression and hypotension. Intraoperative and postoperative hypotension commonly occur and are associated with organ injury and poor outcomes. The risk factors for anesthesia‐related adverse events during endoscopy procedures remain uncertain. Geng et al. found that hypoxemia had no relationship with the total dosage of propofol during routine sedation for gastrointestinal endoscopy. A retrospective cohort study showed that higher propofol doses were associated with a higher incidence of arterial hypotension events. Similarly, an exploratory analysis found that longer periods of propofol sedation and larger propofol doses were associated with longer‐lasting and more‐profound hypotension. In the present study, blood pressure, heart rate, and SpO2 in the majority of the subjects declined to different degrees during the procedure; the decline became obvious with time and an increase in total propofol doses. Individuals undergoing deep‐sedated EGD followed by deep‐sedated colonoscopy (Group B) received the highest dose of propofol and experienced a greater drop in vital signs than the other two groups (P < 0.05). Previous studies demonstrated that hypoxemia is not uncommon (6.8% to 32%) with propofol sedation in gastrointestinal endoscopy examinations. , , , , , , , , The mean SaO2 dropped to 88.53 ± 6.032% in Group B in the present study, but previous studies mainly focused on the incidence of hypoxemia without reporting the mean value of SaO2 with propofol mono‐sedation. Similar with the result in a study conducted by Gustavo Andrade de Paulo et al. , the mean lowest SaO2 in monitored anesthesia care group was 90.03 ± 7.37%, but fentanyl was used besides propofol on a case‐by‐case basis. As there is no universally recognized definition of hypoxemia which varied in literature with differences in duration of oxygen desaturation (for ≥ 15 s; for > 30 s; for ≥ 5 min; for any duration during the endoscopy procedure; duration not mentioned), and oxygen saturation (< 90%; < 85%; < 92%), , , , , , , , , the results of hypoxemia rate were uncomparable.

This is the first multicenter prospective study investigating the optimal model for same‐day painless BDE under propofol sedation. Our study was designed with high‐quality control by only including the following: experienced endoscopists; high‐definition colonoscopes; patients with high bowel preparation quality; endoscopists with a colonoscopy withdrawal time no less than 6 min; and adapted dynamic position changes during withdrawal in unsedated colonoscopy, which are unique in eliminating many of the confounding variables found in prior studies. However, there were also several limitations. First, although the study intended to distinguish tiny difference which could be exaggerated in large outpatient volume between different sedation models and demonstrate a convincing conclusion with large sample size, it might create an exaggerated tendency to reject null hypotheses with clinically negligible differences. Second, the use of dynamic position changes in two of the three study groups might introduced unknown bias. However, position changes were regularly taken in routine colonoscopy without deep sedation and the use of dynamic position change reflects the real‐world condition. Third, the endoscopists and patients were not absolutely blinded to the sedation model, which was inevitable considering the study design. Fourth, the procedures were performed by experienced endoscopists, so such a conclusion cannot be applied to trainee endoscopists. But this suggests that endoscopists should improve their insertion skills rather than depend on sedation. Fifth, propofol was used for sedation in this study, and other sedative agents warrant further investigation.

In conclusion, for same‐day painless BDE, deep‐sedated esophagogastroduodenoscopy followed by unsedated colonoscopy appears to be an effective sedative strategy with the benefits of satisfactory patient comfort, reduced sedation dose, less cardiovascular stress, faster recovery, shorter discharge time and high colonoscopy quality. Tailoring sedation use to achieve comfortable procedures, enhance examination performance, and speed up patient turnover while lowering risks and costs, remains an important area for future research.