Sedation Choice Does Not Impact Procedure Duration in Endoscopic Food Bolus Disimpaction - A Multisite Experience

Introduction: Esophageal food impaction (EFI) is a common gastrointestinal complaint, often prompting presentation to the emergency department (ED) and requiring esophagogastroduodenoscopy (EGD) for disimpaction. Methods for procedural sedation include moderate sedation (MS) or anesthesia administered sedation (AAS), which refers to monitored anesthesia care and general anesthesia. Endoscopy staff typically administers MS, but this may be burdensome to the endoscopist managing a potentially emergent condition. We aimed to evaluate differences in case duration with EFI interventions under MS versus AAS and their clinical implications. Methods: We conducted a retrospective review of 554 adult patients who presented to the ED with suspected EFI at the 3 Lifespan academic or community hospital sites from 2015 to 2021. Forty-five patients were excluded for absence of EFI on EGD. We compared procedure time (“scope in” and “scope out”) and sedation duration by MS versus AAS. Procedure and sedation durations were also compared by Charlson Comorbidity Index (CCI) and rate of complications (perforation, aspiration, esophageal ulceration, surgical intervention). Chi-square, Fisher exact test, and Student’s t-tests were performed for descriptive analysis to report demographics and other health-related measurements. Analysis was performed in SAS version 9.4. Results: The main significant finding was a lower average sedation duration under MS (93.4±165.2 minutes) versus AAS (176.1±541.8) (P = 0.0423). The average procedure duration was not statistically significant (MS 19.3±90.2 versus AAS 27.8±36.1; P = 0.1758). Further findings that did not reach statistical significance are as follows: procedures with at least 1 complication had average procedure and sedation durations of 32.1±30.5 and 338.4±635.5, compared to no complications at 22.1±75.8 (P = 0.2657) and 117.7±346 (P = 0.1867), respectively. Average procedure and sedation duration among individuals with CCI >2 was 26.0±30.8 and 194.7±658.0, compared with individuals with CCI ≤ 2 at 21.6±81.7 (P = 0.4367) and 108.9±245.6 (P = 0.2213), respectively (Figure 1, Table 1) Conclusion: In this multisite cohort study, we found no association between overall procedure duration in MS versus AAS, despite a lower sedation time under MS. Furthermore, comorbidity burden was not demonstrated to impact procedural or sedation duration, and neither procedural nor sedation duration were associated with complication rates.Figure 1.: Procedure duration by moderate sedation (midazolam and fentanyl) and anesthesia administered sedation (monitored anesthesia care or general anesthesia). Table 1. - Baseline Patient ENCOUNTER characteristics Patient Characteristics Moderate Sedation (n = 316, 62.1%) Anesthesia Administered Sedation (n = 193, 37.9%) P-Value Overall (n = 509) Male gender, no. (%) 202 (63.9) 118 (61.1) 0.5282 320 (62.9) White race, no. (%) 266 (84.2) 184 (95.3) 0.0001 450 (88.4) Hispanic or Latino, no. (%) 20 (6.3) 8 (4.2) 0.0261 28 (5.5) Age at admission, mean (SD) 59.1 (20.6) 56.7 (22.0) 0.2153 58.2 (21.2) Hospitalized, no. (%) 37 (11.7) 59 (30.6) < 0.0001 96 (18.9) Setting procedure was performed < 0.0001 ER/ICU, no. (%) 59 (18.7) 38 (19.7) 97 (19.1) Endoscopy unit, no. (%) 255 (80.1) 31 (16.1) 286 (56.2) Operating room, no. (%) 2 (0.6) 124 (24.8) 126 (24.8) BMI, mean (SD) 28.1 (5.9) 27.0 (5.5) 0.0822 27.7 (5.8) Tobacco, no. (%) 33 (11.8) 22 (12.3) 0.8819 55 (12.0) Marijuana, no. (%) 9 (4.2) 17 (17.2) < 0.0001 26 (8.2) Alcohol, no. (%) 98 (38.9) 75 (45.5) 0.1833 173 (41.5) CCI, mean (SD) 1.4 (2.6) 1.0 (2.3) 0.0608 1.3 (2.5) ER, Emergency Room; ICU, Intensive Care Unit; CCI, Charlson Comorbidity Index; Moderate Sedation = Midazolam and Fentanyl. Anesthesia Administered Sedation = Monitored Anesthesia Care or General Anesthesia.