To analyze the burden associated with performing inappropriate esophagogastroduodenoscopies (EGDs) in a tertiary endoscopy unit. We also sought to determine whether the clinical appropriateness of EGDs is associated with the use of sedation, thus also testing the hypothesis that prescribers assign EGDs requests of low clinical value with deep sedation, since these have longer waiting periods.

Retrospective observational study, conducted at a single center, including all consecutive requests for elective diagnostic EGD over a 3-month period (N = 314), excluding EGDs performed for therapeutic purposes or in an emergency setting. The appropriateness of the indication was assessed according to ASGE/ESGE criteria. Patient demographics, source of request (outpatients vs. inpatients) and type of sedation were recorded. The type of sedation was classified as no sedation, conscious sedation (benzodiazepines administered by the gastroenterologist), or deep sedation (performed by an anesthesiologist).  Statistical analysis included descriptive statistics, chi-square tests and estimation of effect measures with 95% confidence intervals (CI). Significance threshold was p < 0.05.

The average age of patients was 57.7 years, and 54.5% were women. Most requests originated from outpatient clinics (90.8%). Regarding sedation, 39.2% of the EGDs were performed without sedation, 32.8% with conscious sedation, and 29% with deep sedation. In total, 63.7% of requests were considered appropriate and 36.3% inappropriate.

A decrease in the appropriateness rate was observed as the level of sedation increased. The appropriateness rate was highest in exams without sedation (71.7%), decreased in exams with conscious sedation (68.0%), and fell sharply in exams performed under deep sedation, where less than half (48.4%) were in accordance with the indications (p < 0.001). Inappropriate requests were significantly more likely to be scheduled under deep sedation (RR = 1.87; 95% CI 1.33–2.63), p < 0.001.

If triage were implemented, 34 additional slots would be gained in non-sedated EGD shifts, 33 in mild sedation shifts, and 47 in deep sedation shifts, representing a direct recovery of 114 EGD slots in one trimester (456 annualized), which could be reallocated to patients with appropriate indications.

Economic costs were calculated using the unit costs reported by Areia et al. (60€ per EGD without deep sedation and 137€ with deep sedation), and we estimate that at least 10,459€ was spent on unnecessary EGDs (~41,836€ per year, assuming a stable rate).

Environmental costs were considered using the values of Elli et al. (5.43 kg of CO₂ per EGD), and we concluded that our cohort emitted at least 619 kg of CO₂ in unnecessary EGDs (about 2,476 kg of CO₂ per year, equivalent to the consumption of 1,000 liters of gasoline).

This 3-month cohort demonstrated that more than one-third of elective EGDs are inappropriate and confirmed that as the level of sedation increases, so do inappropriate requests. This burden translates into a substantial waste of resources with loss of procedural capacity (>450 slots/year), direct economic costs (>40,000€/year), and a major environmental impact (>2,400 kg CO₂/year). These results underscore the urgent need to implement effective triage strategies to optimize resource allocation, reduce costs, and mitigate the environmental impact associated with unnecessary procedures.