Unsedated diagnostic endoscopy safety and ability for immediate patient discharge should be judged in light of the adequate performance of the examination and patients’ preferences. The study aimed to evaluate the impact of unsedated diagnostic endoscopy on performance measures

We performed a systematic review across MEDLINE and Cochrane Central Register for all types of trials assessing the effect of unsedated endoscopy on endoscopy performance from 2014 to 2025. Diagnostic colonoscopy quality measures (Adenoma Detection Rate - ADR, cecal Intubation Rate – CIR) and diagnostic ultrathin or transnasal gastroscopy completion rates, as well as patient-reported discomfort rates, comprised our outcomes. We conducted pairwise meta-analyses to present effect sizes for study outcomes, represented as either Odds Ratios (OR) or Mean Differences (MD), along with 95% confidence intervals (CI). The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach.

Eight studies (six retrospective cohort, one RCT, and one cross-sectional) with 60383 patients (53633 sedated, 6750 unsedated) examining the efficacy of unsedated versus sedated diagnostic colonoscopy were included. Compared to colonoscopy under sedation, unsedated colonoscopy resulted in similar ADR [OR 0.97, 95% CI (0.84-1.13), I²=71%] as well as CIR [OR 1.65, 95% CI (0.45-6.01), I²=91%]; there was low confidence in estimates. Notably, colonoscopy without sedation was not associated with an increased level of patients’ discomfort. [MD=0.45; 95% CI (0.11-1.83); I²=100%] compared to sedated procedures. The certainty of evidence was very low. Three RCTs with 703 patients (354 sedated, 349 unsedated) evaluated unsedated versus sedated diagnostic gastroscopy. Their pooled results showed a marginally higher procedure completion rate with the use of unsedated gastroscopy [OR 95% CI 0.98, (0.96-1.00), p=0.70; I²=100%] but significantly lower distress rates [MD -1.01, 95% CI (-1.60 - -0.42), I²=0%]. The certainty of evidence was very low.

Recent evidence indicates that unsedated diagnostic endoscopy is feasible and efficacious in willing patients compared to standard endoscopy under sedation.