Adequate mucosal visualization is essential for high-quality esophagogastroduodenoscopy (EGD), as suboptimal inspection has been associated with missed upper gastrointestinal neoplasia. Recent meta-analyses report that up to 10% of upper gastrointestinal cancers and 23.9% of esophageal adenocarcinomas in Barrett’s esophagus are diagnosed within a short interval after a negative EGD, underscoring the importance of optimal mucosal visibility (1). The presence of salivary residues and gastric foam frequently impairs visibility, requiring intraprocedural instillation of water and antifoaming agents, like simethicone, through the endoscope channel using a syringe. Oral administration of Simethicone prior to EGD has been proposed as a simple alternative to improve mucosal visibility while reducing syringe use and overall simethicone consumption (2). Furthermore, Simethicone is not–water soluble and difficult to remove from endoscope channels, despite high level disinfection. It is frequently detected during borescope inspection of patient ready endoscope, where residues have been associated with retained moisture, biofilm formation, and infection risk (3). The American Gastroenterological Association therefore recommend minimizing its use and concentration and avoiding administration through the irrigation channel (1). Unlike the American guidelines, the European Society of Gastrointestinal Endoscopy (ESGE) does not impose such restrictions on its intraprocedural use. Instead, ESGE recommends intraprocedural Simethicone administration only when persistent bubbles or biliary fluids remain after oral premedication, impairing adequate mucosal visualization (2). 

We conducted a non-inferiority case–control study comparing two simethicone administration strategies. We included only elective outpatient EGDs, excluding inpatient and emergency procedures. Standard endoscopic instillation via syringe, used only when considered necessary to improve mucosal visualization, was adopted in February, April, and June 2023, whereas oral premedication with 20 drops (0.6 mL) of simethicone diluted in 50 mL of water, administered 5 minutes before the procedure, was adopted in March, May and July 2023. A monthly alternation of the two strategies was adopted to limit selection bias linked to consecutive EGDs. Outcomes included the proportion of procedures requiring additional syringe use instillation, total simethicone consumption, and overall procedural costs.

A total of 1368 EGDs were performed during the study period (710 in the intervention group and 658 in the control group). Additional syringe use was required in 5% of cases in the intervention group compared with 51% in the control group. The number of syringe use decreased from 337 to 22 in the intervention group, representing a 94% reduction. Simethicone consumption decreased from 0.95 mL to 0.64 mL/per exam (-32%). Costs decreased from € 0.270 to €0.097/per gastroscopy (–64 %), corresponding to an estimated annual saving of €173/1000 exams. 

This study support that the application of current ESGE recommendations is safe, effective, and cost-saving strategy. It maintains diagnostic quality reducing procedural costs, representing an improvement for routine endoscopy practice.