The optimal sedation regimen for gastrointestinal endoscopy that balances efficacy with patient safety remains undecided. We conduct a systematic review and meta-analysis aimed to compare the efficacy and safety of remimazolam combined with esketamine (RE) versus propofol combined with esketamine (PE) for sedation during gastrointestinal endoscopy

A systematic literature search was conducted in fuor search engines including PubMed, Cochrane Library, Scopus, and Web of Science using the keywords "remimazolam," "propofol," "esketamine," and "gastrointestinal endoscopy." We included only  randomized controlled trials (RCTs) comparing RE with PE. The primary outcomes were sedation sucuess rate and induction time and the incidence of adverse events, including hypotension, bradycardia, respiratory depression, tachycardia, injection pain, and nausea/vomiting. Data were pooled using a random-effects model

Four RCTs involving a total of 1219 patients (617 in the RE group and 602 in the PE group) were included in the meta- analysis. The sedation success rate was comparable between the two groups (Risk Ratio [RR] 1.00; 95% CI [0.98, 1.01]).

Compared to the PE group, the RE group showed a significantly longer induction time (Mean Difference 10.97 seconds; 95% CI [3.12, 18.82]). However, the RE group was associated with a significantly lower incidence of several adverse events. The risk of bradycardia (RR 0.32; 95% CI [0.11, 0.94]), respiratory depression (RR 0.33; 95% CI [0.18, 0.58]), and injection pain (RR 0.03; 95% CI [0.00, 1.05]) was significantly lower in the remimazolam group

There were no statistically significant differences between the groups in the incidence of hypotension (RR 0.60; 95% CI [0.34, 1.07]), nausea and vomiting (RR 0.95; 95% CI [0.53, 1.70]), or tachycardia (RR 0.95; 95% CI [0.09, 10.39]).

When combined with esketamine for gastrointestinal endoscopy, remimazolam demonstrates comparable sedative efficacy to propofol. While remimazolam has a longer induction time, it offers a superior safety profile, with significantly lower risks of bradycardia, respiratory depression, and injection pain. These findings suggest that remimazolam combined with esketamine is a safe and effective alternative to the propofol-based regimen