Sedation is required to perform endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) given the duration and complexity of these advanced procedures. 

Sedation options include anesthetist-directed sedation vs. gastroenterologist-directed sedation. 

Although anesthetist-directed sedation has been shown to shorten induction and recovery times, it is not established whether it impacts likelihood of procedure completion. 

Dr James Buxbaum and colleagues from California, USA assessed whether anesthetist-directed sedation impacts the success of advanced endoscopy procedures.

The team prospectively assessed the sedation strategy for patients undergoing ERCP and EUS between 2010 and 2013. 

Although assignment to anesthetist-directed sedation vs. gastroenterologist-directed sedation was not randomized, it was determined by day of the week. 

A sensitivity analysis using propensity score matching was used to model a randomized trial. 

The research team's main outcome, procedure failure, was defined as an inability to satisfactorily complete the ERCP or EUS such that an additional endoscopic, radiographic, or surgical procedure was required. 

Failure was further categorized as failure due to inadequate sedation vs. technical problems.

During the 3-year study period, 60% of the 1,171 procedures were carried out with gastroenterologist-directed sedation, and 40% were carried out with anesthetist-directed sedation. 

The researchers found that failed procedures occurred in 13% of gastroenterologist-directed sedation cases compared with 9% of anesthetist-directed sedation procedures.

This was driven by a higher rate of sedation failures in the gastroenterologist-directed sedation group at 7%, than in the anesthetist-directed sedation group at 1%. 

The team observed no difference in technical success between the gastroenterologist-directed sedation, and anesthetist-directed sedation groups. 

The researchers were able to match 417 gastroenterologist-directed sedation cases to 417 anesthetist-directed sedation cases based on procedure type, indication, and propensity score. 

Analysis of the propensity score-matched patients confirmed our findings of increased sedation failure but not technical failure in gastroenterologist-directed sedation compared with anesthetist-directed sedation procedures. 

The team noted that adverse events of sedation were rare in both groups. 

Failed ERCP in the gastroenterologist-directed sedation group resulted in a total of 93 additional days of hospitalization. 

The researchers estimated that $67,891 would have been saved if anesthetist-directed sedation had been used for all ERCP procedures. 

No statistically significant difference in EUS success was identified, although this sub-analysis was limited by sample size.

Dr Buxbaum's team concludes, "Anesthetist-directed sedation improves the success of advanced endoscopic procedures."

"Its routine use may increase the quality and efficiency of these services."