Post written by Ali El Mokahal, MD, from the American University of Beirut, Beirut, Lebanon.

In this study, we investigated the impact of procedural sequence during same-day bidirectional endoscopy conducted with the patient under monitored anesthesia care. Our primary outcome was the time to recovery from sedation.

We also evaluated the amount of sedation administered, time spent in deep sedation, as well as patient and endoscopist satisfaction and compared the incidence of adverse events.

Studies regarding the optimal procedural sequence for same-day bidirectional endoscopy have been heterogenous in their outcomes, and the effect of different sequences on clinical outcomes is unclear.

In this clinical trial, we randomized 120 patients, with 60 undergoing EGD as the initial procedure and 60 undergoing colonoscopy first. Our findings revealed no clinically significant differences between the procedural sequences in patients undergoing same-day bidirectional endoscopy.

In addition to the myriad factors assessed in prior studies, to our knowledge, this was the first to assess the time spent in deep sedation as a clinical outcome, and we found no difference between the 2 sequences. As such, the decision of which procedure is performed first needs to be individualized according to the patient and the setting.

A major benefit of performing EGD first is that biopsy forceps can be reused in the subsequent colonoscopy, but this is not possible with the reverse sequence.

Moreover, in scenarios where there is concern for aerosolization of airborne pathogens, colonoscopy can be performed first to minimize the exposure time of healthcare workers to infectious agents.

Flowchart describing patient enrollment in the study. E-C, EGD first followed by colonoscopy; C-E, colonoscopy first followed by EGD.

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