Propofol Versus Remimazolam in Gastrointestinal Endoscopy: A Comprehensive Systematic Review and Meta-Analysis of Randomized Controlled Trials

Propofol is the most commonly used intravenous anesthetic for endoscopic surgery, although it comes with various adverse effects. Research indicates that Remimazolam, which is considered a safe general anesthetic, is being increasingly adopted as an alternative to propofol in clinical settings. Our meta-analysis sought to evaluate whether the rate of adverse reactions associated with Remimazolam in gastrointestinal endoscopic procedures is acceptable, and whether its surgical success rate is at least comparable to that of propofol. Following the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines, we searched five electronic databases (PubMed, Scopus, Cochrane Library, Embase, and Web of Science) to identify eligible studies published up to January 2025. Using R version R.4.4, we reported outcomes as risk ratios (RRs) or mean differences (MDs) and confidence intervals (CIs). A P-value of ≤ 0.05 is considered statistically significant. Our meta-analysis included 37 studies encompassing 8533 patients. The results, analyzed using a random effects model, demonstrated no statistically significant difference in induction time between the two sedative groups, with an overall MD of 0.11 min (95% [- 0.10; 0.31], p = 0.2977). Patients in the Remimazolam group experienced longer total sedation times than those receiving Propofol, with an MD of 1.84 min (95% CI [0.61; 3.07], p = 0.0033). The pooled analysis indicated low heterogeneity (I 2 = 4.2%). There was no statistically significant difference between the two sedatives in procedure time, with an MD of 0.16 (95% CI: [−0.13; 0.45], p = 0.2689). The pooled analysis displayed moderate heterogeneity (I 2 = 43.5%, p = 0.0052). Remimazolam has demonstrated safety, showing a reduced incidence of hypotension, bradycardia, respiratory depression, and hypoxemia compared to propofol. However, efficacy outcomes including the induction time and total procedure time were comparable between the two groups. However, the results were heterogeneous, which could be due to variability in the perfumed procedures, co-analgesics or dosing.