Anesthesia with remimazolam versus dexmedetomidine and midazolam for the endoscopic submucosal dissection of the esophagus, stomach, and colorectum: A retrospective comparative study.

Objective Endoscopic submucosal dissection (ESD) requires prolonged and stable sedation. Although midazolam combined with dexmedetomidine (MDZ+DEX) is widely used, delayed postoperative awakening and hemodynamic instability remain concerns, particularly in elderly patients. This study aimed to compare the efficacy and safety of remimazolam (RMZ) with MDZ+DEX for sedation during ESD. Methods This single-center retrospective study was conducted in Japan. The primary outcome was the quality of postoperative awakening. The secondary outcomes included procedural outcomes and sedation-related adverse events, such as hypotension, bradycardia, and hypoxemia. Patients A total of 195 patients who underwent ESD between January 2023 and October 2025 were analyzed. The patients were divided into the RMZ group (n=69) and the MDZ+DEX group (n=126). Results The baseline patient and procedural characteristics were comparable between the two groups. The Postprocedural Richmond Agitation-Sedation Scale scores did not differ significantly. However, poor postoperative awakening was significantly less frequent in the RMZ group than in the MDZ+DEX group (27.5% vs. 76.2%, p<0.01). A propensity score matching analysis created 54 matched pairs, yielding a significantly lower rate of poor awakening in the RMZ group (27.8% vs. 68.5%, p<0.01). In patients aged ≥65 years, the incidence of hypotension was significantly lower in the RMZ group, accompanied by more favorable postoperative recovery profiles. No intraoperative perforations occurred in the RMZ group. Conclusion Remimazolam was associated with improved postoperative awakening and a lower incidence of hemodynamic adverse events compared with MDZ+DEX, particularly in elderly patients. Therefore, RMZ may be a useful alternative sedation strategy for ESD.