Automated endoscope reprocessors

Duodenoscope-Associated Infections: Update on an Emerging Problem

The duodenoscope is among the most complex medical instruments that undergo disinfection between patients. Transmission of infection by contaminated scopes has remained a challenge since its inception. Notable risk factors for pathogen transmission include non-adherence to disinfection guidelines, encouragement of biofilm deposition due to complex design and surface defects and contaminated automated endoscope reprocessors. The most common infections following endoscopy are endogenous infections involving the patient's own gut flora. Exogenous infections, on the other hand, are associated with contaminated scopes and can theoretically be prevented by effective reprocessing. Pseudomonas aeruginosa is currently the most common organism isolated from contaminated endoscopes. Of note, reports of multidrug-resistant duodenoscopy-associated outbreaks have surfaced recently, many of which occurred despite adequate reprocessing. The FDA and CDC currently recommend comprehensive cleaning followed with at least high-level disinfection for reprocessing of flexible GI endoscopes. Reports of duodenoscope-related outbreaks despite compliance with established guidelines have prompted professional and government bodies to revisit existing guidelines and offer supplementary recommendations for duodenoscope processing. For the purposes of this review, we identified reports of duodenoscope-associated infections from 2000 till date. For each outbreak, we noted the organisms isolated, the number of cases reported, any possible explanations of contamination, and the measures undertaken to end each outbreak. We have also attempted to present an overview of recent developments in this rapidly evolving field.

Portable disposable ultrathin endoscopy tested through percutaneous endoscopic gastrostomy

BACKGROUND

A portable disposable ultrathin endoscope (DUE) with high visual quality and maneuverability would reduce the need for expensive facilities and emergency endoscopy could be available anywhere. It would increase patient satisfaction, prevent unnecessary sedation, and reduce infection. Our aim was to evaluate the usefulness of portable DUE in performing percutaneous endoscopic gastrostomy (PEG).

METHODS

We prospectively enrolled patients who underwent PEG under DUE guidance and compared them with historical controls who underwent PEG under conventional ultrathin endoscopy (CUE) guidance. The primary outcomes were successful stomach visualization and PEG tube insertion.

RESULTS

Twenty-five patients (19 male) were enrolled and compared with 25 gender and indication-matched controls. The most common indications for PEG were aspiration due to stroke or brain injury, dementia, and head and neck cancer. Entrance into the stomach was achieved in 92.0% (23/25) and 96% (24/25) in the DUE and CUE groups, and PEG was performed in 91.3% (21/23) and 95.8% (23/24), respectively. The mean insertion time for the DUE and CUE groups were 22.7 ± 9.3 minutes and 17.1 ± 5.7 minutes (P = 0.044). The 3 cases of failure to reach the stomach in both groups were caused by esophageal blockage. The 3 cases of failed PEG tube insertion were caused by poor visualization of the insertion site. Bleeding and pneumoperitoneum occurred in 1 and 2 patients in the DUE group. One case of fever was noted in the CUE group. All adverse events were conservatively managed.

CONCLUSIONS

Our study shows that portable DUE in facilities without endoscopy equipment may be clinically feasible.

Setting up the Pediatric Endoscopy Unit

As pediatric gastrointestinal endoscopy continues to develop and evolve, pediatric gastroenterologists are more frequently called on to develop and direct a pediatric endoscopy unit. Lack of published literature and focused training in fellowship can render decision making about design, capacity, operation, equipment purchasing, and staffing challenging. To help guide management decisions, we distributed a short survey to 18 pediatric gastroenterology centers throughout the United States and Canada. This article provides practical guidance by summarizing available expert opinions on the topic of setting up a pediatric endoscopy unit.

Endoscope Reprocessing: Update on Controversial Issues

Several issues concerning endoscope reprocessing remain unresolved based on currently available data. Thus, further studies are required to confirm standard practices including safe endoscope shelf life, proper frequency of replacement of some accessories including water bottles and connecting tubes, and microbiological surveillance testing of endoscopes after reprocessing. The efficacy and cost-effectiveness of newer technology that allows automated cleaning and disinfection is one such controversial issue. In addition, there are no guidelines on whether delayed reprocessing and extended soaking may harm endoscope integrity or increase the bioburden on the external or internal device surfaces. In this review, we discuss the unresolved and controversial issues regarding endoscope reprocessing.

Survey of endoscope reprocessing in Korea

Background/Aims

There is a growing emphasis on quality management in endoscope reprocessing. Previous surveys conducted in 2002 and 2004 were not practitioner-oriented. Therefore, this survey is significant for being the first to target actual participants in endoscope reprocessing in Korea.

Methods

This survey comprised 33 self-filled questions, and was personally delivered to nurses and nursing auxiliaries in the endoscopy departments of eight hospitals belonging to the society. The anonymous responses were collected after 1 week either by post or in person by committee members.

Results

The survey included 100 participants. In the questionnaire addressing compliance rates with the reprocessing guideline, the majority (98.9%) had a high compliance rate compared to 27% of respondents in 2002 and 50% in 2004. The lowest rate of compliance with a reprocessing procedure was reported for transporting the contaminated endoscope in a sealed container. Automated endoscope reprocessors were available in all hospitals. Regarding reprocessing time, more than half of the subjects replied that reprocessing took more than 15 minutes (63.2%).

Conclusions

The quality management of endoscope reprocessing has improved as since the previous survey. A national survey expanded to include primary clinics is required to determine the true current status of endoscope reprocessing.

Is peracetic acid suitable for the cleaning step of reprocessing flexible endoscopes?

The bioburden (blood, protein, pathogens and biofilm) on flexible endoscopes after use is often high and its removal is essential to allow effective disinfection, especially in the case of peracetic acid-based disinfectants, which are easily inactivated by organic material. Cleaning processes using conventional cleaners remove a variable but often sufficient amount of the bioburden. Some formulations based on peracetic acid are recommended by manufacturers for the cleaning step. We performed a systematic literature search and reviewed the available evidence to clarify the suitability of peracetic acid-based formulations for cleaning flexible endoscopes. A total of 243 studies were evaluated. No studies have yet demonstrated that peracetic acid-based cleaners are as effective as conventional cleaners. Some peracetic acid-based formulations have demonstrated some biofilm-cleaning effects and no biofilm-fixation potential, while others have a limited cleaning effect and a clear biofilm-fixation potential. All published data demonstrated a limited blood cleaning effect and a substantial blood and nerve tissue fixation potential of peracetic acid. No evidence-based guidelines on reprocessing flexible endoscopes currently recommend using cleaners containing peracetic acid, but some guidelines clearly recommend not using them because of their fixation potential. Evidence from some outbreaks, especially those involving highly multidrug-resistant gram-negative pathogens, indicated that disinfection using peracetic acid may be insufficient if the preceding cleaning step is not performed adequately. Based on this review we conclude that peracetic acid-based formulations should not be used for cleaning flexible endoscopes.

Residual bioburden in reprocessed side-view endoscopes used for endoscopic retrograde cholangiopancreatography (ERCP)

BACKGROUND AND STUDY AIM

Worldwide some endoscopy units routinely continue to use manual reprocessing techniques for disinfection of side-view endoscopes. The aim of this study was to evaluate the outcome quality of manual reprocessing techniques for removal and inactivation of the bioburden from side-view endoscopes used for endoscopic retrograde cholangiopancreatography (ERCP) in a tertiary referral endotherapy unit in Sri Lanka.

METHODS

102 samples obtained from two different flexible side-view endoscopes (Olympus TJF Q 180V and Olympus TJF 160 R) were tested for microbial growth. Three samples were collected each time; one swab from the tip before and another after manual reprocessing. The third sample was collected by flushing the working channel with sterile normal saline after manual reprocessing. Microorganisms were identified by culturing the samples.

RESULT

: After reprocessing, culture-positive rates were 20 % and 9 % for the samples obtained from the tip and the working channel of the side-view endoscopes, respectively. Klebsiella spp. and Candida spp. were found to be the commonest microorganisms in the samples from the tips and from the working channels, respectively, of the reprocessed side-view endoscopes.

CONCLUSION

There is a high culture-positive rate after reprocessing of the side-view endoscopes using the manual reprocessing procedure, despite strict adherence to the protocol for reprocessing.

Concept and design engineering: endourology operating room

PURPOSE OF REVIEW

A dedicated operating room with fluoroscopic imaging capability and adequate data connectivity is important to the success of any endourology program. Proper understanding of the recent developments in technology in relation to operating room is necessary before planning an endourology operating room.

RECENT FINDINGS

An endourology operating room is a fluorocompatible operating room with enough space to accommodate equipment like multiple flat monitors to display video, C-arm with its monitor, ultrasonography machine, laser machine, intracorporeal lithotripsy unit, irrigation pumps and two large trolleys with instruments. This operating room is integrated with devices to continuously record and archive data from endovision and surface cameras, ultrasound and fluoroscopy. Moreover, advances made in data relay systems have created seamless two-way communication between the operating room and electronic medical records, radiological picture archiving and communication system, classroom, auditorium and literally anywhere in the world.

SUMMARY

A dedicated endourology operating room is required for any hospital, which has a significant amount of endourology procedures. A custom-made integrated endourology operating room will facilitate endourology procedures, smoothen the workflow in operating room and improve patient outcomes. Meticulous planning and involving experts in the field are critical for the success of the project.

Recent update of gastrointestinal endoscope reprocessing

As infection-related issues have become one of the most important concerns in endoscopy centers, proper reprocessing of endoscopes has attracted great interest. Compliance with established guidelines for reprocessing is critical to prevent pathogen transmission. However, hospital compliance with guidelines has not been satisfactory. To increase compliance, efforts have focused on developing new and more innovative disinfectants and an automated endoscope reprocessor. Reprocessing must be performed by appropriately trained personnel and regular monitoring of reprocessing is essential for quality assurance to improve compliance.