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Friedlander JA, Leinwand K, Bhardwaj V, Nguyen N. A guide on transnasal endoscopy: setting up a pediatric unsedated endoscopy program. Front Pediatr 2024; 11:1267148. [PMID: 38293661 PMCID: PMC10825669 DOI: 10.3389/fped.2023.1267148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 12/04/2023] [Indexed: 02/01/2024] Open
Abstract
Background Unsedated transnasal endoscopy is becoming an increasingly popular option for the evaluation of upper gastrointestinal tract disorders in adults and children worldwide. This innovative technology has transformative potential as it provides for a more efficient, safe, and cost-effective method for endoscopy and reduces the risks associated with anesthesia, which is particularly relevant in pediatrics as endoscopy is commonly done under general anesthesia or conscious sedation. The aim is to address knowledge gaps amongst pediatric gastroenterologists who may be considering the development of a TNE program, detailing how to implement sedation-free TNE into practice for pediatric patients and current and forthcoming technologies. Methods We conducted a comprehensive review of current literature and collection of data from experts and clinicians in the field on how sedation-free programs were started and being conducted. We aimed to collate the data to provide a guide to address knowledge gaps with a focus on setting up and starting a sedation-free endoscopy program. Results Here in, we provide a detailed guide for implementing a sedation-free endoscopy program in pediatrics including design and layout of a TNE unit, special staffing needs, equipment, current and forthcoming technologies, financial considerations and training considerations. We highlight special considerations that are relevant in pediatrics incorporating distraction or dissociation techniques such as Virtual Reality Systems, developmentally appropriate preparation for children, and topical analgesia. Conclusion Sedation-free endoscopy is a rapidly growing option for pediatric patients. Development of an unsedated pediatric endoscopy program will improve patient care, decrease the need for anesthesia, provide a lower cost and safe alternative to traditional sedated endoscopy, and is a viable component to a pediatric gastroenterology practice.
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Affiliation(s)
| | - Kristina Leinwand
- Pediatric Gastroenterology, Northwest Permanente/Kaiser Permanente Physicians & Surgeons, Portland, OR, United States
- Division of Pediatric Gastroenterology, Oregon Health & Sciences University, Portland, OR, United States
| | - Vrinda Bhardwaj
- Division of Gastroenterology, Hepatology and Nutrition, Children’s Hospital Los Angeles, Los Angeles, CA, United States
- University of Southern California, Los Angeles, CA, United States
| | - Nathalie Nguyen
- Gastrointestinal Eosinophilic Diseases Program, Section of Pediatric Gastroenterology, Hepatology and Nutrition, University of Colorado School of Medicine; Digestive Health Institute, Children’s Hospital Colorado, Aurora, CO, United States
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Lisotti A, Fusaroli P, Napoleon B, Cominardi A, Zagari RM. Single-use duodenoscopes for the prevention of endoscopic retrograde cholangiopancreatography -related cross-infection – from bench studies to clinical evidence. World J Methodol 2022; 12:122-131. [PMID: 35721249 PMCID: PMC9157629 DOI: 10.5662/wjm.v12.i3.122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 01/16/2022] [Accepted: 03/17/2022] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Several strategies have been implemented to reduce or abolish the life-threatening risk of endoscopic retrograde cholangiopancreatography (ERCP)-related multidrug-resistant infections due to duodenoscopes contaminations; among those strategies, serial microbiologic tests, thorough reprocessing schedules, and use of removable scope cap have been adopted, but the potential cross-infection risk was not eliminated.
AIM To review available evidence in the field of single-use duodenoscopes (SUD) use for ERCP.
METHODS An overview on ongoing clinical studies was also performed to delineate which data will become available in the next future.
RESULTS One bench comparative study and four clinical trials performed with EXALT model-D (Boston Scientific Corp., United States) have been identified. Of them, one is a randomized controlled trial, while the other three studies are prospective single-arm, cross-over studies. Pooled technical success rate (4 studies, 368 patients) was 92.9% [95% confidence interval (CI): 89.9-95.5; I2: 11.8%]. Pooled serious adverse event (4 studies, 381 patients) rate was 5.9% [3.7%-8.5%; I2: 0.0%].
CONCLUSION Although few clinical trials are available, evidence is concordant in identifying an absolute feasibility and safety and feasibility for SUD use for ERCP. The expertise and quality of evidence in this field are going to be improved by further large clinical trials; data on cost-effectiveness and environmental impact will be needed for a worldwide spread of SUD use for ERCP.
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Affiliation(s)
- Andrea Lisotti
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Pietro Fusaroli
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Bertrand Napoleon
- Gastroenterology Unit, Hôpital privé Jean Mermoz - Ramsay Générale de Santé, Lyon 69008, FR, France
| | - Anna Cominardi
- Gastroenterology Unit, Hospital of Imola, University of Bologna, Imola 40026, BO, Italy
| | - Rocco Maurizio Zagari
- Dipertimento Di Scienze Mediche e Chirurgiche, Università di Bologna, Policlinico San Orsola Malpighi, Bologna 40138, Italy
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Tran VN, Park S, Khan F, Truong VG, Jeong S, Lee DH, Kim YM, Kang HW. Collective bacterial disinfection by opto-chemical treatment on mature biofilm in clinical endoscope. JOURNAL OF PHOTOCHEMISTRY AND PHOTOBIOLOGY. B, BIOLOGY 2022; 226:112367. [PMID: 34847498 DOI: 10.1016/j.jphotobiol.2021.112367] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023]
Abstract
The present study proposes an innovative opto-chemical treatment using a basket-integrated optical device (BIOD) to disinfect mature bacterial biofilm on endoscope channels. A BIOD was designed to position an optical diffuser on the central axis of an endoscope channel and to distribute laser light concentrically to the bacterial biofilm on the channel surface. To apply thermal damage and oxidative stress to the bacterial biofilm, a low concentration of a crosslinking agent (glutaraldehyde ~0.5%) was combined with 808 nm infrared (IR) and 405 nm blue (BL) laser lights. The applied irradiances of IR and BL were 10 W/cm2 and 1.6 W/cm2 for Teflon channel model and 20 W/cm2 and 3.2 W/cm2 for a clinical model, respectively. Individual irradiation of either IR or BL for 180 s induced the maximum temperatures of 62 ± 2 °C and 53 ± 3 °C on the biofilm, respectively. The simultaneous opto-chemical treatment reduced a significant population of the bacterial biofilms (7.5-log10 for Staphylococcus aureus and 7.1-log10 for Pseudomonas aeruginosa), which were 2.9-fold and 3.9-fold higher than that of the standard treatment with 2% glutaraldehyde (GA) solution, respectively. The proposed opto-chemical disinfection method can help reduce multi-drug resistant bacteria and prevent cross-infection during the clinical usage of a flexible endoscope.
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Affiliation(s)
- Van Nam Tran
- Industry 4.0 Convergence Bionics Engineering, Pukyong National University, Busan 48513, South Korea
| | - Suhyun Park
- Department of Electronic and Electrical Engineering, Ewha Womans University, Seoul 03760, South Korea
| | - Fazlurrahman Khan
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, South Korea
| | - Van Gia Truong
- Industry 4.0 Convergence Bionics Engineering, Pukyong National University, Busan 48513, South Korea
| | - Seok Jeong
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22212, South Korea
| | - Don Haeng Lee
- Division of Gastroenterology, Department of Internal Medicine, Inha University College of Medicine, Incheon 22212, South Korea
| | - Young-Mog Kim
- Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, South Korea; Department of Food Science and Technology, Pukyong National University, Busan 48513, South Korea
| | - Hyun Wook Kang
- Industry 4.0 Convergence Bionics Engineering, Pukyong National University, Busan 48513, South Korea; Research Center for Marine Integrated Bionics Technology, Pukyong National University, Busan 48513, South Korea; Department of Biomedical Engineering, Pukyong National University, Busan 48513, South Korea.
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Kwakman JA, Rauwers AW, Klaassen CHW, Bruno MJ, Vos MC. Investigation of possible transmission of a susceptible microorganism through a contaminated duodenoscope; a case report. Antimicrob Resist Infect Control 2021; 10:127. [PMID: 34454611 PMCID: PMC8403455 DOI: 10.1186/s13756-021-00996-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2021] [Accepted: 08/20/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Despite compliance to extensive reprocessing protocols, duodenoscopes have been linked to outbreaks of susceptible and multi-drug resistant organisms (MDRO) due to persistent duodenoscope contamination. Duodenoscope-associated infections (DAIs) based on transmission of susceptible microorganisms are likely to be underreported due to detection bias. CASE PRESENTATION We describe the retrospective detection of a DAI case caused by a susceptible microorganism which at the time of clinical infection was not recognized as such. During 2017 and 2018, duodenoscopes were cultured on a daily basis due to research activities. While analyzing this data, it was found that a duodenoscope had been contaminated with Enterobacter cloacae complex over a period of 3 months. We checked whether patients treated with this duodenoscope had developed infections and found one patient with an E. cloacae cholangitis 3 months after the ERCP (Endoscopic retrograde cholangiopancreaticography) procedure. The isolates on the duodenoscope and in the patients' blood culture were indistinguishable by amplified fragment length polymorphism (AFLP). By classical multi-locus sequence typing (MLST), both strains were of the same (but novel) sequence type. Application of whole genome MLST showed 93 (out of 3757) allelic differences. CONCLUSION This case report describes a plausible link between a contaminated duodenoscope and a patient infection with E. cloacae. Transmission of susceptible E. cloacae was highly suspected from AFLP and MLST results; by WGS, 93 allelic differences were found which proves closely related strains. This report shows that DAIs by susceptible microorganisms can be easily missed and therefore its true prevalence remains underscored.
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Affiliation(s)
- Judith A Kwakman
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Dr. Molewaterplein 40, Mailbox 2040, Rotterdam, The Netherlands. .,Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Arjan W Rauwers
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Dr. Molewaterplein 40, Mailbox 2040, Rotterdam, The Netherlands.,Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Corné H W Klaassen
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Marco J Bruno
- Department of Gastroenterology and Hepatology, Erasmus MC University Medical Center, Dr. Molewaterplein 40, Mailbox 2040, Rotterdam, The Netherlands
| | - Margreet C Vos
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Larsen S, Russell RV, Ockert LK, Spanos S, Travis HS, Ehlers LH, Mærkedahl A. Rate and impact of duodenoscope contamination: A systematic review and meta-analysis. EClinicalMedicine 2020; 25:100451. [PMID: 32954234 PMCID: PMC7486302 DOI: 10.1016/j.eclinm.2020.100451] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND Multiple infection outbreaks have been linked to contaminated duodenoscopes worldwide. However, the contamination rate of patient-ready duodenoscopes varies highly amongst published studies testing this subject. We aimed to estimate the contamination rate of reprocessed patient-ready duodenoscopes for endoscopic retrograde cholangio-pancreatography (ERCP) based on currently available data. METHODS We searched the PubMed and Embase databases from January 1, 2010 until March 10, 2020, for citations investigating contamination rates of reprocessed patient-ready duodenoscopes. Studies not assessing other types of endoscopes than duodenoscopes were excluded from the analysis. Study eligibility and data extraction was evaluated by three reviewers independently. A random-effects model (REM) based on the proportion distribution was used to calculate the pooled total contamination rate of reprocessed patient-ready duodenoscopes. Subgroup analyses were carried out to assess contamination rates when using different reprocessing methods by comparing single high-level disinfection (HLD) with double HLD and ethylene oxide (EtO) gas sterilization. Additionally, we investigated the contamination rate between studies conducted following an outbreak compared to non-outbreak-initiated studies. FINDINGS We identified 15 studies that fulfilled the inclusion, which included 925 contaminated duodenoscopes from 13,112 samples. The calculated total weighted contamination rate was 15.25% ± 0.018 (95% confidence interval [Cl]: 11.74% - 18.75%). The contamination rate after only using HLD was 16.14% ± 0.019 (95% Cl: 12.43% - 19.85%) and after using either dHLD or EtO the contamination rate decreased to 9.20% ± 0.025 (95% Cl: 4.30% - 14.10%). Studies conducted following an outbreak (n=4) showed a 5.72% ± 0.034 (95% Cl: 0.00% - 12.43%) contamination rate, and non-outbreak-initiated studies (n=11) revealed a contamination rate of 21.50% ± 0.031 (95% Cl: 15.35% - 27.64%). INTERPRETATION This is the first meta-analysis to estimate the contamination rate of patient-ready duodenoscopes used for ERCP. Based on the available literature, our analysis demonstrates that there is a 15.25% contamination rate of reprocessed patient-ready duodenoscopes. Additionally, the analysis indicates that dHLD and EtO reprocessing methods are superior to single HLD but still not efficient in regards to cleaning the duodenoscopes properly. Furthermore, studies conducted following an outbreak did not entail a higher contamination rate compared to non-outbreak-initiated studies. FUNDING The authors received no financial support for the research, authorship, and/or publication of this article.
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Key Words
- AGA, American Gastroenterological Association
- AORN, The Joint Commission and The Association of Perioperative Registered Nurses
- Bacterial*
- CDC, Center for Disease Control and Prevention
- CFU, colony-forming units
- CRE, carbapenem-resistant Enterobacteriaceae
- Cl, confidence interval
- Cross infection
- Drug Resistance
- Duodenoscopes
- ERCI, Environmental Risk Communications, Inc.
- ERCP, endoscopic retrograde cholangio-pancreatography
- Equipment contamination
- EtO, ethylene oxide
- FDA, Food & Drug Administration
- HLD, high-level disinfection
- Infection Control
- MDR, multi-drug-resistant
- MeSH, medical subject headings
- Multiple
- PRISMA, Preferred Reporting Items for Systematic Reviews and Meta-Analyses
- REM, random-effects model
- dHLD, double high-level disinfection
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Affiliation(s)
- Sara Larsen
- Ambu A/S, Ambu A/S, Baltorpbakken 13, 2750 Ballerup, Denmark
| | | | | | - Stephen Spanos
- Anesthesia and Acute Pain Department of Anesthesia University of Utah Primary Children's Hospital, United States
| | | | - Lars Holger Ehlers
- Department of Business and Management, Danish Center for Healthcare Improvements, Aalborg University, Aalborg, Denmark
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