High-level endoscope disinfection processes in emerging economies: financial impact of manual process versus automated endoscope reprocessing

Remimazolam versus propofol for sedation in gastrointestinal endoscopic procedures: a systematic review and meta-analysis

BACKGROUND

Propofol has a favourable efficacy profile in gastrointestinal endoscopic procedures, however adverse events remain frequent. Emerging evidence supports remimazolam use in gastrointestinal endoscopy. This systematic review and meta-analysis compares remimazolam and propofol, both combined with a short-acting opioid, for sedation of adults in gastrointestinal endoscopy.

METHODS

We searched MEDLINE, Embase, and Cochrane databases for randomised controlled trials comparing efficacy-, safety-, and satisfaction-related outcomes between remimazolam and propofol, both combined with short-acting opioids, for sedation of adults undergoing gastrointestinal endoscopy. We performed sensitivity analyses, subgroup assessments by type of short-acting opioid used and age range, and meta-regression analysis using mean patient age as a covariate. We used R statistical software for statistical analyses.

RESULTS

We included 15 trials (4516 subjects). Remimazolam was associated with a significantly lower sedation success rate (risk ratio [RR] 0.991; 95% confidence interval [CI] 0.984-0.998; high-quality evidence) and a slightly longer induction time (mean difference [MD] 9 s; 95% CI 4-13; moderate-quality evidence), whereas there was no significant difference between the sedatives in other time-related outcomes. Remimazolam was associated with significantly lower rates of respiratory depression (RR 0.41; 95% CI 0.30-0.56; high-quality evidence), hypotension (RR 0.43; 95% CI 0.35-0.51; moderate-quality evidence), hypotension requiring treatment (RR 0.25; 95% CI 0.12-0.52; high-quality evidence), and bradycardia (RR 0.42; 95% CI 0.30-0.58; high-quality evidence). There was no difference in patient (MD 0.41; 95% CI -0.07 to 0.89; moderate-quality evidence) and endoscopist satisfaction (MD -0.31; 95% CI -0.65 to 0.04; high-quality evidence) between both drugs.

CONCLUSIONS

Remimazolam has clinically similar efficacy and greater safety when compared with propofol for sedation in gastrointestinal endoscopies.

An Actuated Variable-View Rigid Scope System to Assist Visualization in Diagnostic Procedures

OBJECTIVE

Variable-view rigid scopes offer advantages compared to traditional angled laparoscopes for examining a diagnostic site. However, altering the scope's view requires a high level of dexterity and understanding of spatial orientation. This requires an intuitive mechanism to allow an operator to easily understand the anatomical surroundings and smoothly adjust the scope's focus during diagnosis. To address this challenge, the objective of this work is to develop a mechanized arm that assists in visualization using variable-view rigid scopes during diagnostic procedures.

METHODS

A system with a mechanized arm to maneuver a variable-view rigid scope (EndoCAMeleon - Karl Storz) was developed. A user study was conducted to assess the ability of the proposed mechanized arm for diagnosis in a preclinical navigation task and a simulated cystoscopy procedure.

RESULTS

The mechanized arm performed significantly better than direct maneuvering of the rigid scope. In the preclinical navigation task, it reduced the percentage of time the scope's focus shifted outside a predefined track. Similarly, for simulated cystoscopy procedure, it reduced the duration and the perceived workload.

CONCLUSION

The proposed mechanized arm enhances the operator's ability to accurately maneuver a variable-view rigid scope and reduces the effort in performing diagnostic procedures.Clinical and Translational Impact Statement: The preclinical research introduces a mechanized arm to intuitively maneuver a variable-view rigid scope during diagnostic procedures, while minimizing the mental and physical workload to the operator.

Scope actuation system for articulated laparoscopes

BACKGROUND

An articulated laparoscope comprises a rigid shaft with an articulated distal end to change the viewing direction. The articulation provides improved navigation of the operating field in confined spaces. Furthermore, incorporation of an actuation system tends to enhance the control of an articulated laparoscope.

METHODS

A preliminary prototype of a scope actuation system to maneuver an off-the-shelf articulated laparoscope (EndoCAMaleon by Karl Storz, Germany) was developed. A user study was conducted to evaluate this prototype for the surgical paradigm of video-assisted thoracic surgery. In the study, the subjects maneuvered an articulated scope under two modes of operation: (a) actuated mode where an operating surgeon maneuvers the scope using the developed prototype and (b) manual mode where a surgical assistant directly maneuvers the scope. The actuated mode was further assessed for multiple configurations based on the orientation of the articulated scope at the incision.

RESULTS

The data show the actuated mode scored better than the manual mode on all the measured performance parameters including (a) total duration to visualize a marked region, (a) duration for which scope focus shifts outside a predefined visualization region, and (c) number of times for which scope focus shifts outside a predefined visualization region. Among the different configurations tested using the actuated mode, no significant difference was observed.

CONCLUSIONS

The proposed articulated scope actuation system facilitates better navigation of an operative field as compared to a human assistant. Secondly, irrespective of the orientation in which an articulated scope's shaft is inserted through an incision, the proposed actuation system can navigate and visualize the operative field.

A cost comparison between reusable flexible and disposable laryngoscopes

OBJECTIVES

To compare the costs of disposable laryngoscopes to reusable scopes in outpatient and inpatient settings.

METHODS

The total variable and fixed costs involved in flexible scope reprocessing were collected from two general otolaryngology clinics, a pediatric otolaryngology clinic, and a children's hospital. Variable costs of disposable materials and labor were collected from 65 scope reprocessing events to identify the cost of reprocessing. Fixed costs of scope maintenance, monitors, video towers, and storage equipment were collected from financial records. Fixed and variable costs were analyzed to identify the cost per scope event. The costs were then compared to a theoretical model where disposable scopes were used to meet the volume demands of each clinic and children's hospital setting. The model of disposable scopes was generated after obtaining volume costs specific to each setting from a disposable scope company.

RESULTS

The average cost of a reusable scope model per scope event was $66.02 ± 4.49 at the three clinics and $130.66 at the children's hospital. The average cost of the disposable scope model per scope event was $152.55 ± 0.55 in the three clinics and $172.61 in the children's hospital. The cost differences were $86.53 ± 3.96 and $41.95 respectively.

CONCLUSIONS

In an outpatient clinic, reusable scopes are less expensive than a disposable scope model. In children's hospital inpatient setting, the difference in costs between disposable and reusable scopes is lower. When considering other non-economic factors, disposable scopes may be a feasible option, especially in the children's hospital setting.

Flexible gastrointestinal endoscope processing challenges, current issues and future perspectives

BACKGROUND

At present, the most frequent method for processing flexible gastrointestinal (GI) endoscopes is cleaning followed by high-level disinfection as terminal sterilization is often not practicable. Post-processing monitoring studies consistently show high levels of positive cultures remaining on endoscopes, which can lead to patient infection and even fatality. The processing deficiency is attributed to the complex design of endoscopes, incomplete cleaning, formation of biofilms and lack of margin of safety with high-level disinfection.

OBJECTIVE

To demonstrate that flexible GI endoscopes can be practicably terminally sterilized.

METHODS

An endoscope sterilization cycle was developed in a vaporized hydrogen peroxide sterilization system. The cycle was used to study the sterilization of flexible GI endoscopes which included colonoscopes and duodenoscope and material compatibility for both original flexible GI endoscopes and those experimentally modified endoscopes using compatible materials.

RESULTS

Testing demonstrated that the vaporized hydrogen peroxide can sterilize flexible GI endoscopes (colonoscopes, duodenoscope) with a sterility assurance level of 10^-6. Additionally, no recoverable survivors were detected when devices were artificially soiled with hard water and serum. Material compatibility test results demonstrated that replacing molybdenum disulphide lubricant with a graphite-based inert lubricant can make them compatible with vaporized hydrogen peroxide sterilizers.

CONCLUSION

Flexible GI endoscopes can be practicably terminally sterilized using vaporized hydrogen peroxide sterilization technologies if their materials are revised to become compatible.

Methods for Endoscope Reprocessing

Over the past 2 decades, in hospital centers worldwide, there have been numerous outbreaks of multidrug-resistant organisms that have since been attributed to endoscopic transmission of the infections between patients, primarily from duodenoscopes. These outbreaks have focused the attention of endoscope manufacturers, professional societies, and regulatory agencies on improving the reprocessing of these devices. The key steps in this process are point-of-use precleaning, leak testing, manual cleaning, high-level disinfection, and finally drying and storage. The promise of these initial efforts suggest that the aim of minimizing and ultimately eliminating events of endoscope-/duodenoscope-associated transmission of infectious organisms between patients can be achieved.

Enhanced manual cleaning efficacy of duodenoscope in endoscopy units: Results of a multicenter comprehensive quality control program

BACKGROUND

Multiple outbreaks from contaminated duodenoscopes have been reported since 2008. This study assessed results of a multicenter comprehensive quality control (QC) program to enhance manual cleaning efficacy of duodenoscopes in endoscopy units.

METHODS

Digestive Endoscopy Society of Taiwan implemented a QC program with adenosine triphosphate (ATP) testing of patient-used duodenoscopes in 2 rounds of on-site audit in endoscopy units. ATP samples were obtained from 5 different locations of the duodenoscope after manual cleaning. Duodenoscope exceeding ATP benchmark of 200 relative light units indicated inadequate manual cleaning.

RESULTS

During the first round on-site audit, 12 hospitals and 27 patient-used duodenoscopes were analyzed. Distal end outer surface (29.6%), elevator mechanism (51.9%), distal attachment cap (59.3%), elevator wire channel (37.0%), and suction biopsy channel (37.0%) were inadequately cleaned. Overall, 19 (70.4%) duodenoscopes had inadequate manual cleaning, ranging widely from 0%-100% among endoscopy units. During the follow-up on-site audit, 32 patient-used duodenoscopes were analyzed, and 6 (18.8%) had inadequate manual cleaning.

CONCLUSIONS

ATP tests may provide real-time feedback on the cleaning efficacy of patient-used duodenoscopes. Implementing a comprehensive QC program could enhance the efficacy of manual cleaning in endoscopy units.

Guidelines for standardizing cleansing and disinfection of gastrointestinal endoscopes

As part of the activities toward standardizing endoscopy procedures, the Japan Gastroenterological Endoscopy Society has prepared guidelines for cleansing and disinfection of gastrointestinal endoscopes. The environment of gastrointestinal endoscopy differs between Japan and advanced Western countries. In advanced Western countries, gastrointestinal endoscopy is performed almost exclusively at specialized facilities, where strict provisions are observed for cleansing and disinfecting endoscopes. In Japan, however, gastrointestinal endoscopy is performed even in small clinics, and the annual number of gastrointestinal endoscopy cases is enormous. In addition, the method for cleansing and disinfecting endoscopes differs among hospitals. Although there is a distinct lack of evidence for how gastrointestinal endoscopes are cleaned and disinfected, it is necessary to standardize the method for doing so to advance the field of endoscopic medicine.

Potential testing of reprocessing procedures by real-time polymerase chain reaction: A multicenter study of colonoscopy devices

BACKGROUND

Reprocessing of endoscopes is key to preventing cross-infection after colonoscopy. Culture-based methods are recommended for monitoring, but alternative and rapid approaches are needed to improve surveillance and reduce turnover times. A molecular strategy based on detection of residual traces from gut microbiota was developed and tested using a multicenter survey.

METHODS

A simplified sampling and DNA extraction protocol using nylon-tipped flocked swabs was optimized. A multiplex real-time polymerase chain reaction (PCR) test was developed that targeted 6 bacteria genes that were amplified in 3 mixes. The method was validated by interlaboratory tests involving 5 reference laboratories. Colonoscopy devices (n = 111) were sampled in 10 Italian hospitals. Culture-based microbiology and metagenomic tests were performed to verify PCR data.

RESULTS

The sampling method was easily applied in all 10 endoscopy units and the optimized DNA extraction and amplification protocol was successfully performed by all of the involved laboratories. This PCR-based method allowed identification of both contaminated (n = 59) and fully reprocessed endoscopes (n = 52) with high sensibility (98%) and specificity (98%), within 3-4 hours, in contrast to the 24-72 hours needed for a classic microbiology test. Results were confirmed by next-generation sequencing and classic microbiology.

CONCLUSIONS

A novel approach for monitoring reprocessing of colonoscopy devices was developed and successfully applied in a multicenter survey. The general principle of tracing biological fluids through microflora DNA amplification was successfully applied and may represent a promising approach for hospital hygiene.

Retrospective study of Candida sp. contaminations of endoscopes at the University Hospital of Tlemcen (Algeria)

BACKGROUND

Improper cleaning and disinfection of endoscopes has been responsible for multiple nosocomial outbreaks and sometimes serious life-threatening infections.

OBJECTIVE

The aim of our study is, at first, to identify Candida species responsible for the contamination of endoscopes, and to determine the minimal inhibitory concentrations of planktonic (MIC) and sessile cells (SMIC) of amphotericin B (AmB) against our isolated strains.

MATERIALS AND METHODS

The present study was performed on four endoscopes in the department of gastroenterology at the University Hospital of Tlemcen (Algeria). A total of 300 samples from endoscopes were examined over a period of 3years.

RESULTS

Thirty-four strains of Candida sp. were isolated, representing 11.33% of the considered samples. The number of isolated strains dropped significantly in the second and the third year compared to the first year of our study. After testing the antifungal property of amphotericin B, we showed clearly that the sessile cells of Candida sp. were much more resistant than their planktonic counterparts (suspended cells).

CONCLUSION

The methods of sterilization of the endoscopes are very important; drying by compressed air is a critical step that reduces significantly the number of yeasts contamination.

Duodenoscopy related infection risk and duodenoscope cleaning and disinfection

With the development of minimally invasive techniques, duodenoscope, as an instrument for diagnosis and treatment of pancreaticobiliary diseases, has been gradually applied in clinical practice. Iatrogenic infection caused by duodenoscopy is a well-documented complication, which has gained extensive attention especially in duodenoscope cleaning and disinfecting. It has been postulated that the complexity in design of duodenoscope makes cleaning difficult and poses a risk for nosocomial infections. As such, it is of positive practical significance to analyze the factors that affect cleaning and disinfecting and to take effective measures to do them better, in order to prevent nosocomial infection. This paper briefly reviews the cleaning and sterilizing of duodenoscope and the risk of infection associated with duodenoscopy.

Effectiveness of current disinfection procedures against biofilm on contaminated GI endoscopes

BACKGROUND AND AIMS

Attention to patient safety has increased recently due to outbreaks of nosocomial infections associated with GI endoscopy. The aim of this study was to evaluate current cleaning and disinfection procedures of endoscope channels with high bioburden and biofilm analysis, including the use of resistant mycobacteria associated with postsurgical infections in Brazil.

METHODS

Twenty-seven original endoscope channels were contaminated with organic soil containing 10(8) colony-forming units/mL of Pseudomonas aeruginosa, Staphylococcus aureus, or Mycobacterium abscessus subsp bolletii. Biofilms with the same microorganisms were developed on the inner surface of channels with the initial inoculum of 10(5) colony-forming units/mL. Channels were reprocessed following current protocol, and samples from cleaning and disinfection steps were analyzed by bioluminescence for adenosine triphosphate, cultures for viable microorganisms, and confocal microscopy.

RESULTS

After contamination, adenosine triphosphate levels increased dramatically, and high bacterial growth was observed in all cultures. After cleaning, adenosine triphosphate levels decreased to values comparable to precontamination levels, and bacterial growth was demonstrated in 5 of 27 catheters, 2 with P aeruginosa and 3 with M abscessus. With regard to induced biofilm, a remarkable reduction occurred after cleaning, but significant microbial growth inhibition occurred only after disinfection. Nevertheless, viable microorganisms within the biofilm were still detected by confocal microscopy, more so with glutaraldehyde than with peracetic acid or O-phataladehyde.

CONCLUSION

After the complete disinfection procedure, viable microorganisms could still be detected within the biofilm on endoscope channels. Prevention of biofilm development within endoscope channels should be a priority in disinfection procedures, particularly for ERCP and EUS.

High-level disinfection of gastrointestinal endoscope reprocessing

High level disinfection (HLD) of the gastrointestinal (GI) endoscope is not simply a slogan, but rather is a form of experimental monitoring-based medicine. By definition, GI endoscopy is a semicritical medical device. Hence, such medical devices require major quality assurance for disinfection. And because many of these items are temperature sensitive, low-temperature chemical methods, such as liquid chemical germicide, must be used rather than steam sterilization. In summarizing guidelines for infection prevention and control for GI endoscopy, there are three important steps that must be highlighted: manual washing, HLD with automated endoscope reprocessor, and drying. Strict adherence to current guidelines is required because compared to any other medical device, the GI endoscope is associated with more outbreaks linked to inadequate cleaning or disinfecting during HLD. Both experimental evaluation on the surveillance bacterial cultures and in-use clinical results have shown that, the monitoring of the stringent processes to prevent and control infection is an essential component of the broader strategy to ensure the delivery of safe endoscopy services, because endoscope reprocessing is a multistep procedure involving numerous factors that can interfere with its efficacy. Based on our years of experience in the surveillance of culture monitoring of endoscopic reprocessing, we aim in this study to carefully describe what details require attention in the GI endoscopy disinfection and to share our experience so that patients can be provided with high quality and safe medical practices. Quality management encompasses all aspects of pre- and post-procedural care including the efficiency of the endoscopy unit and reprocessing area, as well as the endoscopic procedure itself.