Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement

Green Endoscopy: A Review of Global Perspectives on Environmental Sustainability of Gastrointestinal Endoscopy

Endoscopic procedures are the cornerstone of intervention in gastroenterology-from evaluating common illnesses to non-surgically managing complex diseases. Expectedly, these procedures are linked to greenhouse gas (GHG) emissions globally and contribute significantly to the global climate change crisis. Professional gastroenterology societies globally raise awareness of this evolving crisis and suggest specific measures to appropriately measure the burden contributed by endoscopy units and mitigate the environmental impact of this common clinical practice. To the unsuspecting eye, the solution to this crisis is relatively simple: decrease the utilization of endoscopic procedures. However, the dependence of modern medicine on these procedures, both diagnostically and therapeutically, makes it significantly more challenging to reduce their utilization. Instead, a structured approach to systematically consider the specific indications for each procedure, minimize waste generation, promote recycling of waste products, and limit the number of repeat endoscopies until clinically necessary may be more pragmatic to reduce GHG emissions globally. In this narrative review, we discuss the perspectives of global gastroenterology societies on sustainable or "green" endoscopy and summarize their recommendations to aid the day-to-day gastroenterologist in making their contribution to environmental sustainability while providing optimal care to their patients.

Evaluating the risk of duodenoscope-associated colonization and duodenoscope-associated infection: a prospective observational study

BACKGROUND

The risk of duodenoscope-associated colonization (DAC) and infection (DAI) after endoscopic retrograde cholangiopancreatography (ERCP) with a contaminated duodenoscope remains unknown. Determining the incidence of these events is crucial for developing prevention strategies.

AIM

To assess the incidence of DAC and DAI.

METHODS

This prospective observational study included adult patients who underwent ERCP from January 2022 to December 2023. Duodenoscopes were sampled prior to each procedure. Contamination was defined as the presence of micro-organisms of gut or oral origin (MGO). Post ERCP, upon availability of culture results, patients exposed to contaminated duodenoscopes were asked to provide a stool sample and were followed for six months. Micro-organisms isolated from patient samples and clinical cultures were compared with those found in the duodenoscopes. Whole-genome sequencing (WGS) was used to confirm DAC or DAI.

FINDINGS

Among 341 ERCP patients, 73 (21.4%) procedures involved MGO-contaminated duodenoscopes. No duodenoscope-associated outbreaks occurred during the study. Stool samples were returned by 45 of the 73 patients (61.6%). Additionally, 80 MGOs from clinical cultures and 37 residual samples were stored. WGS was performed on eight duodenoscope-patient micro-organism pairs from six patients. No DAC or DAI cases were detected.

CONCLUSION

In a non-outbreak setting, supported by monthly routine microbiological surveillance and a quarantine protocol for duodenoscopes, the risk of DAC and DAI appears low. These findings suggest limited value in intensive patient surveillance for DACs/DAIs. Further research is warranted to confirm these results and address knowledge gaps regarding risk factors for DACs and DAIs.

A Predictive Model Based on Quantitative Fecal Immunochemical Test Can Stratify the Risk of Colorectal Cancer in an Organized Screening Program

BACKGROUND & AIMS

A significant number of post fecal immunochemical test (FIT) colonoscopies in European-organized colorectal cancer (CRC) screening programs are performed beyond the recommended 31-day threshold due to overburdened colonoscopy services. We aimed to develop a simple predictive model to stratify CRC risk of FIT+ patients.

METHODS

In a cohort of screenees undergoing colonoscopy following a positive (≥20 μg hemoglobin/g feces) OC-sensor FIT result between 2004 and 2019, we derived and validated logistic regression-based models including variables independently associated with CRC and advanced neoplasms. Odds ratios (ORs) and 95% confidence intervals (CIs) were reported.

RESULTS

Overall, 40,276 patients (46% female; mean age, 66 ± 4 years) undergoing post FIT colonoscopy were included. Variables independently associated with CRC were age ≥70 years (OR, 1.20; 95% CI, 1.03-1.40), male sex (OR, 1.23; 95% CI, 1.11-1.37), fecal hemoglobin level (50-199 μg/g: OR, 2.84; 95% CI, 2.47-3.27; ≥200 μg/g: OR, 6.91; 95% CI, 5.99-7.98), and first round of FIT (OR, 1.53; 95% CI, 1.35-1.73). The discriminative ability of the model was good (area under the receiver operating characteristic, 0.75; 95% CI, 0.73-0.77) in the validation cohort. Applying the model would lead to over two-thirds decrease in delayed CRC diagnoses, considering various scenarios of timely colonoscopy scheduling after FIT+.

CONCLUSIONS

We derived and validated a predictive model for risk stratification of patients with positive FIT in a large CRC screening cohort. Applying our model in screening practice would allow policy makers to effectively prioritize FIT+ individuals based on the risk of CRC, substantially reducing the rate of delayed CRC diagnosis.

Streamlining Endoscopy Cleaning: The Impact of a New Detergent on Time and Water Use

Reprocessing reusable flexible endoscopes is resource-intensive and involves high water consumption. This study evaluated the impact of replacing a standard detergent with EndoPreZyme™, a novel detergent, at Blackpool Teaching Hospitals NHS Foundation Trust. We assessed manual cleaning times, water usage, costs, and technician experiences. A direct observational time system analysis was conducted over two one-week periods to record technician tasks before and after implementing EndoPreZyme™, allowing for the omission of the final rinse after manual cleaning. Technician surveys captured user experiences during the transition. The results showed that removing the final rinse after manual cleaning reduced water consumption by 25 litres per endoscope, resulting in an estimated saving of 725,000 L annually. The average manual cleaning time decreased from 13 min 10.2 s to 11 min 10.7 s-a reduction of 1 min 59.5 s per endoscope (15%). This efficiency gain translated to approximately 962.9 fewer technician hours being required annually for manual cleaning. Cost analysis revealed a slight per-endoscope cost reduction (GBP 4.88 vs. GBP 4.90). Technicians reported improved productivity, reduced workload, and an awareness of water conservation. These findings demonstrate that EndoPreZyme™ supports NHS sustainability goals by decreasing water usage and enhancing operational efficiency in healthcare delivery.

Climate change and continued professional development (CPD): Is it time for all CPD diaries to include carbon footprint estimates?

The triple threat of changing climate, loss of biodiversity and pollution poses a significant challenge to our patients and the planet, and healthcare contributes to all three elements of the threat. The carbon footprint of continued professional development (CPD) is increasingly recognised, although a cognitive dissonance exists whereby climate change is acknowledged but air travel to conferences continues unabated. A CO2 allowance for CPD activities has been suggested previously. We suggest that CO2 footprint estimates could be incorporated into existing CPD diaries as a step towards visualising the environmental impact of CPD. Electronic CPD diaries are already widely used and typically contain dates and locations for CPD activities. It would be relatively easy and inexpensive to add an estimate of CO2 footprint to these diaries. Such an approach would initiate reflection, promote insight and help facilitate behavioural change. We call on institutions involved in CPD licensing, administration and documentation to trial this approach and share their experience.

Environmental footprint of a colonoscopy procedure: Life cycle assessment

Background and study aims

Gastroenterology is a specialty that has evolved rapidly over time, especially in terms of advancements in endoscopic procedures. However, these advancements also present challenges, given the substantial resource demands associated with endoscopy procedures. Numerous actions could be taken to develop a resilient healthcare system that consumes as few resources as possible, but recommendations are needed to prioritize which processes could be improved. We aimed to evaluate the environmental footprint of a colonoscopy procedure, and to identify the main contributing impact process categories.

Methods

A single-center observational study was conducted at a Dutch university hospital. No clinical patient data were collected, but the colonoscopy procedure was studied. Data were collected during 13 colonoscopies. Life cycle assessment (LCA) was used to calculate environmental impact.

Results

Damage to human health from one colonoscopy was 11.3·10 -5 disability-adjusted life-years, equivalent to 1 hour. A single colonoscopy resulted in emission of 56.4 kg of CO 2 -equivalent (CO 2 eq), equal to driving a car for 255 km or 55 days of emissions for an average European household. Transportation of patients and staff (76.5%) and disposables (13.5%) were the greatest contributors to damage to human health.

Conclusions

Among the 13 colonoscopies studied, the environmental impact was mainly attributable to transportation of patients and staff, and disposables. Therefore, raising awareness about the impact of transportation by car, and reducing resource consumption, particularly of disposable products, should be prioritized. Implementing alternatives to colonoscopy, such as intestinal ultrasound, could reduce the environmental footprint of the healthcare system.

First step to environmentally sustainable endoscopy practice: a prospective study of minimizing multiple device use during screening colonoscopy at a large tertiary center

The healthcare sector generates 8% of greenhouse gas emissions in the USA, of which gastrointestinal (GI) endoscopy is the third largest contributor. Single-use tools are a major contributor to modifiable waste generation during GI endoscopy. Through a quality improvement initiative, we aimed to reduce endoscopy waste by urging gastroenterologists to be mindful of tools used during polypectomies by avoiding using multiple tools.We discussed green endoscopy initiatives in monthly journal club and business meetings. Over 14 weeks, 210 patients were included in the pre-intervention group and 112 in the post-intervention group.At baseline, 34% of colonoscopies required no intervention, 32% required one tool (either biopsy forceps or a snare), and 33% required multiple tools. After the intervention, the use of just one tool increased (17 percentage point increase; P=0.003) and the use of multiple tools decreased significantly (16 percentage point decrease; P=0.002). The odds ratio for use of a single tool compared with multiple tools after the intervention was 3.0 (95%CI 1.6 to 5.5; P=0.005).This single-center quality improvement study noted a significant change in practice patterns favoring the use of a single tool over multiple tools during colonoscopies after an environmentally conscious practice intervention was applied. This intervention can be readily applied to reduce endoscopy-related waste.

Management of epithelial precancerous conditions and early neoplasia of the stomach (MAPS III): European Society of Gastrointestinal Endoscopy (ESGE), European Helicobacter and Microbiota Study Group (EHMSG) and European Society of Pathology (ESP) Guideline update 2025

At a population level, the European Society of Gastrointestinal Endoscopy (ESGE), the European Helicobacter and Microbiota Study Group (EHMSG), and the European Society of Pathology (ESP) suggest endoscopic screening for gastric cancer (and precancerous conditions) in high-risk regions (age-standardized rate [ASR] > 20 per 100 000 person-years) every 2 to 3 years or, if cost-effectiveness has been proven, in intermediate risk regions (ASR 10-20 per 100 000 person-years) every 5 years, but not in low-risk regions (ASR < 10).ESGE/EHMSG/ESP recommend that irrespective of country of origin, individual gastric risk assessment and stratification of precancerous conditions is recommended for first-time gastroscopy. ESGE/EHMSG/ESP suggest that gastric cancer screening or surveillance in asymptomatic individuals over 80 should be discontinued or not started, and that patients' comorbidities should be considered when treatment of superficial lesions is planned.ESGE/EHMSG/ESP recommend that a high quality endoscopy including the use of virtual chromoendoscopy (VCE), after proper training, is performed for screening, diagnosis, and staging of precancerous conditions (atrophy and intestinal metaplasia) and lesions (dysplasia or cancer), as well as after endoscopic therapy. VCE should be used to guide the sampling site for biopsies in the case of suspected neoplastic lesions as well as to guide biopsies for diagnosis and staging of gastric precancerous conditions, with random biopsies to be taken in the absence of endoscopically suspected changes. When there is a suspected early gastric neoplastic lesion, it should be properly described (location, size, Paris classification, vascular and mucosal pattern), photodocumented, and two targeted biopsies taken.ESGE/EHMSG/ESP do not recommend routine performance of endoscopic ultrasonography (EUS), computed tomography (CT), magnetic resonance imaging (MRI), or positron emission tomography (PET)-CT prior to endoscopic resection unless there are signs of deep submucosal invasion or if the lesion is not considered suitable for endoscopic resection.ESGE/EHMSG/ESP recommend endoscopic submucosal dissection (ESD) for differentiated gastric lesions clinically staged as dysplastic (low grade and high grade) or as intramucosal carcinoma (of any size if not ulcerated or ≤ 30 mm if ulcerated), with EMR being an alternative for Paris 0-IIa lesions of size ≤ 10 mm with low likelihood of malignancy.ESGE/EHMSG/ESP suggest that a decision about ESD can be considered for malignant lesions clinically staged as having minimal submucosal invasion if differentiated and ≤ 30 mm; or for malignant lesions clinically staged as intramucosal, undifferentiated and ≤ 20 mm; and in both cases with no ulcerative findings.ESGE/EHMSG/ESP recommends patient management based on the following histological risk after endoscopic resection: Curative/very low-risk resection (lymph node metastasis [LNM] risk < 0.5 %-1 %): en bloc R0 resection; dysplastic/pT1a, differentiated lesion, no lymphovascular invasion, independent of size if no ulceration and ≤ 30 mm if ulcerated. No further staging procedure or treatment is recommended.Curative/low-risk resection (LNM risk < 3 %): en bloc R0 resection; lesion with no lymphovascular invasion and: a) pT1b, invasion ≤ 500 µm, differentiated, size ≤ 30 mm; or b) pT1a, undifferentiated, size ≤ 20 mm and no ulceration. Staging should be completed, and further treatment is generally not necessary, but a multidisciplinary discussion is required. Local-risk resection (very low risk of LNM but increased risk of local persistence/recurrence): Piecemeal resection or tumor-positive horizontal margin of a lesion otherwise meeting curative/very low-risk criteria (or meeting low-risk criteria provided that there is no submucosal invasive tumor at the resection margin in the case of piecemeal resection or tumor-positive horizontal margin for pT1b lesions [invasion ≤ 500 µm; well-differentiated; size ≤ 30 mm, and VM0]). Endoscopic surveillance/re-treatment is recommended rather than other additional treatment. High-risk resection (noncurative): Any lesion with any of the following: (a) a positive vertical margin (if carcinoma) or lymphovascular invasion or deep submucosal invasion (> 500 µm from the muscularis mucosae); (b) poorly differentiated lesions if ulceration or size > 20 mm; (c) pT1b differentiated lesions with submucosal invasion ≤ 500 µm with size > 30 mm; or (d) intramucosal ulcerative lesion with size > 30 mm. Complete staging and strong consideration for additional treatments (surgery) in multidisciplinary discussion.ESGE/EHMSG/ESP suggest the use of validated endoscopic classifications of atrophy (e. g. Kimura-Takemoto) or intestinal metaplasia (e. g. endoscopic grading of gastric intestinal metaplasia [EGGIM]) to endoscopically stage precancerous conditions and stratify the risk for gastric cancer.ESGE/EHMSG/ESP recommend that biopsies should be taken from at least two topographic sites (2 biopsies from the antrum/incisura and 2 from the corpus, guided by VCE) in two separate, clearly labeled vials. Additional biopsy from the incisura is optional.ESGE/EHMSG/ESP recommend that patients with extensive endoscopic changes (Kimura C3 + or EGGIM 5 +) or advanced histological stages of atrophic gastritis (severe atrophic changes or intestinal metaplasia, or changes in both antrum and corpus, operative link on gastritis assessment/operative link on gastric intestinal metaplasia [OLGA/OLGIM] III/IV) should be followed up with high quality endoscopy every 3 years, irrespective of the individual's country of origin.ESGE/EHMSG/ESP recommend that no surveillance is proposed for patients with mild to moderate atrophy or intestinal metaplasia restricted to the antrum, in the absence of endoscopic signs of extensive lesions or other risk factors (family history, incomplete intestinal metaplasia, persistent H. pylori infection). This group constitutes most individuals found in clinical practice.ESGE/EHMSG/ESP recommend H. pylori eradication for patients with precancerous conditions and after endoscopic or surgical therapy.ESGE/EHMSG/ESP recommend that patients should be advised to stop smoking and low-dose daily aspirin use may be considered for the prevention of gastric cancer in selected individuals with high risk for cardiovascular events.

Clinical evaluation of a novel single-use therapeutic gastroscope: a pilot feasibility study

The trend toward disposable products in gastrointestinal endoscopy, including single-use endoscopes, remains undeterred, even though crucial questions of sustainability and performance have not been sufficiently studied. The first single-use therapeutic gastroscope was recently approved in Europe, but clinical data to support its use are currently lacking. We aimed to evaluate the performance of this novel device in routine procedures requiring a large working channel.Between January and May 2024, consecutive patients with an indication for therapeutic gastroscopy were included prospectively. The primary outcome was intraprocedural technical success rate.Eight gastrointestinal bleedings, two pancreatic necrosectomies, four foreign body removals, four stent placements, and two cryo-balloon ablations were performed. The technical success rate was 84% (16/19 patients). Crossover to a standard endoscope was required in three procedures. Clinical success was achieved in all cases with technical success. Overall user experience was 3.2 on a Likert scale of 1-5. No adverse events were reported.The single-use therapeutic gastroscope demonstrated feasibility in various therapeutic procedures; however, a 16% crossover rate and fair user assessment score suggest that further technical improvements to the device are necessary.

Micro-bacterial assessment of disposable gowns with a focus on green endoscopy in gastrointestinal endoscopy procedures: A Japanese pilot study for healthcare waste reduction

Objective

This study aimed to implement green endoscopy through the microbiological assessment of gowning techniques during endoscopy to reduce carbon emissions and separate medical waste.

Methods

Twenty-five patients who performed esophagogastroduodenoscopy from March to May 2024 were included in this study. Four sections of the isolation gowns (anterior, posterior, right, and left) were cut into 2 cm2 after endoscopy, and the rate of microbial contamination was examined using the stamp method.

Results

The endoscopic examination time was 8 min (6-12), and endoscopy was performed by 10 expert endoscopists, six endoscopists, and nine residents. The overall isolation gown contamination rate was 56%, with 25%, 20.8%, 20.8%, and 33.3% in the front, back, as well as right and left arms, respectively. The rates of isolation gown contamination rates in the expert endoscopists, endoscopists, and residents groups were 30%, 50%, and 77.8%, respectively, with a higher rate in the residents group. Regardless of the physician's performance, bacterial detection was consistently higher in the left arm (42.9% vs. 40% vs. 25%; p = 0.093). The detected bacteria comprised 58% Gram-positive and 42% Gram-negative organisms, including those from tap water used for endoscopy bacteria and obtained from the participant's skin or mouth. No pathogenic organisms were detected.

Conclusions

The bacteria detected in disposable gowns after gastrointestinal endoscopy were non-pathogenic. Thus, our findings suggest that changing all personal protective equipment of respective endoscopes might not be essential. We advocate for green endoscopy to achieve sustainable development goals and reduce medical waste.

Examination of endoscopic intracanal observation with an ultrafine-diameter scope

OBJECTIVES

The endoscopic channel can be damaged by instruments during use and cleaning, leading to contamination, infection, and increased repair costs. However, few devices are available to observe the inside of the endoscopic channel. This study employed an ultrafine-diameter scope to examine damage in the endoscopic channel.

METHODS

Fifty-eight endoscopes used at our institution were examined for scratches, discoloration, or deformation in the endoscopic channel using an ultrafine-diameter scope.

RESULTS

Damage was observed in seven of the 24 observation endoscopes and 27 of the 34 therapeutic endoscopes, with damage being more common in the therapeutic endoscopes. Scratches were observed in nine of the 25 upper gastrointestinal endoscopes, 23 of the 24 colonoscopes, and one of the two echoendoscopes. Additionally, two colonoscopes, one echoendoscope, and one double-balloon endoscope showed indentation or narrowing near the curvature.

CONCLUSIONS

The use of an ultrafine-diameter scope enabled the detection of minute damage and deformations in the channel. Periodic observation with the ultrafine-diameter scope may promote the long-term use of the scopes.

APAGE Position Statements on Green and Sustainability in Gastroenterology, Hepatology, and Gastrointestinal Endoscopy

BACKGROUND AND AIM

The APAGE Position Statements aimed to provide guidance to healthcare practitioners on clinical practices aligned with climate sustainability.

METHODS

A taskforce convened by APAGE proposed provisional statements. Twenty-two gastroenterologists from the Asian Pacific region participated in online voting and consensus was assessed through an anonymized and iterative Delphi process.

RESULTS

There were five sections that addressed the rationale for climate action, the importance of adopting principles of waste management, clinical practice, gastrointestinal endoscopy, and issues related to advocacy and research. Sixteen statements achieved consensus and included the following: 1. APAGE recommends adopting prompt measures to reduce the carbon footprint of clinical practice due to the importance of climate action and its health cobenefits. 5. APAGE recommends adherence to professional clinical guidelines to optimize clinical care delivery in gastroenterology and hepatology to avoid the environmental impact of unnecessary procedures and tests. 8. APAGE recommends an emphasis on health promotion, disease prevention, and appropriate screening and surveillance, when resources are available, to reduce the environmental impact of managing more advanced diseases that require more intensive resources. 12. APAGE recommends that technological advances in endoscopic imaging and artificial intelligence, when available, be used to improve the precision of endoscopic diagnosis to reduce the risk of missed lesions and need for unnecessary biopsies. 13. APAGE recommends against the routine use of single-use endoscopes.

CONCLUSION

The position statements provide guidance to healthcare practitioners on clinical practices in gastroenterology, hepatology, and endoscopy that promote climate sustainability.

The Future of Minimally Invasive GI and Capsule Diagnostics (REFLECT), October 2024

The fifth annual REFLECT (The futuRE oF MinimalLy InvasivE GI and Capsule diagnosTics) symposium, held in October 2024 in Nyborg, Denmark, focused on advancements in minimally invasive gastrointestinal (GI) diagnostics, particularly capsule endoscopy (CE) technologies. Key discussions included clinical updates, innovations in hardware and software, and the growing role of colon CE (CCE) in colorectal cancer screening. The event provided a platform for clinicians, engineers, industry representatives, and scientists to exchange knowledge and present the latest advancements in the field. Discussions covered clinical studies, future research protocols, and technological innovations, with also a notable focus on commercial solutions and expansion of the implementation of capsule endoscopy. The symposium also highlighted the significance of predictive models for patient selection and developments in panenteric CE. Innovative technologies presented included robotics for drug delivery and magnetic endoscopic guidance systems. AI advancements were discussed for their potential to reduce diagnostic fatigue and standardize image interpretation, but ethical concerns and the need for transparent algorithms remain. The importance of multidisciplinary collaboration was emphasized to bridge innovation and clinical practice. Home-based CCE delivery emerged as a promising model, despite mixed results from environmental impact assessments. Overall, REFLECT 2024 reinforced the clinical utility and challenges of capsule-based diagnostics, advocating for ongoing interdisciplinary research to support safe and effective integration into healthcare systems.

Endoscopic Sustainability PrimAry Reporting Essentials (E-SPARE): European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

A growing number of studies aim to evaluate gastrointestinal (GI) endoscopy services from the perspective of their environmental impact. However, there are currently no guidelines or frameworks which provide specifically for the reporting of endoscopy sustainability studies, and a variety of metrics and assessment tools have been employed in the literature. To improve the clarity, transparency, and quality of reporting, the European Society of Gastrointestinal Endoscopy (ESGE) has developed a reporting framework for the community of researchers interested in conducting studies on sustainable GI endoscopy.

Endoscopic En Bloc Vs Piecemeal Resection of Large Colonic Adenomas: Carbon Footprint Post Hoc Analysis of a Randomized Trial

BACKGROUND AND AIMS

Endoscopy makes a significant contribution to the carbon footprint of healthcare. A randomized trial (RESECT-COLON) demonstrated that endoscopic submucosal dissection (ESD) decreases the recurrence rate of large adenomas (>25 mm) vs piecemeal endoscopic mucosal resection (P-EMR), reducing the need for follow-up colonoscopy. We aimed to compare the carbon footprint of those 2 strategies.

METHODS

Devices used for both procedures were collected prospectively for each of the 359 patients. P-EMR and ESD were assessed using the life cycle assessment, evaluating 4 parameters: endoscopes and disposable medical products, electricity consumption, anesthetic products, and patient transport. The carbon footprint of the follow-up was simulated in both arms with different scenarios. We performed a post hoc analysis of the carbon footprint of these 2 strategies over 18 months.

RESULTS

Carbon footprint of a single P-EMR procedure was 63.5 kg carbon dioxide equivalent (CO2e) vs 73.2 kg CO2e for ESD (half for patient transport). Including follow-up in local centers, P-EMR generates 93.5 kg CO2e and ESD 76.3 kg CO2e, corresponding to an absolute reduction of 17 kg CO2e (18%) per procedure for ESD. Simulating a strategy of P-EMR resection and follow-up both performed in local centers, the global impact with 18 months follow-up would be 67.3 kg CO2e, favoring P-EMR over ESD.

CONCLUSIONS

ESD strategy for lesions over 25 mm could reduce the environmental impact by reducing the associated follow-up colonoscopies and transports of patients. If P-EMR could be performed in local centers with similar quality, results would be in favor of local P-EMR.

Survey of the endoscopy workforce’s perception of sustainability

Objective

The National Health Service is a significant contributor to greenhouse gas emissions, with endoscopy ranking as the third highest contributor of waste in healthcare. We aimed to ascertain the endoscopy workforce attitudes towards sustainable practices, barriers to change and potential solutions towards achieving a more sustainable endoscopy practice.

Methods

A prospective cross-sectional online survey was distributed to endoscopy staff through the Joint Advisory Group on Gastrointestinal Endoscopy, the British Society of Gastroenterology (BSG), the Green Endoscopy Centre for Sustainable Healthcare Network and trainee research networks. The survey used a 5-point Likert scale to include:

(1) perceived importance of sustainability in endoscopy, (2) factors contributing to waste generation in endoscopy, (3) barriers to sustainability in endoscopy and (4) strategies for sustainable change

Results

Of 202 participants, 83% were highly concerned about climate change and 71% recognised the significant carbon footprint generation within endoscopy. Lack of environmental consideration (77%), personal protective equipment and decontamination (76%), and packaging of single-use items (74%) were considered the most significant factors impacting waste generation in endoscopy. Participants ranked poor access to recyclable equipment (55%), poor awareness (52%) and poor attitudes (47%) as the main barriers to sustainable change. Concerningly, only a third would inform others if they noticed the wasting of resources.

An overwhelming majority agreed with the BSG prioritising sustainability highly (84%), with 88.6% supporting policy and guideline development on sustainable endoscopy practice.

Conclusion

We identified a strong consensus supporting the BSG’s prioritisation of activities relating to sustainability and climate change, with endoscopy being a key area of focus for improvement.

Results of AIPO Italian survey on sustainability in Interventional Pulmonology

BACKGROUND

Sustainability in medicine is gaining increasing importance. In interventional pulmonology only few studies demonstrated the impact of mechanisms involved in CO2 equivalent production; moreover, operators' sensitivity to sustainability and each center's recycling processes are highly variable. We conducted a national survey among interventional pulmonologists on perception of sustainability resulting from their work, and how endoscopic activity impacts the production of recyclable material.

METHODS

A 26-item questionnaire was sent to each AIPO member registered in the interventional pulmonology study group. Items were divided in four topics: demographic data, perception of the problem, measures in place to improve sustainability and potentially feasible measure to improve the problem.

RESULTS

We obtained a 16.2% response rate and majority of participants work in high volume centers. Climate change was perceived as an important problem but responders though that physicians are few involved mainly due to lack of awareness of the problem. Recycling programs are widely available with differentiation between recyclable and potentially contaminated material. The disposable bronchoscopes use was perceived to increase carbon footprint. Most critical interventions to improve sustainability suggested were: optimization of separate waste collection, instrument reprocessing procedures, adherence to guidelines to reduce unnecessary procedures and improving staff awareness. Most participants believed that scientific societies should establish a working group on climate change.

CONCLUSIONS

The sustainability of daily activity in interventional pulmonology is a cause for concern among interventional pulmonologists while the lack of awareness remains the main reason for the poor perception of the problem; sustainability represents a need and an opportunity for interventional pulmonologists to align with other disciplines, but this concept can also be extended to all areas of pneumology.

Carbon footprinting and environmental impact of gastrointestinal endoscopy procedures at a tertiary care institution: a prospective multi-dimensional assessment

BACKGROUND

Given the imperative to combat climate change, reducing the healthcare sector's implications on the environment is crucial.

OBJECTIVE

This study aims to offer a comprehensive assessment of the environmental impact of gastrointestinal endoscopy (GIE) procedures, specifically focusing on greenhouse gas (GHG) emissions and waste generation.

DESIGN

A prospective study was conducted at the Asian Institute of Gastroenterology (AIG Hospitals), Hyderabad, India, from 29 May to 10 June 2023, including all consecutive GIE procedures. Carbon emissions for various variables involved were calculated with specific emission factors using 'The GHG Protocol'.

RESULTS

Based on data from 3244 consecutive patients undergoing 3873 procedures, the study revealed a total carbon footprint of 148 947.32 kg CO2e or 38.45 kg CO2e per procedure. Excluding patient travel, the emissions were 6.50 kg CO2e per procedure. The total waste generated was 1952.50 kg, averaging 0.504 kg per procedure, far less than 2-3 kg per procedure in the West. The waste disposal breakdown was 9.5% direct landfilling, 64.8% incineration, then landfilling and 25.7% recycling, which saved 380 kg CO2e. India effectively recycles 25.7% of hospital-related waste, which undergoes landfilling in the West. The primary contributors to GHG emissions were patient travel (83.09%), electricity consumption (10.42%), medical gas transport and usage (3.63%) and water consumption (1.86%). Diagnostic procedures generate less waste and lower carbon footprint than therapeutic procedures.

CONCLUSION

This study highlights the significant environmental footprint of GIE procedures, emphasising the importance of optimising practices to reduce patient travel and repeat procedures, alongside improving electricity and water management for sustainable healthcare.

Diagnostic work-up of bile duct strictures: European Society of Gastrointestinal Endoscopy (ESGE) Guideline

1: ESGE recommends the combination of endoscopic ultrasound-guided tissue acquisition (EUS-TA) and endoscopic retrograde cholangiopancreatography (ERCP)-based tissue acquisition as the preferred diagnostic approach for tissue acquisition in patients with jaundice and distal extrahepatic biliary stricture in the absence of a pancreatic mass. 2: ESGE suggests that brushing cytology should be completed along with fluoroscopy-guided biopsies, wherever technically feasible, in patients with perihilar biliary strictures. 3: ESGE suggests EUS-TA for perihilar strictures when ERCP-based modalities yield insufficient results, provided that curative resection is not feasible and/or when cross-sectional imaging has shown accessible extraluminal disease. 4: ESGE suggests using standard ERCP diagnostic modalities at index ERCP. In the case of indeterminate biliary strictures, ESGE suggests cholangioscopy-guided biopsies, in addition to standard ERCP diagnostic modalities. Additional intraductal biliary imaging modalities can be selectively used, based on clinical context, local expertise, and resource availability.

Environmental footprint and material composition comparison of single-use and reusable duodenoscopes

BACKGROUND

Infection outbreaks associated with contaminated reusable duodenoscopes (RUDs) have induced the development of novel single-use duodenoscopes (SUDs). This study aimed to analyze the material composition and life cycle assessment (LCA) of RUDs and SUDs to assess the sustainability of global and partial SUD implementation.

METHODS

A single-center study evaluated material composition analysis and LCA of one RUD and two SUDs from different manufacturers (A/B). Material composition analysis was performed to evaluate the thermochemical properties of the duodenoscope components. The carbon footprint was calculated using environmental software. We compared the sustainability strategies of universal use of RUDs, frequent use of RUDs with occasional SUDs, and universal use of SUDs over the lifetime of one RUD.

RESULTS

RUDs were substantially heavier (3489 g) than both SUD-A (943 g) and SUD-B (716 g). RUDs were mainly metal alloys (95%), whereas SUDs were mainly plastic polymers and resins (70%-81%). The LCA demonstrated the sustainability of RUDs, with a life cycle carbon footprint 62-82 times lower than universal use of SUDs (152 vs. 10 512-12 640 kg CO2eq) and 10 times lower than occasional use of SUDs (152 vs. 1417-1677 kg CO2eq). Differences were observed between SUD-A and SUD-B (7.9 vs. 6.6 kg CO2eq per endoscope). End-of-life incineration emissions for SUDs were the greatest environmental contributors.

CONCLUSIONS

Widespread adoption of SUDs has greater environmental challenges; it requires a balance between infection control and environmental responsibility. Carbon footprint labelling can help healthcare institutions make sustainable choices and promote environmentally responsible healthcare practices.

Ripple Effect: Safety, Cost, and Environmental Concerns of Using Sterile Water in Endoscopy

The gastroenterology societies are committed to reducing the carbon footprint of endoscopies and hence, re-examining waste-generating practices. One such practice is the recommendation to use sterile water during endoscopy for endoscopy lens cleaning and colon irrigation. We critically reviewed all published medical literature and guidelines on the safety of the type of water used in endoscopy. We calculated the cradle-to-grave carbon footprint of a 1-L sterile water bottle and compared it to published studies on bottled drinking water. Guidelines recommending sterile water during endoscopy are based on limited evidence and mostly expert opinions. Referenced studies utilize care protocols that are not practiced. There is also considerable cross-referencing of review articles and guidelines. Two clinical studies directly comparing tap and sterile water in gastrointestinal endoscopy found tap water to be a safe and practical cost-saving alternative to sterile water. The calculated carbon footprint of bottled sterile water is 575 g CO2 equivalent. No direct evidence supports the recommendation and widespread use of sterile water during gastrointestinal endoscopy procedures. It contributes to health-care waste and climate change and is costly. We recommend tap water be used to fill sterile water bottles until evidence shows the need for alternative practice. It would be prudent to re-evaluate guidelines and write new ones that consider harm to the environment and society in the provision of care to patients, especially when the intervention may be more harmful than the risk it aims to address.

Measuring Medical Waste from Gastrointestinal Endoscopies in South Korea to Estimate Their Carbon Footprint

Background/Aims

Although gastrointestinal endoscopy (GIE) is a major contributor to the carbon footprint of national healthcare, the amount of medical waste generated by GIE procedures is not reported in South Korea. This study aimed to measure the amount of medical waste generated from GIE procedures in South Korea.

Methods

We conducted a 5-day audit of medical waste generated during GIEs at seven hospitals. During the study period, medical waste in the endoscopy examination rooms was measured twice daily and documented as mass (kg). To calculate the mean mass of disposable waste generated during one esophagogastroduodenoscopy (EGD) and one colonoscopy, the mean mass of medical waste generated from seven examinations was calculated. The mean mass of medical waste generated during GIEs was calculated by dividing the total mass of medical waste generated by the number of GIE procedures.

Results

Overall, 3,922 endoscopies were performed and 4,558 kg of waste was generated. The mean weight of medical waste generated per endoscopy was 1.34 kg. Each EGD and colonoscopy generated a mean of 0.24 kg and 0.43 kg of disposable waste, respectively. Applying the mean waste estimates from this study to annual GIE procedures performed in South Korea in 2022 showed that the total medical waste produced from GIE was 13,704,453 kg. In addition, the total masses of medical waste produced during EGD and colonoscopy procedures were 819,766 kg and 2,889,478 kg, respectively.

Conclusions

Our quantitative measurement showed that a large amount of medical waste is generated from GIE procedures. However, further research is warranted to reduce medical waste generated during GIE, which is an urgent unmet need.

Review Article: Green Management of IBD-New Paradigms for an Eco-Friendly Approach

BACKGROUND

The worldwide prevalence of inflammatory bowel disease (IBD) is increasing, with its potential evolution as a global disease and a consequent increase in its burden on healthcare systems. These estimates do not factor in the 'real' price of IBD, which, beyond curbing career aspirations, instilling social stigma, and impairing the quality of life in patients, could also significantly affect the environment.

AIM

To highlight potential areas for intervention and develop management strategies aimed at minimising environmental impacts in the field of IBD over time.

METHODS

Various aspects of IBD care (organisation of IBD centres, diagnostics and therapeutics) are examined from an environmental sustainability perspective.

RESULTS

Each stage, from the patient's means of transport to the hospital to the physician's diagnostic and therapeutic decisions, contribute to CO2 and waste production. Strategies to contain the environmental impact are feasible. Some are easy to implement, such as ensuring the appropriateness of the diagnostic and therapeutic pathway for patients; others need to be implemented in synergy with healthcare providers' policies and pharmaceutical companies.

CONCLUSIONS

With an inevitable increase in the number of patient visits, endoscopies, laboratory testing, and long-term therapeutic strategies for IBD, the clinical community should be aware of environmental concerns and investigate possible strategies to reduce the environmental impact of IBD care.

Development and validation of a competency evaluation index system for nurse endoscopists with different stages performing endoscopy nursing in China: A modified Delphi study

BACKGROUND

The advancement of endoscopic techniques has resulted in an increasing need for comprehensive competency in endoscopy nursing. However, there is currently no unified competency evaluation index system for nurse endoscopists in China.

AIMS

To develop and validate of a competency evaluation index system for nurse endoscopists with different stages performing endoscopy nursing in China.

DESIGN

A modified Delphi study.

SETTINGS

Data were collected in a medical university affiliated hospital.

PARTICIPANTS

A total of 569 participants in different fields were included at various phases of this research.

METHODS

The preliminary indicators were designed after conducting a literature review, semi-structured interviews and questionnaires. Two rounds of correspondence with 30 experts using the Delphi method were conducted to evaluate the content of the index followed by reliability and validity tests. The competency evaluation index system for nurse endoscopists at different stages was developed through expert meetings based on the Delphi consultation results according to the novice-to-expert model.

RESULTS

After two rounds of Delphi method consultation, we have established 4 first-level indicators ('Cognitive skill', 'Practice professional skills', 'Professional development skills' and 'Personal characteristics and inner qualities') and 21 s-level indicators, which are the detailed description of first-level indicators. According to the index weight analysis, the four first-level indicators are ranked from the largest to the smallest as practical professional skills, cognitive skills, professional development skills, personal characteristics and intrinsic qualities. Three different stages of nurse endoscopists competency evaluation forms and criteria were developed: primary stage (New skilled), intermediate stage (Capable) and advanced stage (Expert).

CONCLUSIONS

The establishment of a competency evaluation index system based on the novice-to-expert model can accurately assess competency levels and help to effectively train the nurse endoscopists at different stages. Future research should focus on imbedding these competencies in nurse education.

Impact of Borescope Inspections on Endoscope Repair Frequency and Costs

Background: Infections and injuries have been linked to endoscopes with visible damage or residue. Guidelines recommend visual inspection to identify endoscopes requiring repair or further cleaning. This study sought to evaluate the impact of routine borescope inspections on repair frequency and costs. Methods: Retrospective analysis was performed on a database of endoscope repairs compiled for a three-year period by a large academic medical center that began performing borescope inspections for every endoscope after manual cleaning. Endpoints included total number of repairs, total repair cost, mean cost per repair, mean turnaround time per repair, and procedural usage between repairs. Subgroup analysis was performed to identify repair patterns by endoscope type. Results: The total cost of repairs decreased from $1,212,702 in 2022 to $724,419 in 2024. The number of repairs required annually was similar over time, but reductions occurred in the proportion of repairs classified as major (12.1% to 3.2%) and the mean cost per repair ($4,426 to $2,337; P < 0.001). Mean turnaround time for repairs decreased (from 24.1 to 15.5 days; P < 0.001). Mean number of uses between repairs increased over time (from 52.1 to 87.2; P < 0.001), and the facility decreased the size of the endoscope fleet from 593 to 508. Conclusion: Significant reductions in endoscope repair frequency and cost occurred over time in a large, centralized endoscope processing department that performed borescope inspections of every endoscope after manual cleaning.

Online patient endoscopy education platform improves outpatient bowel preparation quality: Retrospective observational study

Background and study aims High-quality bowel preparation is integral to high-quality colonoscopy and adenoma detection. Studies evaluating the effect of pre-colonoscopy educational videos on bowel preparation quality have been variable. We investigated whether augmenting bowel preparation education using our professionally produced, patient-oriented, online educational video series would improve preparation quality, reduce need for repeat procedures, and improve adenoma detection rate (ADR). Patients and methods We conducted a pilot, retrospective, single-center observational study using endoscopy data from a tertiary hospital. Colonoscopy outcomes were compared between two discrete 6-month study periods, before (control group) and after (video group) implementation of the online video intervention. All patients received standard-of-care written and verbal instructions. The video group received a link providing access to the video platform. Primary outcome was adequacy of bowel preparation (defined by the Aronchick Scale). Secondary outcomes included rate of repeat colonoscopy due to inadequate preparation, ADR, and sessile serrated lesion (SSL) detection rate. Results The video intervention group had a lower rate of inadequate bowel preparation compared with the control group (6.3% vs 9.8%, P = 0.018). There was no difference between groups in rate of repeat colonoscopies due to inadequate preparation ( P = 0.62), ADR ( P = 0.11), or SSL detection rate ( P = 0.94). Multivariable analysis did not reveal any independent predictors of bowel preparation quality. Conclusions Our study supports the addition of a novel patient-oriented online educational video resource as an effective tool in enhancing bowel preparation adequacy while maintaining provision of high-quality colonoscopy.

Exploring the feasibility of home-delivered capsule endoscopy with 5G support: innovations and carbon footprint insights

INTRODUCTION

Colorectal cancer (CRC) poses a significant global health threat, necessitating early detection. Traditional diagnostic tools like optical colonoscopy have limitations prompting our '5G-SUCCEEDS' initiative to explore a novel approach involving remote colon capsule endoscopy (CCE).

METHODS

This prospective feasibility study was conducted at a single hospital in England. Between December 2022 and September 2023, we introduced a remote CCE service within the 5G-SUCCEEDS framework. We undertook a feasibility study of CCE in patients with low-risk/moderate-risk CRC stratified by faecal haemoglobin. Outcomes included carbon footprint analysis (outlined through three potential clinical pathways) and patient-reported outcomes through structured questionnaires and interviews.

RESULTS

Among 25 participants, 88% expressed satisfaction with remote CCE. 82% were willing to have remote CCE if clinically indicated in future. CCE findings included adenomatous polyps (58%), normal results (17%) and diverticulosis (21%), with no cancers identified in this pilot. Notably, we found that the carbon footprint associated with delivery of CCE at home (pathway 3) was lower compared with CCE delivered in a clinical setting (pathway 2). A fully optimised, automated scaled-up pathway would combine the delivery and collection of CCE equipment within a local area to reduce the carbon footprint of the travel element by 75%. Moreover, the conversion rate into a colonoscopy pathway is not static and clinicians acknowledge that this could be as low as 28%. Carbon footprint is more favourable for home-delivered CCE in the optimised scenario, while less so when considering the need for additional procedures (colonoscopy conversion).

CONCLUSION

The 5G-SUCCEEDS initiative highlights the feasibility and advantages of home-based diagnostics using CCE.

Environmental impact of single-use versus reusable gastroscopes

INTRODUCTION

The environmental impact of endoscopy is a topic of growing interest. This study aimed to compare the carbon footprint of performing an esogastroduodenoscopy (EGD) with a reusable (RU) or with a single-use (SU) disposable gastroscope.

METHODS

SU (Ambu aScope Gastro) and RU gastroscopes (Olympus, H190) were evaluated using life cycle assessment methodology (ISO 14040) including the manufacture, distribution, usage, reprocessing and disposal of the endoscope. Data were obtained from Edouard Herriot Hospital (Lyon, France) from April 2023 to February 2024. Primary outcome was the carbon footprint (measured in Kg CO2 equivalent) for both gastroscopes per examination. Secondary outcomes included other environmental impacts. A sensitivity analysis was performed to examine the impact of varying scenarios.

RESULTS

Carbon footprint of SU and RU gastroscopes were 10.9 kg CO2 eq and 4.7 kg CO2 eq, respectively. The difference in carbon footprint equals one conventional car drive of 28 km or 6 days of CO2 emission of an average European household. Based on environmentally-extended input-output life cycle assessment, the estimated per-use carbon footprint of the endoscope stack and washer was 0.18 kg CO2 eq in SU strategy versus 0.56 kg CO2 eq in RU strategy. According to secondary outcomes, fossil eq depletion was 130 MJ (SU) and 60.9 MJ (RU) and water depletion for 6.2 m3 (SU) and 9.5 m3 (RU), respectively.

CONCLUSION

For one examination, SU gastroscope have a 2.5 times higher carbon footprint than RU ones. These data will help with the logistics and planning of an endoscopic service in relation to other economic and environmental factors.

The environmental impact of small-bowel capsule endoscopy

INTRODUCTION

 The environmental impact of endoscopy, including small-bowel capsule endoscopy (SBCE), is a topic of growing attention and concern. This study aimed to evaluate the greenhouse gas (GHG) emissions (kgCO2) generated by an SBCE procedure.

METHODS

 Life cycle assessment methodology (ISO 14040) was used to evaluate three brands of SBCE device and included emissions generated by patient travel, bowel preparation, capsule examination, and video recording. A survey of 87 physicians and 120 patients was conducted to obtain data on travel, activities undertaken during the procedure, and awareness of environmental impacts.

RESULTS

 The capsule itself (4 g) accounted for < 6 % of the total product weight. Packaging (43-119 g) accounted for 9 %-97 % of total weight, and included deactivation magnets (5 g [4 %-6 %]) and paper instructions (11-50 g [up to 40 %]). A full SBCE procedure generated approximately 20 kgCO2, with 0.04 kgCO2 (0.2 %) attributable to the capsule itself and 18 kgCO2 (94.7 %) generated by patient travel. Capsule retrieval using a dedicated device would add 0.98 kgCO2 to the carbon footprint. Capsule deconstruction revealed materials (e. g. neodymium) that are prohibited from environmental disposal; 76 % of patients were not aware of the illegal nature of capsule disposal via wastewater, and 63 % would have been willing to retrieve it. The carbon impact of data storage and capsule reading was negligible.

CONCLUSION

 The carbon footprint of SBCE is mainly determined by patient travel. The capsule device itself has a relatively low carbon footprint. Given that disposal of capsule components via wastewater is illegal, retrieval of the capsule is necessary but would likely be associated with an increase in device-related emissions.

Development of Iron-Based Single Atom Materials for General and Efficient Synthesis of Amines

Earth abundant metal-based heterogeneous catalysts with highly active and at the same time stable isolated metal sites constitute a key factor for the advancement of sustainable and cost-effective chemical synthesis. In particular, the development of more practical, and durable iron-based materials is of central interest for organic synthesis, especially for the preparation of chemical products related to life science applications. Here, we report the preparation of Fe-single atom catalysts (Fe-SACs) entrapped in N-doped mesoporous carbon support with unprecedented potential in the preparation of different kinds of amines, which represent privileged class of organic compounds and find increasing application in daily life. The optimal Fe-SACs allow for the reductive amination of a broad range of aldehydes and ketones with ammonia and amines to produce diverse primary, secondary, and tertiary amines including N-methylated products as well as drugs, agrochemicals, and other biomolecules (amino acid esters and amides) utilizing green hydrogen.

Green endoscopy, one step toward a sustainable future: Literature review

Rapid climate change or climate crisis is one of the most serious emergencies of the 21st century, accounting for highly impactful and irreversible changes worldwide. Climate crisis can also affect the epidemiology and disease burden of gastrointestinal diseases because they have a connection with environmental factors and nutrition. Gastrointestinal endoscopy is a highly intensive procedure with a significant contribution to greenhouse gas (GHG) emissions. Moreover, endoscopy is the third highest generator of waste in healthcare facilities with significant contributions to carbon footprint. The main sources of direct carbon emission in endoscopy are use of high-powered consumption devices (e.g. computers, anesthesia machines, wash machines for reprocessing, scope processors, and lighting) and waste production derived mainly from use of disposable devices. Indirect sources of emissions are those derived from heating and cooling of facilities, processing of histological samples, and transportation of patients and materials. Consequently, sustainable endoscopy and climate change have been the focus of discussions between endoscopy providers and professional societies with the aim of taking action to reduce environmental impact. The term "green endoscopy" refers to the practice of gastroenterology that aims to raise awareness, assess, and reduce endoscopy´s environmental impact. Nevertheless, while awareness has been growing, guidance about practical interventions to reduce the carbon footprint of gastrointestinal endoscopy are lacking. This review aims to summarize current data regarding the impact of endoscopy on GHG emissions and possible strategies to mitigate this phenomenon. Further, we aim to promote the evolution of a more sustainable "green endoscopy".

Endoscopic Grading and Sampling of Gastric Precancerous Lesions: A Comprehensive Literature Review

Gastric cancer remains a disease with an ominous prognosis, while early gastric cancer has a good-to-excellent prognosis, with 5-year survival rates of up to 92.6% after successful endoscopic resection. In this context, the accurate identification of patients with established gastric precancerous lesions, namely chronic atrophic gastritis and intestinal metaplasia, is the first step in a stepwise approach to minimize cancer risk. Although current guidelines advocate for the execution of random biopsies to stage the extent and severity of gastritis/intestinal metaplasia, modern biopsy protocols are still imperfect as they have limited reproducibility and are susceptible to sampling error. The advent of novel imaging-enhancing modalities, i.e., high-definition with virtual chromoendoscopy (CE), has revolutionized the inspection of gastric mucosa, leading to an endoscopy-based staging strategy for the management of these premalignant changes in the stomach. Nowadays, the incorporation of CE-targeted biopsies in everyday clinical practice offers not only the robust detection of premalignant lesions but also an improvement in quality, by reducing missed diagnoses along with mean biopsies and, thus, the procedural costs and the environmental footprint. In this review, we summarize the recent evidence regarding the endoscopic grading and sampling of gastric precancerous lesions.

Colorectal polypectomy and endoscopic mucosal resection: European Society of Gastrointestinal Endoscopy (ESGE) Guideline - Update 2024

1:  ESGE recommends cold snare polypectomy (CSP), to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of diminutive polyps (≤ 5 mm).Strong recommendation, high quality of evidence. 2:  ESGE recommends against the use of cold biopsy forceps excision because of its high rate of incomplete resection.Strong recommendation, moderate quality of evidence. 3:  ESGE recommends CSP, to include a clear margin of normal tissue (1-2 mm) surrounding the polyp, for the removal of small polyps (6-9 mm).Strong recommendation, high quality of evidence. 4:  ESGE recommends hot snare polypectomy for the removal of nonpedunculated adenomatous polyps of 10-19 mm in size.Strong recommendation, high quality of evidence. 5:  ESGE recommends conventional (diathermy-based) endoscopic mucosal resection (EMR) for large (≥ 20 mm) nonpedunculated adenomatous polyps (LNPCPs).Strong recommendation, high quality of evidence. 6:  ESGE suggests that underwater EMR can be considered an alternative to conventional hot EMR for the treatment of adenomatous LNPCPs.Weak recommendation, moderate quality of evidence. 7:  Endoscopic submucosal dissection (ESD) may also be suggested as an alternative for removal of LNPCPs of ≥ 20 mm in selected cases and in high-volume centers.Weak recommendation, low quality evidence. 8:  ESGE recommends that, after piecemeal EMR of LNPCPs by hot snare, the resection margins should be treated by thermal ablation using snare-tip soft coagulation to prevent adenoma recurrence.Strong recommendation, high quality of evidence. 9:  ESGE recommends (piecemeal) cold snare polypectomy or cold EMR for SSLs of all sizes without suspected dysplasia.Strong recommendation, moderate quality of evidence. 10:  ESGE recommends prophylactic endoscopic clip closure of the mucosal defect after EMR of LNPCPs in the right colon to reduce to reduce the risk of delayed bleeding.Strong recommendation, high quality of evidence. 11:  ESGE recommends that en bloc resection techniques, such as en bloc EMR, ESD, endoscopic intermuscular dissection, endoscopic full-thickness resection, or surgery should be the techniques of choice in cases with suspected superficial invasive carcinoma, which otherwise cannot be removed en bloc by standard polypectomy or EMR.Strong recommendation, moderate quality of evidence.

Role of endoscopy in hepatology

The growing and evolving field of EUS and advanced hepatobiliary endoscopy has amplified traditional upper gastrointestinal endoscopy and unveiled novel options for remaining unsolved hepatobiliary issues, both diagnostically and therapeutically. This conceptually appealing and fascinating integration of endoscopy within the practice of hepatology is referred to as 'endo-hepatology'. Endo-hepatology focuses on the one hand on disorders of the liver parenchyma and liver vasculature and of the hepatobiliary tract on the other hand. Applications hanging under the umbrella of endohepatology involve amongst others EUS-guided liver biopsy, EUS-guided portal pressure measurement, EUS-guided portal venous blood sampling, EUS-guided coil & glue embolization of gastric varices and spontaneous portosystemic shunts as well as ERCP in the challenging context of (decompensated cirrhosis) and intraductal cholangioscopy for primary sclerosing cholangitis. Although endoscopic proficiency however does not necessarily equal in an actual straightforward end-solution for currently persisting (complex) hepatobiliary situations. Therefore, endohepatology continues to generate high-quality data to validate and standardize procedures against currently considered (best available) "golden standards" while continuing to search and trying to provide novel minimally invasive solutions for persisting hepatological stalemate situations. In the current review, we aim to critically appraise the status and potential future directions of endo-hepatology.

Advanced trainee perceptions of disposable duodenoscopes and disposable endcaps: results of a nationwide survey

INTRODUCTION

Disposable duodenoscopes and duodenoscopes with disposable endcaps are being used in clinical practice to reduce or eliminate the risk of transmitting infections. The study aim was to assess perceptions and experiences regarding the use of these duodenoscopes among advanced endoscopy fellows in a nationally representative sample.

METHODS

A 17-item electronic survey was sent to 74 advanced endoscopy training programs. The survey was completed by 50 participants and their responses were included for analysis.

RESULTS

Most participants were from academic training programs (82.7%) and identified as being in their 7th year of post graduate training (92%; PGY-7). Participants performed an average of 414 ERCPs. 29% reported difficulty with cannulation using disposable duodenoscopes versus 15.7% with duodenoscopes with disposable endcaps (vs. standard duodenoscope). 96% of trainees perceived disposable duodenoscopes as not cost effective and 92% stated they would not use this device during independent practice. 100% of trainees stated that they would use duodenoscopes with disposable endcaps during independent practice. For their most challenging cases, 90% of trainees preferred using standard reprocessable duodenoscopes while no trainee indicated they would prefer using a disposable duodenoscope in this scenario. 82% of participants stated that disposable duodenoscopes and disposable endcaps should be used exclusively or preferentially for high-risk patients citing cost, functionality, and concerns regarding environmental impact.

DISCUSSION

Advanced endoscopy fellows perceive disposable duodenoscopes as impacting technical maneuverability. Concerns about functionality, cost effectiveness and environmental impact are barriers to adoption.

Ecogastroenterology: cultivating sustainable clinical excellence in an environmentally conscious landscape

Gastrointestinal practices, especially endoscopy, have a substantial environmental impact, marked by notable greenhouse gas emissions and waste generation. As the world struggles with climate change, there emerges a pressing need to re-evaluate and reform the environmental footprint within gastrointestinal medicine. The challenge lies in finding a harmonious balance between ensuring clinical effectiveness and upholding environmental responsibility. This task involves recognising that the most significant reduction in the carbon footprint of endoscopy is achieved by avoiding unnecessary procedures; addressing the use of single-use endoscopes and accessories; and extending beyond the procedural suites to include clinics, virtual care, and conferences, among other aspects of gastrointestinal practice. The emerging digital realm in health care is crucial, given the potential environmental advantages of virtual gastroenterological care. Through an in-depth analysis, this review presents a path towards sustainable gastrointestinal practices, emphasising integrated strategies that prioritise both patient care and environmental stewardship.

Assessing the impact of center volume on the cost-effectiveness of centralizing ERCP

BACKGROUND AND AIMS

ERCP is a complex endoscopic procedure in which the center's procedure volume influences outcomes. With the increasing healthcare expenses and limited resources, promoting cost-effective care becomes essential for healthcare provision. This study was a cost-effectiveness analysis to evaluate the hypothesis that high-volume (HV) centers perform ERCP with higher quality at lower costs than low-volume (LV) centers.

METHODS

A baseline case compared the current distribution of ERCPs among HV and LV centers with a hypothetical scenario in which all ERCPs are performed at HV centers. A cost-effectiveness analysis was constructed, followed by 1- and 2-way sensitivity analyses, and probabilistic sensitivity analysis using Monte Carlo simulations.

RESULTS

In the baseline case, the incremental cost-effectiveness ratio was -$151,270 per year, due to the hypothetical scenario's lower costs and slightly higher quality-adjusted life years. The model was most sensitive to changes in transportation costs (109.34%), probability of significant adverse events (AEs) after successful ERCP at LV centers (42.12%), utility after ERCP with significant AEs (30.10%), and probability of significant AEs after successful ERCP at HV centers (23.53%); only transportation costs above $3655 changed the study outcome, however. The current ERCP distribution would only be cost-effective if LV centers achieved higher success (≥92.4% vs 89.3%), with much lower significant AEs (≤.5% vs 6.7%). The study's main findings remained unchanged while combining all model parameters in the probabilistic sensitivity analysis.

CONCLUSIONS

Our findings show that HV centers have high-performance rates at lower costs, raising the need to consider the principle of centralization of ERCPs into HV centers to improve the quality of care.