Life cycle assessment of routinely used endoscopic instruments and simple intervention to reduce our environmental impact

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.

Perspectives and awareness of endoscopy healthcare professionals on sustainable practices in gastrointestinal endoscopy: results of the LEAFGREEN survey

BACKGROUND

Gastrointestinal (GI) endoscopy is one of healthcare's main contributors to climate change. We aimed to assess healthcare professionals' attitudes and the perceived barriers to implementation of sustainable GI endoscopy.

METHODS

The LEAFGREEN web-based survey was a cross-sectional study conducted by the European Society of Gastrointestinal Endoscopy (ESGE) Green Endoscopy Working Group. The questionnaire comprised 39 questions divided into five sections (respondent demographics; climate change and sustainability beliefs; waste and resource management; single-use endoscopes and accessories; education and research). The survey was available via email to all active members of the ESGE and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) in March 2023.

RESULTS

407 respondents participated in the survey (11% response rate). Most participants (86%) agreed climate change is real and anthropogenic, but one-third did not consider GI endoscopy to be a significant contributor to climate change. Improvement in the appropriateness of endoscopic procedures (41%) and reduction in single-use accessories (34%) were considered the most important strategies to reduce the environmental impact of GI endoscopy. Respondents deemed lack of institutional support and knowledge from staff to be the main barriers to sustainable endoscopy. Strategies to reduce unnecessary GI endoscopic procedures and comparative studies of single-use versus reusable accessories were identified as research priorities.

CONCLUSIONS

In this survey, ESGE and ESGENA members acknowledge climate change as a major threat to humanity. Further improvement in sustainability beliefs and professional attitudes, reduction in inappropriate GI endoscopy, and rational use of single-use accessories and endoscopes are critically required.

Healthcare in the era of climate change and the need for environmental sustainability

ABSTRACT

Climate change is an existential threat to humanity. While the healthcare sector must manage the health-related consequences of climate change, it is a significant contributor to greenhouse gas emissions, responsible for up to 4.6% of global emission, aggravating global warming. Within the hospital environment, the three largest contributors to greenhouse gas emissions are the operating theatre, intensive care unit and gastrointestinal endoscopy. Knowledge of the health-related burden of climate change and the potential transformative health benefits of climate action is important to all health professionals, as they play crucial roles in effecting change. This article summarises the available literature on the impact of healthcare on climate change and efforts in mitigation, focusing on the intrinsic differences and similarities across the operating theatre complex, intensive care unit and gastrointestinal endoscopy unit. It also discusses strategies to reduce carbon footprint.

Environmentally sustainable gastroenterology practice: Review of current state and future goals

OBJECTIVES

The health-care sector contributes 4.6% of global greenhouse gas emissions, with gastroenterology playing a significant role due to the widespread use of gastrointestinal (GI) endoscopy. In this review, we aim to understand the carbon footprint in gastroenterology practice associated with GI endoscopy, conferences and recruitment, identify barriers to change, and recommend mitigating strategies.

METHODS

A comprehensive search of PubMed, Embase, and the Cochrane Library was conducted to explore the carbon footprint in gastroenterology practice, focusing on endoscopy, inpatient and outpatient settings, and recruitment practices. Recommendations for mitigating the carbon footprint were derived.

RESULTS

This narrative review analyzed 34 articles on the carbon footprint in gastroenterology practice. Carbon footprint of endoscopy in the United States is approximately 85,768 metric tons of CO2 emission annually, equivalent to 9 million gallons of gasoline consumed, or 94 million pounds of coal burned. Each endoscopy generates 2.1 kg of disposable waste (46 L volume), of which 64% of waste goes to the landfill, 28% represents biohazard waste, and 9% is recycled. The per-case manufacturing carbon footprint for single-use devices and reusable devices is 1.37 kg CO2 and 0.0017 kg CO2, respectively. Inpatient and outpatient services contributed through unnecessary procedures, prolonged hospital stays, and excessive use of single-use items. Fellowship recruitment and gastrointestinal conferences added to the footprint, mainly due to air travel and hotel stays.

CONCLUSION

Gastrointestinal endoscopy and practice contribute to the carbon footprint through the use of disposables such as single-use endoscopes and waste generation. To achieve environmental sustainability, measures such as promoting reusable endoscopy equipment over single-use endoscopes, calculating institutional carbon footprints, establishing benchmarking standards, and embracing virtual platforms such as telemedicine and research meetings should be implemented.

Audit of hemostatic clip use after colorectal polyp resection in an academic endoscopy unit

Background and study aims Prophylactic closure of endoscopic resection defects reduces delayed hemorrhage after resection of non-pedunculated colorectal lesions ≥ 20 mm that are located proximal to the splenic flexure and removed by electrocautery. The risk of delayed hemorrhage after cold (without electrocautery) resection is much lower, and prophylactic clip closure after cold resection is generally unnecessary. The aim of this study was to audit clip use after colorectal polyp resection in routine outpatient colonoscopies at two outpatient centers within an academic medical center. Patients referred for resection of known lesions were excluded. Patients and methods Retrospective chart analysis was performed as part of a quality review of physician adherence to screening and post-polypectomy surveillance intervals. Results Among 3784 total lesions resected cold by 29 physicians, clips were placed after cold resection on 41.7% of 12 lesions ≥ 20 mm, 19.3% of 207 lesions 10 to 19 mm in size, and 2.8% of 3565 lesions 1 to 9 mm in size. Three physicians placed clips after cold resection of lesions 1 to 9 mm in 18.8%, 25.5%, and 45.0% of cases. These physicians accounted for 8.1% of 1- to 9-mm resections, but 69.7% of clips placed in this size range. Electrocautery was used for 3.1% of all resections. Clip placement overall after cold resection (3.9%) was much lower than after resection with electrocautery (71.1%), but 62.4% of all clips placed were after cold resection. Conclusions Audits of clip use in an endoscopy practice can reveal surprising findings, including high and variable rates of unnecessary use after cold resection. Audit can potentially reduce unnecessary costs, carbon emissions, and plastic waste.

Reducing scope 3 carbon emissions in gastrointestinal endoscopy: results of the prospective study of the 'Green Endoscopy Project Würzburg'

OBJECTIVE

Carbon emissions generated by gastrointestinal endoscopy have been recognised as a critical issue. Scope 3 emissions are mainly caused by the manufacturing, packaging and transportation of purchased goods. However, to our knowledge, there are no prospective data on the efficacy of measurements aimed to reduce scope 3 emissions.

DESIGN

The study was performed in a medium-sized academic endoscopy unit. Manufacturers of endoscopic consumables were requested to answer a questionnaire on fabrication, origin, packaging and transport. Based on these data, alternative products were purchased whenever possible. In addition, staff was instructed on how to avoid waste. Thereafter, the carbon footprint of each item purchased was calculated from February to May 2023 (intervention period), and scope 3 emissions were compared with the same period of the previous year (control period).

RESULTS

26 of 40 companies answered the questionnaire. 229 of 322 products were classified as unfavourable. A switch to alternative items was possible for 47/229 items (20.5%). 1666 endoscopies were performed during the intervention period compared with 1751 examinations during the control period (-4.1%). The number of instruments used decreased by 10.0% (3111 vs 3457). Using fewer and alternative products resulted in 11.5% less carbon emissions (7.09 vs 8.01 tons of carbon equivalent=tCO2 e). Separation of waste led to a reduction of 20.1% (26.55 vs 33.24 tCO2e). In total, carbon emissions could be reduced by 18.4%.

CONCLUSION

Use of fewer instruments per procedure, recycling packaging material and switching to alternative products can reduce carbon emissions without impairing the endoscopic workflow.

Materials Science Toolkit for Carbon Footprint Assessment: A Case Study for Endoscopic Accessories of Common Use

Ironically, healthcare systems are key agents in respiratory-related diseases and estimated deaths because of the high impact of their greenhouse gas emissions, along with industry, transportation, and housing. Based on safety requirements, hospitals and related services use an extensive number of consumables, most of which end up incinerated at the end of their life cycle. A thorough assessment of the carbon footprint of such devices typically requires knowing precise information about the manufacturing process, which is rarely available in detail because of the many materials, pieces, and steps involved during the fabrication. Yet, the tools most often used for determining the environmental impact of consumer goods require a bunch of parameters, mainly based on the material composition of the device. Here, we report a basic set of analytical methods that provide the information required by the software OpenLCA to calculate the main outcome related to environmental impact, greenhouse gas emissions. Through thermogravimetry, calorimetry, infrared spectroscopy, and elemental analysis, we proved that obtaining relevant data for the calculator in the exemplifying case of endoscopy tooling or accessories is possible. This routine procedure opens the door to a broader, more accurate analysis of the environmental impact of everyday work at hospital services, offering potential alternatives to minimize it.

Single-use accessories and endoscopes in the era of sustainability and climate change-A balancing act

Gastrointestinal (GI) endoscopy is among the highest waste generator in healthcare facilities. The major reasons include production of large-volume non-renewable waste, use of single-use devices, and reprocessing or decontamination processes. Single-use endoscopic accessories have gradually replaced reusable devices over last two decades contributing to the rising impact of GI endoscopy on ecosystem. Several reports of infection outbreaks with reusable duodenoscopes raised concerns regarding the efficacy and adherence to standard disinfection protocols. Even the enhanced reprocessing techniques like double high-level disinfection have not been found to be the perfect ways for decontamination of duodenoscopes and therefore, paved the way for the development of single-use duodenoscopes. However, the use of single-use endoscopes is likely to amplify the net waste generated and carbon footprint of any endoscopy unit. Moreover, single-use devices challenge one of the major pillars of sustainability, that is, "reuse." In the era of climate change, a balanced approach is required taking into consideration patient safety as well as financial and environmental implications. The possible solutions to provide optimum care while addressing the impact on climate include selective use of disposable duodenoscopes and careful selection of accessories during a case. Other options include use of disposable endcaps and development of effective high-level disinfection techniques. The collaboration between the healthcare professionals and the manufacturers is paramount for the development of environmental friendly devices with low carbon footprint.

Challenges of developing a green gastroenterology evidence base and how trainee research networks can fill the gaps

Trainee research networks are a collaborative effort to enable high-quality multicentre audits or research that is more widely accessible to trainees. Such networks lead, design and deliver research at a far higher scale than could be achieved locally and are carried out solely by trainees. There is an increasing focus on delivering research that is not only environmentally sustainable but also focuses on areas that can reduce the carbon footprint of service provision in gastroenterology and hepatology. In this manuscript, we performed a scoping review to understand the current evidence base of the impact of gastroenterology and hepatology services on the environment as well as exploring any association between pollution and climate change with gastrointestinal and liver disease. We further discuss the barriers that researchers face in delivering environmentally sustainable research, the limitation in clinical guidelines related to practicing environmentally sustainable gastroenterology and hepatology and how the trainee research networks are ideally placed to initiate change by developing, disseminating and implementing best practice in ‘green Gastroenterology’.