Environmentally Sustainable Endoscopy Practices

Abstract Climate change affects each and every one of us and has far reaching consequences. As healthcare providers and responsible citizens, it is our duty to make our practices environmentally sustainable. Endoscopy practice involves frequent use of single-use items, resource-heavy decontamination practices, water consumption, patient and staff travel as well as high electricity consumption. The present review highlights the measures that can be taken to reduce the carbon footprint of endoscopy practice. Proper waste management, judicious use of electricity, proper selection of cases for anesthesia and biopsy, and appropriate use of noninvasive tests in practice are discussed in the review.


Introduction
Climate change affects each and every one of us and has far reaching consequences.As healthcare providers and responsible citizens, it is our duty to make our practices environmentally sustainable.The healthcare sector is responsible for significant greenhouse gas emissions worldwide.Gastrointestinal (GI) endoscopy practice involves frequent use of singleuse items, resource-heavy decontamination practices, water consumption, patient and staff travel as well as high electricity consumption.With the awareness that there is an urgent need to reduce environmental impact of healthcare, there is considerable interest in reducing the carbon footprint of GI endoscopy practice.However, this change should not adversely affect the desired patient care, training needs, and clinical standards.2][3] The present review discusses how we can make endoscopy more environmentally sustainable in the Indian milieu.

Magnitude of the Problem
The carbon footprint of endoscopy practice is considerable.It is attributable to high patient load, travel by patients and staff, single-use consumables, waste generation, and resource-heavy decontamination processes.Studies from Unit-ed States have highlighted that endoscopy is the third highest generator of waste in healthcare.The estimated carbon footprint of endoscopy in the United States is at 85,768 metric tons of CO2 emissions annually, equivalent to more than 9 million gallons of gasoline consumed, 94 million pounds of coal burned, and 212 million miles driven in average nonelectric car.Sequestering these CO2 emissions would require an additional 112,000 acres of new forests per year. 4Studies have shown that each endoscopy bed-day creates nearly 3 kg in waste, and 13,500 tons of plastic waste in the United States per year are generated by endoscopy practice. 5,6The West has woken up to the serious environmental consequences of endoscopy practice.Several societies have proposed guidelines and position statements for environmentally sustainable endoscopy practices. 2,7

Endoscopy Planning
Planning of endoscopy procedures in advance and giving same-day appointments if the patient has two procedures help in reducing travel and sedation related costs.This preprocedure planning also minimizes use of accessories like peripheral lines and tubings.Same-day procedures reduce consumption of water, energy, and personal protective equipment. 8Upper GI endoscopy before colonoscopy has been shown to be the optimal sequence since it leads to reduced sedation levels and shorter recovery time. 9,10Another important aspect is to reduce re-procedure rates.This can be done by proper patient education to assure good bowel preparation and optimization of patient condition before planning the procedure.Re-procedures can be avoided by having a multidisciplinary team planning in complex cases, for example, large polyps, complex endoscopic retrograde cholangiopancreatography, to place patients in appropriate specialist lists.

Rationalizing Endoscopy Workload
Studies have shown that up to 56% of referrals for upper GI endoscopies and between 23 and 52% for colonoscopies may be inappropriate. 11,12Moreover, endoscopic evaluation seldom helps in guiding management in patients with some chronic scenarios like dyspepsia and constipation. 13Proper patient selection for endoscopy is, therefore, needed, for example, endoscopic evaluation for patients with dyspepsia/constipation only if alarm symptoms are present or recurrent symptoms are noted, using stool test for Helicobacter pylori antigen.

Waste Generation and Segregation
Proper waste management involves waste reduction, proper segregation, and disposal.Waste reduction strategies will be discussed later.Proper segregation of waste is important as it reduces the amount of waste going to the landfills.As endoscopy units generate significant amount of waste, 5,6 it is useful that proper waste disposal bins and recycling bins are placed in every unit (►Fig.1).Biohazardous waste products like blood or blood products, soiled materials from patients, suction canisters, and sharp bin material need to be disposed properly as per institutional practices.Disposable gloves and gowns used for endoscopic procedures should not be placed into these containers.It is important to note that nonsoiled plastic waste from accessories and other sources can be diverted to recycling and thereby reduce waste generation (►Fig. 1).][23] The coronavirus pandemic can be regarded as the watershed moment in terms of endoscopy practice.The highvolume use of single-use plastics in personal protective equipment resulted in enormous waste generation.Use of reusable rather than disposable gowns has shown to reduce carbon footprint by two-thirds.Environmental impact of gloves can be reduced by using powder coating gloves rather than chlorination to reduce stickiness. 24It is important to follow all infection control measures, yet remain aware of the sustainability practices.

Minimizing Paper and Plastic Use
A significant proportion (30%) of all hospital waste is paper.Paper is used for printing reports, taking consent, recording patient vitals, and postendoscopy instructions.Additionally, a lot of departmental activities and communication use paper.Comprehensive use of electronic records for all administrative, nursing, and endoscopic documentation can go a long way in creating paperless endoscopy units. 25Using recycled paper and printing in black and white should also be considered. 26

Minimizing Water Wastage
Installation of low flow devices on taps and toilets and using sensor activated taps help in reducing waster wastage.In endoscopy, full hand disinfection is not required and use of Sustainable Endoscopy Jain 145 alcohol rubs instead of hand washing may be done when hands are not visibly soiled or in contact with potential spore-forming pathogens. 27,28Both alcohol-based gels and petrochemical soaps are not environmentally safe as they contaminate water sources. 29Use of natural and environment friendly products may be the way forward.

Preventing Electricity Misuse
Endoscopy units use electricity for lighting, air conditioning, computers, printers, and endoscopy equipment.Sources of electricity wastage include usage of energy inefficient bulbs and lack of attention to whether lights and devices such as computers are switched off when not in use and at the end of the working day. 30Heating, ventilation, and air conditioning are responsible for the greatest proportion of end-use energy in hospitals.Judicious use of these devices and proper implementation of energy saving interventions can go a long way in making endoscopy departments more environmentally sustainable.

Limiting Use of Single-Use Plastics
Majority of the patients who undergo endoscopy are given food and beverages after endoscopy in plastic or polystyrene cups.All single-use disposable cups have significant environmental impact and contribute to carbon footprint.Encouraging patients to bring their own glasses and water bottles may help to curb use of single-use plastics.

Endoscope Cleaning and Disinfection of Equipment-Points to Ponder
Post-procedure cleaning and reprocessing of endoscopy equipment are labor and resource intensive.There is a need to make all steps more energy efficient and environment friendly.The chemicals used in cleaning should have clinical efficacy but minimal environmental impact with suggested characteristics of pH neutrality, biodegradability, and marine life safety certification.In addition, consideration of safety of the chemicals used for the personnel involved in decontamination should also be considered.Research is needed to make such innovative products. 2,7ndoscope manufacturers' guidance specifies the use of sterile water in decontamination and through auxiliary waterjet channels.Further, sterile water is used in intraprocedural mucosal washing of colon with pump irrigation, water-assisted colonoscopy, filling syringes, and endoscope reprocessing.Industrial production of sterile water incurs energy consumption and environmental impact at several stages.It is packed in plastic containers and packaging, transported to sites and eventually these containers are discarded into a nonrecyclable waste stream.Use of sterile water can be minimized by proper efforts and using hospital-based system enabling the production of "sterile" water like local reverse osmosis, ultrafiltration or autoclave-sterilization systems.With proper and stringent local infection control and water quality monitoring, use of industrially produced and packaged sterile water can be significantly reduced. 2

Reuse of Endoscopy Accessories
Endoscopic procedures require multiple accessories like biopsy forceps, hold and cold snares, diathermy pads, and others.2][33] The cost of these devices is unrealistic compared to procedural costs and reimbursement rates in Indian setting.Moreover, their disposal after each procedure generates tremendous plastic waste.Whenever such single-use devices are reused, there should be proper guidance as per hospital policies. 34In India and other resource-constrained areas, majority of the centers use accessories and mouth guards multiple times after proper disinfection.Sterilization is required for reusable accessory that breaches mucosal contact like biopsy forceps. 35Innovation in equipment design and sterilization techniques is the need of the hour as this may help to facilitate waste minimization.

Reducing Biopsy Load
The carbon footprint of routine histopathology from GI biopsies is immense and processing of every three histology pots is equivalent to the carbon emissions of driving 2 miles in an average car. 36It is important to discourage use of routine biopsies and avoid biopsies when they are unlikely to change patient management.It is important to use alternative investigations if available and when endoscopy is not a "must," for example, fecal calprotectin for assessing disease activity in inflammatory bowel disease, liver stiffness measurement to identify risk of advanced fibrosis and varices, and use of serological tests to make diagnosis of celiac disease.Research has shown that upper GI endoscopy itself influences the clinical management of patients in approximately only one-sixth of cases. 37Use of mucosal enhancement techniques, optical biopsy, and artificial intelligence can help in better assessment of polyps and reduce the need for biopsies. 38,39Further workup is required before the impact of such interventions can be judged.

Anesthesia during Endoscopy
Use of anesthesia/sedation during endoscopy alleviates anxiety and makes patient more comfortable.However, it is associated with significantly higher environmental impact with use of anesthesia equipment, electricity, prolonged hospital stay, and use of inhalational gases like oxygen.It is important of counsel patients properly and create a patient friendly atmosphere so that majority of the diagnostic procedures can be done without anesthesia.Anesthesia should be used only if patient is unwilling for diagnostic procedure without sedation or if a therapeutic procedure is planned.

Single-Use Duodenoscopes-Uses and Carbon Footprint
Of late, there has been considerable interest in single-use endoscopes for GI endoscopy. 40The advantages of single-use endoscopes include lower acquisition costs, no reprocessing costs, and no risk of cross-contamination.However, to meet ever growing demands of endoscopes, this would lead to increased risk of plastic pollution and increase in net waste. 41,42Carbon dioxide emissions associated with single-use scopes are 24 to 47 times that of reusable scopes 43 with major emissions being related to manufacturing.In the present scenario, use of single-use duodenoscopes has been restricted to highly selective indications like when infectious risk is of heightened concern; safe and effective decontamination represents a significant challenge; the risk of not performing endoscopy is an overriding concern.

Conclusion and Future Directions
►Table 1 summarizes the key elements in environmentally sustainable endoscopy practice.Each center needs to identify its challenges, seek support of like-minded people, educate staff, and follow a selective approach for endoscopy practice.A recent single-center study from India has highlighted that despite increasing workload, with proper planning and action, it was possible to cut down on electricity bills, paper use, use of plastics, and number of biopsies taken per month. 44arious endoscopy societies in Europe have recommended inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain.There is urgent need to conduct high-quality research to quantify and minimize the environmental impact of GI endoscopy.Industry partners and GI endoscopy companies need to assess, disclose, and audit the environmental impact of their value chain.The final aim is to make GI endoscopy a net-zero greenhouse gas emissions practice by 2050. 7The dictum for green endoscopy practice today is "reduce, reuse, recycle, research and rethink." Apart from the measures discussed above, certain practices like use of solar electricity, solar water heating, waste water management, use of recycled paper, and electronic records can be initiated at hospital level.These practices can reduce carbon footprint of hospitals.This appears to be the way forward.

Fig. 1
Fig. 1 Proper waste management in endoscopy practice-suggested model in Indian setting.