Capsule endoscopy emissions: less than expected and largely influenced by patient transport

Small-bowel capsule endoscopy (SBCE) is a common noninvasive method, based on a single-use consumable, which has transformed the way we track gastrointestinal diseases since its introduction in 2000 [1]. However, as with any other medical supplies, it is crucial to consider the environmental footprint using a standardized approach to assessment of the net greenhouse gas (GHG) emission profile of each procedure, following the current ESGE Green Endoscopy Position Statement [2].

In this issue of Endoscopy, Pioche et al. prospectively performed an eco-audit to quantify the environmental emissions relating to device manufacturing, transportation, and recycling, bowel preparation, and patient travel involved in an SBCE examination for three different brands of device [3]. The study showed that the impact is mainly determined by patient travel, while in comparison the capsule device itself has a low carbon footprint. A full SBCE generated around 20 kg of carbon dioxide equivalents (CO₂), which included 0.2% for the capsule itself and 94.7% generated by patient travel. This was determined through an ISO14040-based life cycle assessment [4] and a patient survey.

The manufacturing process in which the capsule and its packaging are produced remains largely unexplored; however, it is essential to consider the energy consumption, waste generation, and sourcing of materials during this process, as the environmental impact begins with the extraction and refinement of individual components (plastics, electronic components, and batteries). Once manufactured, the capsules need to be transported to healthcare facilities (including shipping and delivery). Prior to the procedure, patients are required to follow a low-fiber diet and take a bowel preparation solution that also has environmental impacts needing to be considered. Furthermore, patients have to travel to the hospital and the device needs to be recycled.

“Further discussion involving manufacturers is required in order to implement proper waste management and recycling of the capsule endoscope components.”

The capsule procedure (including the device and bowel preparation) has relatively low GHG emissions (approximately 1 kgCO₂, accounting for 5% of the total), far less than expected and comparable among the three evaluated capsule brands (PillCam SB3, CapsoCam, and NaviCam). When the packaging is considered, the emissions rise from 0.04 kgCO₂ to 0.29 kgCO₂, mainly owing to the neodymium-made recyclable magnet that is included with each capsule to keep it inactive. Additionally, device shipping from the manufacturing site to the endoscopy unit added 0.48 kgCO₂ and bowel preparation a further 0.28 kgCO₂.

The GHG emissions of SBCE are largely determined by patient travel (18 kgCO₂; 95% of the total), raising concerns about transportation. Patient travel to and from endoscopy units is an area that requires attention as it has an environmental footprint that should not be overlooked, while physician travel does not significantly increase the impact.

In another French study, patients’ modes of transport also emerged as the highest carbon footprint emitter for gastrointestinal endoscopy procedures [5]. Many patients arrive at endoscopy units using private vehicles, which contribute to carbon emissions. To reduce this need for travel and its associated emissions, healthcare providers need to ensure the appropriateness of procedures and avoid those that are unnecessary; where possible, they should explore telemedicine options, allowing patients to ingest the capsule at home and transmit data remotely to reduce the overall carbon footprint. Artificial intelligence (AI) models could also be used to improve the more administrative aspects of healthcare by efficiently managing patient appointments and procedure sequencing to minimize energy consumption, reduce patient waiting times, and improve overall resource efficiency. In this regard, while endoscopy-related patient travel has been identified as a modifiable contributor to GHG emissions, there are few data investigating the scale of the pre-endoscopy patient travel footprint. It can however be reduced by online health education to minimize patient commutes [6].

The LEAFGREEN survey among ESGE and ESGENA members’ forces us to improve the appropriateness of endoscopic procedures and rational use of single-use accessories [7]. This study highlights the importance of global assessment of the carbon footprint. The capsule device itself contributes less to GHG emissions than expected. Device waste mainly comes from packaging, especially the instruction forms (40% of the total). More efficient packaging design and recycling of packaging within endoscopy units could further decrease GHG emissions. Future strategies should rely on the purchase of green products with minimal environmental impact based on material composition analysis, such as consumables made from recycled materials or those that are sustainably sourced [8].

The disposal of capsule components remains a challenge and proper waste management is crucial for minimizing their environmental impact. Given that the disposal of batteries in these devices into the environment is strictly forbidden, recovery of capsules is crucial, yet current retrieval devices generate three times more kgCO₂ than the capsules themselves. Further discussion involving manufacturers is required in order to implement proper waste management and recycling of the capsule endoscope components. In this paper, the surveys of patients and physicians who read capsules demonstrated that most patients (76%) were not aware of the illegal nature of flushing the capsules down the toilet. Moreover 63% would have been willing to retrieve it.

To address these environmental challenges, the medical community must work towards sustainable solutions through prioritizing the use of eco-friendly materials in the production of capsules and the implantation of proper disposal and recycling programs to prevent the release of hazardous substances into the environment. Additionally, manufacturers should innovate to increase the biodegradability of their capsule’s components. Reusable recovery devices and environmentally friendly materials could also be explored.

To summarize, the data presented in this paper can guide us towards more sustainable practices in healthcare, through a more comprehensive understanding of the environmental footprint of capsule endoscopes. The capsule device itself contributes far less than expected, with the GHG emissions of SBCE being largely determined by patient travel and dependent on the patients’ mode of transport. We should encourage environmentally friendly transportation, efficiently managing patient appointments, or consider relocating procedures to the patients’ homes. Further research and collaboration within scientific societies is essential for the implementation of sustainable solutions with a focus on developing environmentally friendly alternatives to optimize the capsule procedure, packaging, and materials.

Publication History

Article published online:
18 June 2024

• References

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