Borescopes are useful tools for inspecting endoscope channels and interior components,
which are otherwise obscured due to being narrow and encased in opaque material. Their
use is now recommended in many reprocessing guidelines. Our research team has conducted
several studies on endoscope reprocessing effectiveness, during which we performed
hundreds of borescope exams on a diverse array of endoscopes, including ureteroscopes,
cystoscopes, bronchoscopes, endobronchial ultrasound endoscopes, gastroscopes, colonoscopes,
duodenoscopes, and endoscopic ultrasound endoscopes. The interior architecture of
various brands and models is diverse, with strikingly different appearance.
Over time, our team and others discovered that nearly 100 % of channels have visible
defects, and the need for borescope inspections has become more apparent [1]
[2]
[3]
[4]. Myriad defects have been observed in patient-ready endoscopes, including fluid
droplets, soil, staining, dents, scratches, shredding, debris, tissue glue, and fragments
of accessories ([Fig. 1]).
Fig. 1 Diverse defects and retained debris in endoscope channels. Source: Ofstead & Associates,
Inc.
The clinical implications are sobering. Several peer-reviewed investigations have
linked infections and deaths to visibly contaminated or damaged endoscopes ([Table 1]) [5]
[6]
[7]. In one outbreak, two multidrug-resistant pathogens harbored inside a bronchoscope
infected 19 patients before a borescope examination detected “proteinaceous debris”
and a channel defect [5]. The authors hypothesized that retained debris “may have contributed to the establishment
of a biofilm and subsequent contamination” and concluded that borescope examination
is a “critical component of device reprocessing” [5]. Numerous adverse events linked to inadequately reprocessed endoscopes have been
reported to the US Food and Drug Administration ([Table 1]). These reports described retained tissue, stents, balloons, and reprocessing brush
tips, which were discovered when they were expelled into another patient during a
subsequent procedure.
Table 1
Patient exposure to endoscopes with damage or retained debris and contamination (2018–2020).
|
Endoscope type
|
Defects or retained material
|
Debris discovery and outcomes
|
|
Infections
|
|
Bronchoscope [5]
|
Channel defects
Proteinaceous debris
|
19 patients infected with superbugs; 10 died
|
|
Duodenoscope [6]
|
Cracked biopsy channel
Brown staining around elevator
|
27 patients infected with superbug
|
|
Ureteroscope [7]
|
Surface cuts
Non-intact channel lining
|
13 patients infected with superbug; 8 developed sepsis
|
|
Exposure to tissue retained in channels
|
|
Bronchoscope [8]
|
Mesh or tissue
|
Pushed from channel into another patient’s lung
|
|
Colonoscope [9]
|
Polyp
|
Pushed from channel into another patient
|
|
Gastroscope [10]
|
Foreign tissue
|
Pushed from channel into another patient
|
|
Exposure to retained devices
|
|
Colonoscope [11]
|
Clip
|
Fell into another patient
|
|
Duodenoscope [12]
|
Pancreatic stent
|
Found in channel after several weeks; retrieved with tweezers
|
|
Gastroscope [13]
|
Banding device
|
Fell into another patient
|
|
Gastroscope [14]
|
Brush tip
|
Pushed out of channel during reprocessing
|
|
Colonoscope [15]
|
Clip
|
Fell into a patient two procedures later
|
|
Duodenoscope [16]
|
Sponge
|
Observed during procedure, pushed out of channel after scope extraction
|
Given our experience with borescope exams, we read with interest the new study by
Barakat et al. on the use of artificial intelligence (AI) to assist with borescope
examinations. We agree that human factors, including training, subjectivity, and the
time and expertise needed to conduct borescope exams, can be barriers to implementation.
We commend the authors for exploring how AI-supported borescope examinations could
overcome these barriers. As Barakat et al. emphasized, endoscopes can be damaged during
routine procedures, reprocessing, or transport, and as such, frequent borescope examinations
would be beneficial. We have observed two approaches to implementing borescope inspections,
namely using them for quality assurance during every reprocessing cycle or for periodic
assessment of the endoscope fleet. Both approaches require careful consideration of
program goals and logistics, such as what borescope sizes are needed; where, when
and by whom exams will be performed; how exams fit into the reprocessing workflow;
what will be done when defects are observed; and how to ensure that borescopes do
not contribute to cross-contamination among the endoscope fleet or borescopist exposure
to pathogens.
The value of inspections is dependent on image quality, which is impacted by the skill
and technique used by the borescopist as well as the size and characteristics of the
endoscope and whether soil, debris, fluid, lubricants, or simethicone are present
and stick to the lens during the exam. The interpretation of observations by human
borescopists or AI systems depends on their experience with diverse internal architecture
of various models of endoscopes, as well as various defects that may be present. Therefore,
both technicians and AI systems require extensive training and competency testing
before they can successfully perform borescope examinations and interpret the findings.
That said, our main criticism of the AI program described by Barakat et al. is that
its accuracy was assessed only by three gastroenterologists whose opinions were deemed
the “gold standard.” Ideally, defects identified by either endoscopists or AI systems
should be validated by experts in endoscope design, reprocessing, and repair. The
ongoing development of such programs will undoubtedly require the collaboration of
multidisciplinary teams including endoscope manufacturing experts, repair technicians,
reprocessing personnel, infection preventionists, researchers, AI software developers,
and clinicians. As the technology progresses, it is hoped that borescope examinations
will become widely adopted as a proactive method for screening endoscopes to identify
those in need of routine maintenance, repair, or refurbishment akin to colon cancer
screening programs that identify patients with conditions that benefit from early
identification and treatment.
