3 The environmental impact of GI endoscopy
GI endoscopy is a resource-intensive activity with a significant yet poorly assessed
environmental impact. GI endoscopy is estimated to be the third highest generator
of hazardous waste in health care facilities.
GI endoscopic instruments and supplies are composed of thermoplastic polymers, metals,
rubber composites, optical glass, and semiconductor materials. Packaging material
typically includes paper, cardboard, and plastic.
GI endoscopy predominantly uses reusable endoscopes and requires a considerable amount
of single-use, plastic-predominant, consumable instruments and supplies.
There is a need to understand and publicly disclose the exact material composition
of GI endoscopic instruments and supplies to estimate their environmental impact.
3.1 The carbon footprint of GI endoscopy
Health care activities have a substantial carbon footprint, accounting for about 1 %
to 5 % of human environmental impact and about 4.4 % of GHG emissions worldwide [5 ]. The major contributors are generation and distribution of energy, including gas
and heat or cooling (40 %), and emissions directly from health care institutions (13 %).
Transport (7 %), pharmaceutical and chemical products (5 %) and waste management (3 %)
also have a considerable environmental burden [15 ]. The United States, China, and the European Union (EU) account for more than half
of all emissions. If the health care sector were a country, it would be the fifth-largest
emitter worldwide [15 ]. Trend analyses show that health care GHG emissions have increased by nearly a third
over the last two decades [5 ], both in low and high income countries [17 ]. Notably, several reports indicate that this carbon footprint is largely avoidable
and could be reduced without compromising quality [5 ]
[15 ]
[18 ]
[19 ].
GI endoscopy has direct and indirect ecological harms ([Fig. 1 ]) and is estimated to be the third highest generator of hazardous waste in health
care facilities (3.09 kg/day/bed) [19 ]. Specific data addressing its environmental impact are very scarce. Furthermore,
available data are based on indirect estimates, heterogeneous assumptions, and calculators
not designed explicitly for GI endoscopy. The reason for this lack of data is multifactorial
and includes a lack of interest from manufacturers, health care providers, and researchers,
as well as difficulties in conducting comprehensive life cycle assessment (i. e.,
lack of methodological consensus and limited data about the origin, manufacturing,
and waste disposal of GI endoscopy products) [20 ]. A summary of available data with current estimates is provided in [Table 3 ]
[6 ]
[21 ]
[22 ]
[23 ]
[24 ].
Fig. 1 The environmental impact of gastrointestinal (GI) endoscopy.
Table 3
Estimates of the environmental impact of gastrointestinal (GI) endoscopy.
First author
Methodology and topic
Estimates
Gayam [21 ]
Cross-sectional study on endoscopy waste and carbon footprint using online calculators.
See Supplementary material for methodology.
It does not include pre- and post-procedure care. Carbon footprint does not include
manufacturing, distribution, disposal, heating, or facility energy needs.
One endoscopic procedure: 1.5 kg of waste (0.3 % kg recyclable).
1-year endoscopy activity in the United States (18 million procedures):
13 500 tons of plastic waste, of which 10 800 tons are nonrecyclable.
CO2 emissions equivalent to more than 3 995 448 gallons of gasoline consumed.
Energy consumption per day in a GI endoscopy unit located in the United States that
averages 40 procedures per day:
Namburar [22 ]
Cross-sectional study of endoscopy waste at 2 academic centers in the United States,
including pre- and post-procedure care.
One endoscopic procedure: 2.1 kg of disposable waste (46 L); 64 % of waste went to
landfill, 28 % was biohazard waste, and 9 % was recycled. Personal protective equipment
accounted for 8 % of waste.
1-year endoscopy activity in the United States: 38 000 metric tons of waste (equivalent
to 25 000 passenger cars).
Universal single-use endoscopes would increase the net waste mass by 40 %.
Siau [6 ]
Narrative review on endoscopic procedure and transport
1-year endoscopy activity in the United States (18 million procedures): 85 768 tonnes
of CO2 → 4.8 kg of CO2 per endoscopy. This calculation includes CO2 related to waste
and basic energy needs.
The carbon footprint of a GI scientist using an electric vehicle and accounting for
conference travel has been estimated at equivalent to 20.8 tonnes of CO2 per year.
Gordon [23 ]
Life cycle assessment of pathology specimen
Equivalent to 0.28 kg CO2 per GI biopsy when 1 jar is used and 0.79 kg CO2 when 3 jars are used; emissions equivalent to driving a typical passenger vehicle
0.7 mile and 2.0 miles, respectively.
Production of supplies was the largest contributor to greenhouse gas emissions.
Hernández [24 ]
Life cycle assessment of single-use duodenoscope
Only presented as a conference abstract
Single-use duodenoscope consumes 467 MJ and releases 29.3 kg of CO2
Reusable duodenoscope 26.8 MJ and 1.55 kg CO2; 20 times less than single-use model.
Duodenoscope with disposable end caps 23.4 MJ and 1.37 kg CO2 .
Vaccari [19 ]
Data on per capita health care spent at the national level, as well as a case study
of a hospital in Italy
Departments with highest generation of hazardous waste per daily occupied bed were:
1 anesthetics, 2 pediatric and intensive care, and 3 gastroenterology–digestive endoscopy
(3.09 kg/day/bed).
Departments with the highest average monthly waste generation rates per clinical procedure
were 1 radiology (0.67 kg/procedure), 2 gastroenterology–digestive endoscopy (0.50 kg/procedure),
and 3 plastic surgery.
3.2 Materials used in GI endoscopes and accessories
The literature search revealed that only very limited information is available on
the type and amount of materials used in GI endoscopy. Available information includes
personal reviews of instruments and supplies and discussion with engineering departments
and company representatives [25 ]
[26 ]. Based on different aspects (structure, properties, processing, and performance),
materials used in medical device manufacturing can be classified into polymers, metals,
ceramics, composites, and biomaterials. Polymers are large molecules made by chemical
linking of repeating units (forming thermoplastics, thermosets, and elastomers), to
provide various forms of rubber and plastics. Metals are commonly used because of
their strength, toughness, durability, and high electrical and thermal conductivity.
These include stainless steel, aluminum, brass, copper, nickel, and titanium. Ceramics
are robust inorganic and nonmetallic materials, including glass and other crystalline
structures with piezoelectric properties. Composite materials combine two or more
of the aforementioned groups [27 ]. For example, the alloy nitinol (nickel and titanium) is used in self-expandable
metal stents. Finally, biomaterials are nonvital materials intended to interact with
biological systems to replace or restore functions [27 ]
[28 ]. In addition, packaging contributes considerably to total materials used, and typically
includes plastic, paper, and cardboard.
Details of the material composition of reusable or single-use GI endoscopic instruments
are not publicly available. The major components of GI reusable endoscopes are metal
(approximately 70 % of total mass) and plastic (25 %–30 %), with a remaining small
proportion of electronic components. In contrast, single-use GI endoscopes consist
primarily of plastic and a lesser proportion of metal. Accessory devices (e. g., water
bottles, irrigation tubes, polyp snares, etc.) are generally plastic-predominant [6 ]. Plastics used in GI endoscopy include some with potential carcinogenic and adverse
effects on health such as polyvinyl chloride (PVC) and phthalates, and hence some
companies are moving towards a PVC-free policy [29 ]. A shift towards recyclable and environmentally friendly GI endoscopy materials
is of paramount importance.
Regarding the nature of materials, there is minimal information from manufacturers.
Unfortunately, current EU regulations on medical devices do not force companies to
publicly detail the composition and sources of materials used in GI endoscopy devices,
and this information is rarely provided to users [30 ]. Knowing the type of material used is key to estimating the environmental impact
of GI endoscopes and devices. A life cycle assessment requires data on how materials
were resourced and used in the manufacturing process. In addition, material type determines
its potential for reuse, for recycling (for instance, thermoplastics can be recycled,
but thermoset plastics cannot), or for incineration and determines the time to decomposition
in a landfill [6 ].
4 The path towards environmentally sustainable GI endoscopy ([Fig. 2 ])
Fig. 2 The path towards sustainable endoscopy.
1 ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact
of GI endoscopy.
4.1 Reducing the carbon footprint before, during, and after GI endoscopy
In our systematic search, we did not find any study that directly evaluated the impact
on environmental outcomes of GI endoscopy or related clinical management (see Supplementary material ).
4.1.1 Clinical management
2 ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies
on the appropriateness of GI endoscopy, to avoid the environmental impact of unnecessary
procedures.
3 ESGE-ESGENA recommend a rational use of periprocedural and intraprocedural medication
to reduce the environmental impact of GI endoscopy.
Several actions beyond the endoscopic procedure itself are of paramount importance
to reduce the carbon footprint.
ESGE-ESGENA consider that reducing the current rate of unnecessary GI endoscopic procedures
is key to that end and should be prioritized by GI endoscopy services and health care
systems. This is probably the most effective action to mitigate the GHG emissions
of GI endoscopy.
Adherence to guidelines ensuring the appropriateness of the indication for GI endoscopy
is vital to optimizing patient care and use of resources [31 ]
[32 ]. Triage of waiting lists and cancellation of unnecessary procedures have proven
useful during the COVID-19 pandemic and deserve to be evaluated in the long term [33 ]
[34 ]
[35 ]. Two recent meta-analyses indicate that the rate of inappropriate upper GI endoscopies
and colonoscopies is 20 %–30 % [36 ]
[37 ]. Limiting endoscopic procedures to only those that are appropriate has been shown
to be cost-effective, reduces procedure-related risks, and significantly increases
the probability of diagnosing relevant findings, including malignancy [36 ]. Nevertheless, appropriateness criteria are not perfect and should always be combined
with clinical judgment [31 ]
[32 ].
Oversurveillance is also common and has been extensively documented in several conditions
such as Barrett’s esophagus [38 ] or colonic polyps [39 ]. In this regard, ESGE has published a document to summarize when endoscopic follow-up
is not recommended [32 ]. Recent guidelines are expected to reduce surveillance colonoscopies by over 80 %,
with notable cost savings and capacity improvements [40 ]. Endoscopy services are encouraged to assess the appropriateness of endoscopy and
to take action when endoscopy has been performed inappropriately [41 ]. Avoiding routine pre-endoscopy testing (e. g., blood tests, electrocardiography,
or chest radiography) can additionally reduce the carbon footprint [42 ].
Medications before endoscopy (e. g. bowel preparation and laxatives for colonoscopy,
or mucolytic solutions before esophagogastroduodenoscopy), during (e. g. sedatives,
antibiotics, or analgesics), and after the procedure also have also an environmental
burden that has not been formally quantified [43 ]. It has recently been estimated that 1 g medication has a CO2 footprint of somewhere between 10 g and 1000 g, compared to 1 g of oil, which has
a 3-g CO2 footprint [44 ]. Thus, the use of medication only when strictly indicated is a simple and ethical
green measure (e. g. avoiding routine saline fluid intravenous solution during sedation,
inadequate antibiotic prophylaxis, etc.) [43 ].
Direct environmental impact comparisons between nitrous oxide and intravenous sedation
strategies specifically in the context of endoscopy have not been published. Nonetheless,
nitrous oxide has a global warming potential of nearly 300 times that of CO2
[45 ], and its negative environmental impact is well recognized in the anesthesiology
community, where significant efforts to minimize its use are underway [46 ]. Moderate versus deep sedation versus endotracheal intubation, and selective versus
universal involvement of an anesthesiologist, are factors that may influence the GI
endoscopy carbon footprint and deserve future assessment.
4 ESGE-ESGENA recommend using low-waste, less invasive alternatives to endoscopy (e. g.
fecal calprotectin, urea breath test, etc.) within the bounds endorsed by evidence-based
clinical guidelines.
Intuitively, using low-waste less invasive alternatives to GI endoscopy is another
sensible approach to limit environmental impact [47 ]. However, manufacturers do not disclose the ecological footprint of less invasive
tests and we lack comparative life cycle assessment studies between these alternative
tests and GI endoscopy. Thus, the benefits of this strategy in all scenarios should
not be entirely assumed, especially for high-tech less invasive tests that require
intense manufacturing and processing. Until further data are available, ESGE-ESGENA
encourage less invasive tests for the indications endorsed by evidence-based clinical
guidelines ([Table 4 ]
[48 ]
[49 ]
[50 ]
[51 ]
[52 ]
[53 ]
[54 ]
[55 ]
[56 ]).
Table 4
Less invasive tests approved by regulatory agencies as alternatives to gastrointestinal
endoscopy.
Less invasive test
Indication endorsed by guidelines
Research
Fecal immunohistochemical testing [48 ]
Colorectal cancer screening
Postpolypectomy surveillance in high risk individuals
Multitarget DNA stool test
Colorectal cancer screening
Postpolypectomy surveillance
Fecal calprotectin [49 ]
[50 ]
Chronic diarrhea
Biomarker in other inflammatory diseases
Urea breath test [51 ]
51 ]
Diagnosis and eradication of Helicobacter pylori
Cytosponge [52 ]
None
Barrett’s esophagus
Elastography and platelet count [53 ]
Screening of esophageal varices in cirrhosis
Noninvasive diagnosis and prognosis of liver disease
Small-bowel capsule [54 ]
Obscure gastrointestinal bleeding
Monitoring mucosal healing in Crohn’s disease
Esophageal and colon capsules [55 ]
None
Upper gastrointestinal symptoms and bleeding
Transnasal unsedated endoscopy [56 ]
None
Barrett’s esophagus
5 ESGE-ESGENA suggest that digitalization, telemedicine, and efficient clinical pathways
may reduce the environmental impact of pre- and post-procedural GI endoscopy-related
health care.
The current COVID-19 crisis has placed telemedicine as a necessary alternative to
face-to-face medical consultations with promising results [57 ], thereby decreasing direct and indirect contributions to the environmental footprint
of health care [58 ]. Although there is no direct evidence, reasonable estimations from a systematic
review suggest that telemedicine reduces the carbon footprint of health care, mainly
by lowering transport-associated GHG emissions [59 ]. The environmental cost of telemedicine equipment was also assessed and was comparatively
low.
Telemedicine has great potential to reduce in-person visits related to low-risk procedures
or visits intended to communicate GI endoscopy results that do not substantially impact
clinical management. However, the efficiency of telemedicine is context-dependent
and some patients express an unwillingness to abandon face-to-face medical consultations
[57 ].
Similarly to the strategies explored in GI endoscopy workflow improvement, specific
local situations (including infrastructure and patient preferences) should be analyzed
to identify actionable factors. The benefits and applicability of telemedicine require
more study to assuage fears of misdiagnosis or of uncertainty, leading to the risk
of double consultations.
4.1.2 Endoscopic intraprocedural management
The specific intraprocedural factors that determine GI endoscopy's environmental impact
include the use of a high volume of single-use consumables, energy and water usage,
medications, and tissue sampling requiring histological analysis ([Fig. 3 ]).
Fig. 3 The “eco-endoscopist.”
6 ESGE-ESGENA suggest that diagnostic strategies that safely reduce the number of samples
sent for histological analysis can reduce the environmental impact. This can be achieved
via optical diagnosis and adherence to guidelines on the indications for endoscopic
tissue sampling.
The processing of biopsies entails an added energy requirement, generates hazardous
waste and is responsible for a significant carbon footprint which increases roughly
proportionally to the number of biopsy specimen bottles sent for histological analysis
[23 ]. Endoscopy’s histopathological output can be reduced without altering the management
of most patients by ensuring that only appropriate biopsies are undertaken [60 ]
[61 ]. Adherence to such guidelines, along with strategies that safely avoid the need
for histological analysis, would likely reduce endoscopy’s carbon footprint.
Optical diagnosis is used for mucosal lesions throughout the GI tract, and is integral
to diagnose-and-leave and resect-and-discard strategies for managing diminutive colorectal
polyps [62 ]. Both these strategies reduce the number of tissue samples sent for analysis and
thereby endoscopy’s carbon footprint. ESGE has endorsed the use of optical diagnosis
in place of histopathology for diminutive colorectal polyps, under strictly controlled
conditions [63 ], and has subsequently published a curriculum to develop and maintain these relevant
skills [64 ]. While a resect-and-discard strategy is referenced in British guidelines [65 ], and the findings of a meta-analysis [66 ] confirm fulfillment of American Society of Gastrointestinal Endoscopy (ASGE) minimum
performance thresholds for imaging technologies [67 ], the practice of these strategies has yet to be widely implemented in those countries.
Medicolegal concerns, lack of awareness, financial incentives, and patient acceptability
are some of the hurdles to their widespread implementation. Substitutes for histopathological
analysis will likely expand further with both the evolving indications for endoscopic
optical diagnosis, such as in the diagnosis of celiac disease [68 ], and the growing use of artificial intelligence (AI) systems.
7 ESGE-ESGENA recommend considering the environmental impact when selecting the appropriate
endoscopic technique. The less resource-intensive technique should be favored, provided
efficacy and safety are maintained.
8 ESGE-ESGENA recommend a rational use of endoscopic accessories during the procedure.
9 ESGE-ESGENA suggest performing most elective endoscopic procedures on an outpatient
basis to avoid overnight hospital stays and hence reduce the environmental impact.
Judicious and rational use of GI endoscopic techniques and accessories is also crucial
to achieving sustainable practice. In this context, less resource-intensive techniques
should be favored, provided efficacy and safety are maintained and their use is supported
by current evidence-based clinical guidelines. Thus, ESGE-ESGENA encourage appropriate
technique selection to avoid the overuse of procedures that may involve a greater
consumption of resources, such as cholangioscopy, endoscopic suturing, full-thickness
resection, or endoscopic submucosal dissection (ESD). This strategy should be balanced
with the GIRFT (“getting it right first time”) principle that aims to reduce the number
of therapeutic procedures that are unnecessarily repeated because a definitive outcome
is not achieved in the initial intervention. These concepts extend not only to GI
endoscopists but to the whole health care chain, including well-informed patients.
Regarding accessories, in clinical practice prophylactic clipping of polyp resection
defects does not always adhere to current recommendations and its overuse should be
discouraged [69 ]. In this sense, determining the average need of accessories per procedure and periodically
revisiting the number of accessories used could help to reduce waste and gain efficiency.
Favoring cold snare polypectomy and underwater endoscopic mucosal resection (EMR)
in validated indications could reduce the procedural carbon footprint. Cold snare
polypectomy avoids the use of an electrosurgical unit and a disposable electrode pad.
Underwater EMR avoids the use of an injection needle, a syringe, and submucosal solution,
as well as the packaging of all these accessories. There is currently little published
experience on the reuse of GI endoscopy accessories (e. g., injection needle, biopsy
forceps, polypectomy snare, etc.) within the same or combined procedures (e. g., gastroscopy
followed by colonoscopy). In the absence of safety or efficacy concerns, prioritizing
the reuse of GI endoscopy accessories within a single procedure should be encouraged
(e. g., using the same polyp snare for the resection of small polyps or the same biopsy
forceps for duodenal and gastric biopsies).
The use of sterile or potable tap water in irrigation bottles is a matter of ongoing
debate and has environmental and financial relevance. The rationale for the use of
sterile water is that the concentration of pathogenic microorganisms in tap water
may exceed the infectious dose and thus cause disease. A recent multisociety guideline
and ESGE-ESGENA guidelines recommend using sterile water following manufacturers’
instructions, based on low quality evidence [70 ]
[71 ]. In the absence of a manufacturer’s recommendation, the endoscopy unit should perform
an independent risk assessment for using sterile versus clean tap water for standard
endoscopic procedures in which mucosal penetration would be unusual [70 ]. Given the concern regarding infection in selected patients, this multisociety guideline
suggests that sterile water should be the primary water source, especially for those
procedures with anticipated traversing of GI mucosa [70 ]. Conversely, some authors advocate using potable tap water because most microorganisms
in tap water are nonpathogenic and do not cause disease except in unusual circumstances
[72 ]. Outside endoscopy practice, randomized controlled trials (RCTs) have shown no difference
between the use of tap water and saline in the rates of infection and healing in the
cleansing of wounds [73 ]. In addition, the exposure of the nonsterile GI lumen to potential pathogens would
theoretically be the same when water is ingested before or after the GI endoscopic
procedure. Furthermore, two studies support the idea that using tap water is safe
and found that the rate of positive water cultures was similar to that of sterile
water [74 ]
[75 ]. The only published reports on transmission of infection by water identified unsterilized
irrigation water bottles as a source of infection [72 ]. Underwater EMR and water-exchange colonoscopy have been performed using clean tap
water without any safety concerns [76 ]
[77 ], although the type of water has not been formally compared in any study and was
overlooked in a recent international consensus study [78 ]. Finally, there are no direct data showing that the use of potable tap water increases
the risk of infection for patients. Thus, the idea of a universal need for sterile
water deserves to be revisited and future guidelines should weigh clinically relevant
infection risks, costs, and environmental concerns.
Finally, most elective GI endoscopic procedures should be performed on an outpatient
basis, as hospitalization for a procedure incurs more resource consumption and CO2 emissions [79 ]. Several reports support that well-selected high risk procedures, including ESD
[80 ], peroral endoscopic myotomy [81 ], or endoscopic retrograde cholangiopancreatography (ERCP) [82 ] can be performed safely without hospitalization. Comorbidity, risks of the procedure,
and accessibility to health care in case of an adverse event should be considered
when deciding the need for admission.
4.2 Endoscopy logistics: a sustainable structure and functioning of the GI endoscopy
unit
10 ESGE-ESGENA recommend applying the principles of sustainable architecture to the
design and construction of GI endoscopy units.
11 ESGE-ESGENA suggest implementing an accreditation process for GI endoscopy units
that embraces sustainability.
12 ESGE-ESGENA recommend favoring the use of renewable energy at GI endoscopy units.
This goal should be achieved in the context of local and national policies.
No studies have assessed the most efficient and sustainable structure of a GI endoscopy
unit. However, some data are available from studies on carbon footprint reduction
in the operating room [83 ]
[84 ]
[85 ]. The design and the functioning of the endoscopy unit as proposed by current guidelines
do not consider the issue of sustainability [71 ]
[86 ]
[87 ]. ESGE-ESGENA advocate incorporating the principles of sustainable architecture and
efficient energy management at every step of this process and suggest implementing
an accreditation process for GI endoscopy units that includes sustainability [88 ]
[89 ]
[90 ]
[91 ]:
Location. There are no studies comparing the environmental impact of hospital-based versus
out-of-hospital GI endoscopy units. Location should take into account local needs
(e. g., low risk versus high risk procedures, number of procedures, etc.) and legislation,
population density, costs, adaptability to changing climate conditions, and local
biodiversity. The endoscopy unit should be easily accessible by public transportation
and located in proximity to patients to minimize travel needs.
Use of sustainable, long-life, and nontoxic building materials.
Heating, cooling, and ventilation. Overcooling and overheating are responsible for billions of tons of CO2 emissions worldwide [92 ]. The optimal temperature and humidity of the endoscopy room have not been established
[93 ]. Local protocols and use of sensors should aim at maintaining a temperature that
takes into account infection control, patient and provider comfort, and energy demands.
Use of renewable energy sources. It has been estimated that 10 %–30 % of the environmental impact related to an operating
room-based surgery comes from electricity consumption [94 ]. Promoting renewable energy at an institutional level should be prioritized.
Efficient workflow and use of space. This concept includes a structure that assures an optimal flow of patients, endoscopy
unit personnel, and supplies; and avoids empty, unused, spaces. Endoscopy rooms that
are not in use should be put into a “sleep” mode to conserve energy, and a plan for
better use of this space implemented. An optimal workflow is crucial for optimizing
the efficiency of the endoscopy unit. The following measures can improve efficiency:
having dedicated staff for performing intravenous access and for obtaining informed
consent before the patient enters the endoscopy room; utilization of block scheduling;
minimizing room turnover times; fluent communication among staff; and consideration
before scheduling of the types of sedation to be administered [95 ]. Instead of morning-only activity, morning and evening shifts have been adopted
by several GI endoscopy units, and this seems to be a reasonable strategy to cope
with the growing demand for GI endoscopy without increasing the number of endoscopy
rooms [96 ]. A meta-analysis suggests that colonoscopy quality is not affected by the time of
the day, provided that endoscopists do not perform full-day shifts [97 ].
Efficient use of natural resources. The unit should incorporate natural light in most rooms as much as possible. Water
efficiency is paramount and can be achieved via low water consumption equipment for
disinfection and reprocessing, efficient laundry, and low-flow toilets in patient
spaces [91 ].
13 ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the
GI endoscopy unit.
14 ESGE-ESGENA recommend revisiting waste management in the GI endosopy unit to ensure
adequate segregation and processing policies. The 3 R (Reduce-Reuse-Recycle) and circular
economy principles should be the core of these policies.
15 ESGE-ESGENA recommend the digitalization of the GI endoscopy unit (including electronic
reporting), minimizing paper printing, and using energy-efficient endoscopy and electronic
devices.
16 ESGE-ESGENA recommend establishing local protocols and environmental educational
programs for personnel to practice in an environmentally friendly and sustainable
way.
Waste management. The majority of health care waste (approximately 85 %) is nonhazardous and similar
to domestic waste, which means that much of it could be recycled [98 ]
[99 ]. Poor medical waste management has a deleterious economic and ecological impact
[19 ]
[22 ]
[100 ]. GI endoscopy waste is often handled inappropriately [101 ], and materials and packaging are rarely recycled [19 ]
[22 ]
[100 ]. Placing labels on waste containers to facilitate segregation and incorporating
recycling bins in the GI endoscopy unit are actions that can be easily implemented.101 ]. Consequently, adequate waste segregation and revisiting institutional waste management
policies are integral to the concept of green GI endoscopy.Table 2 ]); phasing down incineration; ensuring toxicity-free waste; ensuring worker protection;
implementing circular economy principles; and ultimately achieving zero waste ([Fig. 2 ]) [98 ]
[99 ]. Further details on sustainable health care waste management can be found elsewhere
[98 ]
[99 ].
Disinfection and reprocessing. There is a need to examine the environmental impact of our reprocessing processes
and to implement sustainable practice. This includes efficient energy and water use
in washer-disinfectors and using process chemicals that have an environmentally friendly
value [71 ].
Digitalization. The digitalization of GI endoscopy-related health care data, reports, and patient
letters can benefit the environment [102 ]. ESGE-ESGENA recommend minimizing use of paper, printing double-sided if printing
is needed, and using paper products that are made from recycled material and nonbleached
(chlorine bleach releases toxic dioxins into water). Use of 100 % recycled paper is
claimed to reduce GHG emissions by 37 % and water use by 50 % [103 ].
Energy efficiency of electronic devices. This includes GI endoscopy systems and all electronic devices in the unit (computers,
monitors, endoscope reprocessors, etc.). Room lighting can consume more energy than
endoscopy itself [21 ]. Thus, LED lighting or energy-saving light bulbs should be preferred. Energy consumption
is lessened by switching lights off, and turning off computers (or placing them in
“sleep” mode) and also printers, coffee machines, etc., during extended breaks and
at the end of the day [21 ]
[104 ]. Units should consider installing motion sensors to switch off lights. Automatic
control of lighting using daylight-dimming and occupancy sensors leads to major energy
savings [105 ].
Staff education. Implementation of sustainable endoscopy practice requires GI endoscopy team members
to re-examine their habits, modify them if needed, and become educated about the abovementioned
aspects. Members of the endoscopy team can further contribute outside the endoscopy
unit by using public transportation to get to work. Making a public commitment towards
environmentally sustainable practice in the endoscopy unit in the form of a guidance
document sends a clear message to staff, patients, and visitors that the unit cares
about the climate crisis, and that all the agents involved in the health care chain
can do something about it [90 ].
4.3 Single-use products
4.3.1 Single-use accessories
17 ESGE-ESGENA recommend that future clinical guidelines and regulations on GI endoscopy
reprocessing/disinfection should consider the environmental impact of these practices
and that of single-use devices.
18 ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental
and economic impact of single-use GI endoscopic devices. GI and endoscopy societies
should collaborate with industry to minimize the environmental burden of single-use
devices.
A “single-use” device is defined as a medical device intended to be used on one individual
during a single procedure. The “single-use” label is solely based on the decision
of manufacturers [106 ]. The following GI endoscopy accessories have been marketed as resusable and are
still available in some places:
bougie dilators [107 ]
[108 ]
[109 ]
biopsy forceps [110 ]
[111 ]
[112 ]
band ligation devices [113 ]
sphincterotomes [114 ]
[115 ]
[116 ]
[117 ]
[118 ]
baskets for stone retrieval [118 ]
[119 ]
reloadable clip applicators [120 ]
suction and air valves [121 ]
snares, guidewires, and balloon expanders [121 ]
personal protective equipment [122 ].
There has been a shift towards the increasing use of single-use accessories in the
last two decades. The environmental impact of this transition in GI endoscopy has
not been formally addressed and lacks solid scientific background. Data from the anesthesia
community indicate that the widespread use of single-use medical devices in the operating
theatre does not significantly reduce patients’ risk of infection but has a greater
financial, environmental, and social impact than use of reusable devices [123 ].
Despite the strong recommendation of ESGE-ESGENA guidelines for using single-use endoscopic
accessories whenever possible [71 ], and particularly when the epithelial barrier is penetrated [121 ], the real risk of infection transmission due to reusable accessories remains controversial
[114 ]. The 2010 ASGE Technology Committee guideline on ERCP cannulation and sphincterotomy
devices [124 ], claims that reprocessed reusable devices offer potential cost savings when available
and adequately reprocessed [118 ]. Several studies support the idea that reusable devices are safe when adequately
reprocessed [112 ]
[114 ]
[115 ]
[116 ]
[117 ]
[118 ]. Worldwide, although several infection outbreaks have occurred that were related
to duodenoscope reprocessing [125 ]
[126 ]
[127 ]
[128 ], this has never been described with reusable devices. Furthermore, the reuse of
surgical instruments has demonstrated a reduction of 10 % of GHG in a surgical study
[129 ].
On the other hand, other studies suggest that the risk of intection is not null [110 ]
[111 ]
[113 ]
[130 ]. Consideration should also be given to the loss of function of devices after the
reprocessing procedure [121 ]. Also, reprocessing has itself an environmental burden that should be acknowledged.
Reprocessing of single-use devices is forbidden in some but not all EU countries [131 ]. Current EU legislation mentions that reprocessing of devices should only take place
where permitted by national law and mostly with reusable devices. “Reusable” here
means tested by the manufacturer with the demonstration that the device ensures an
equivalent level of safety and performance to the corresponding initial single-use
device [30 ]. Nevertheless, Regulation (EU) 2017 /745 allows member states not to apply all of
the rules relating to manufacturers’ obligations laid down in that Regulation. One
of the conditions for such reprocessing is that it is performed under common specifications.
In particular, the reprocessing cycle should be based on the characteristics of the
single-use device and the results of a technical assessment.
Recommendations on single-use GI endoscopy reprocessing are beyond the scope of this
document. Yet, current clinical guidelines fail to consider sustainability [70 ]
[71 ]
[132 ]. ESGE-ESGENA recommend that future guidelines and legislation on GI endoscopy reprocessing/disinfection
should take this domain into account.
The environmental and economic impact of waste generated by single-use devices is
high. Proactive collaboration between endoscopy societies and manufacturers to provide
single-use devices more responsibly is needed. For instance, the weight and dimensions
of packaging and the amount of material used should be examined. Extensive printed
user instructions are no longer justifiable; instructions for use and guarantee documents
represent around 30 % of the total weight for some devices, mainly in paper which
is not always recycled. A QR code instead of a printed manual for each device is preferable.
Creation of an environmental score for each GI endoscopy device based on its life
cycle (similar to the Nutri-Score for the nutritional value of food) could be of value
in helping to choose the most ecologically desirable devices.
19 ESGE-ESGENA suggest using GI endoscopy devices that have an environmentally sustainable
design (e. g. reloadable clips or band ligators).
The concept of reuse is an integral part of sustainability. Some single-use devices
can be reloaded so that the whole device is not entirely disposed of with each use
[120 ]. This is the case with clips that are available in a single-use but reloadable version.
The same handle (< 80 g) can be used to reload clips during the same procedure (waste
weight between 5 g and 10 g) instead of using a single-use device with a measured
waste weight of more than 80 g for each clip. The same principle applies to reloadable
esophageal variceal band ligators [120 ]
[133 ].
4.3.2 Single-use endoscopes
20 ESGE-ESGENA suggest against routine use of single-use endoscopes. However, their
use could be considered in highly selected patients, on a case-by-case basis.
The main arguments in favor of single-use rather than reusable endoscopes have been
reduction in the risk of infection and greater cost–effectiveness, from a hospital
viewpoint. We reviewed the literature to determine the risk of infection with reusable
endoscopes and appraised the available data on single-use endoscopes. Data are limited,
heterogeneous, and with potential for both overestimation and underestimation:
1 Endoscopy-related infection
. There is no consensus on what constitutes an endoscopy-related infection [126 ]
[134 ]. The estimated risk ranges from 1 in 20 000 to 1 in 1.8 million procedures [135 ]
[136 ]. However, some cost–effectiveness analyses of single-use endoscopes have used a
much higher figure for risk, which may have led to overestimates of the true cost–effectiveness
[137 ]
[138 ]
[139 ]. The risk of a clinically relevant infection is probably very low since multiple
steps are needed (i. e., high enough infectious load leading to bacteremia and bypassing
the immune system). This is further complicated because some of these conditions may
already be present in the patient or inherent to the ERCP and might not impact clinically
relevant outcomes. For instance, in an RCT that evaluated the need for antibiotic
prophylaxis for endocarditis, the authors reported bacteremia in 23 % of patients
after brushing teeth and 60 % after tooth extraction, suggesting that bacteremia is
mostly inconsequential [140 ].
2 Endoscope contamination and infection risk.
Using contamination of the endoscope as a surrogate marker for infection risk to
patients is fraught with inaccuracies and variability. Most studies have centered
around duodenoscopes because of their complex tip design and difficulty in cleaning.
Between 2008 and 2018, there were 24 reported clusters of duodenoscope-associated
multidrug resistant microorganisms, including 490 infected patients and 32 deaths
worldwide [141 ]. In a subsequent systematic review, the calculated minimum estimated duodenoscope-associated
infection risk was 0.01 % and the minimum estimated duodenoscope-associated colonization
was 0.023 %–0.029 % [142 ]. However, a potential risk of infection is inherent with all endoscopies. Ofstead
et al. assessed endoscope reprocessing at three hospitals and detected contamination
in 71 % of endoscopes [143 ]. They examined 45 endoscopes, of which only 5 were duodenoscopes. This study suggests
that contamination of the endoscope rarely translates into clinical infection.
3 Basis of cost–effectiveness analyses.
Available cost–effectiveness analyses are written from a hospital perspective when
considering costs related to capital equipment, reprocessing, maintenance, and potential
post-endoscopic infections [144 ]. These analyses assume a high rate of endoscope-related infection (~1 %) and high
costs of infection treatment in the intensive care unit [137 ]
[138 ]. The convenience and low cost of using single-use endoscopes for a hospital should
not be conflated with a possible reduction of endoscope-associated infections since
the beneficiaries are different.
4 Infection risk and human error.
Infection risk is, to a large extent, due to human error during reprocessing. Inadequate
reprocessing and nonadherence to protocols have been reported with endoscope-related
infections [126 ]. An international survey identified a large variation in endoscope-reprocessing
practices [145 ]. While infection risk cannot be eliminated entirely with adequate reprocessing,
it can be substantially reduced [126 ]. Standardized education and training programs that include a competency assessment,
as well as periodic auditing, and researching more effective methods of endoscope
reprocessing have the potential to reduce infection rates even further. Reinforcing
the importance of hand hygiene and other basic hygiene measures is crucial, whether
or not single-use or reusable endoscopes are employed. These interventions are often
overlooked in routine clinical practice and impact the risk of infection [146 ].
5 Societal impact of single-use endoscopes.
It is essential to review the consequences of adopting single-use endoscopes from
a societal perspective (economy, environment, and social justice). For example, the
cost of a single-use duodenoscope ranges from 1900 to 4000 USD (approximately 1700–3600
EUR) [139 ]
[147 ], and for all the ERCPs performed, the total additional cost load to health care
systems would be billions of euros. This might lead to difficult decisions related
to the reallocation of already limited resources, paring of certain medical services,
or more financial burden on patients. From an environmental perspective, it is estimated
that switching to single-use endoscopes would increase waste by 40 % [22 ]. The carbon footprint of single-use endoscopes remains to be determined, but it
is probably substantial. A recent preliminary study estimated that a single-use duodenoscope
consumes 467 MJ and releases 29.3 kg of CO2 , 20 times more than a reusable one or a duodenoscope with disposable end caps (23.4
MJ and 1.37 kg CO2 ) [24 ]. Disposable end caps and sheaths are available for some marketed duodenoscopes and
could reduce infection risk, but more data are still needed [148 ].
6 Benefit for selected patients.
It has been proposed that immunocompromised patients or those with multidrug-resistant
bacteria are likely to benefit from single-use endoscopes, but the theoretical advantages
of this strategy remain to be proven in comparative studies [149 ]. Available data on single-use endoscopes, mainly duodenoscopes ([Table 5 ], [Table 6 ]), comprise cost–effectiveness analyses based on heterogeneous assumptions [137 ]
[138 ]
[139 ] and studies limited to reports of technical feasibility and procedural safety [152 ]
[154 ]
[157 ]
[158 ]
[159 ]
[160 ]
[161 ].
Table 5
Studies on single-use duodenoscopes: Cost–effectiveness analyses.
First author
Methodology
Assumptions
Results
Conflict of interest (COI), or funded by manufacturer of single-use endoscopes
Barakat [137 ]
Cost–utility analysis from facility viewpoint
Residual contamination after reprocessing not given
Transmission risk from infected endoscope: 30 %
Infection risk after transmission: 50 %
Treatment of infection (cholangitis): $375 000
Cost of single reprocessing: $131
Cost of disposable endoscope: $2991
Post ERCP lifespan: 7 years
QALY value: $100K
At infection rate of < 1 %, disposable cap had the best cost–utility
Not mentioned in journal pre-proof article. In other articles authors have disclosed
research support from companies that manufacture single-use scopes.
Das [139 ]
Cost–effectiveness analysis from patient viewpoint
Residual contamination after reprocessing: 6 %
Transmission risk from infected endoscope: 40 %
Infection risk after transmission: 30 %
Treatment of infection (cholangitis): $40 000 (additional probability ICU costs)
Cost of single reprocessing: $200
Cost of disposable endoscope: $3000
Risk of long-term colonization: 40 %
Willingness to pay: $100 000
HLD was least costly and disposable duodenoscope was the costliest.
Yes
Travis [138 ]
Microcosting analysis to determine cost of ERCP using reusable duodenoscopes.
Cost of reusable duodenoscope: $45 000
Cost of reprocessor: (AER): $35 400
Annual AER maintenance: $5000
Annual endoscope repair cost: $2500
Risk of infection from using reprocessed endoscope: 1 %–1.2 %
Treatment of infection: $47 181
Total per procedure cost:
50 procedures/year, $2729
> 750 procedures/ year, $1292
Yes
Sahu [150 ]
Cost-minimization model to determine procedure cost with reusable endoscope and disposable
sheath systems vs. single-use endoscopes.
Cost of reusable duodenoscope (average): $56 135
Annual cost of reprocessor (AER): $8166
Annual cost of maintenance: $140 337
Life of endoscope: 3 years
Total cost/procedure: $687
Cost of disposable endoscope: $3500
Total per procedure cost:
Infection risk not considered
COI or funding not detailed in the abstract.
HLD, high level disinfection; QALY, quality-adjusted life-year; ERCP, endoscopic retrograde
cholangiopancreatography; ICU, intensive care unit; AER, automated endoscope reprocessor.
Table 6
Studies on single-use duodenoscopes: Clinical studies.
First author
Study design
Sample size
Results
Infection risk compared with reusable endoscopes
COI or funded by manufacturer of single-use duodenoscopes
Napoléon [151 ]
Prospective case series
60
Completion rate: 95 %
No
Yes
Lisotti [152 ]
Meta-analysis
4 studies [151 ]
[153 ]
[155 ]
[156 ]
Technical success: 92.9 %
No
Yes
Muthusamy [153 ]
Case series
73
Procedure completion rate: 96.7 %
No
Yes
Ross [154 ]
Bench simulation study
Preclinical study
Similar task completion times, tip control, and overall performance rating.
No
Yes
Bang [155 ]
Randomized controlled trial
98
Single-use endoscopes required fewer attempts for successful cannulation.
Similar safety profile
No
Yes
Slivka [156 ]
Prospective case series
200
Crossover rate: 9.5 %
No
Yes
COI, conflict of interest.
Summary.
Thus, the available data indicate that clinically relevant endoscope-related infection
risk after adequate endoscope reprocessing is probably minimal, although not zero.
The approach to endoscope-related infections needs to follow the principle of ALARP
(“as low as reasonably practicable”) [162 ] so that the economic, environmental, and social costs in trying to reduce the risk
to zero do not outweigh the benefit gained. A more robust and consensus-driven definition
of endoscope-related infection is needed. Data based on life cycle assessments of
single-use endoscopes and comparative studies focused on clinically relevant outcomes
are mandatory before formal recommendations can be made about their routine use. At
present, the employment of single-use endoscopes in highly selected cases might be
considered individually. Nevertheless, evidence showing a net benefit is lacking and
insufficient to make recommendations.
4.4 Education and training
4.4.1 Incorporating the environmental dimension into curricula and training for GI
endoscopy
21 ESGE-ESGENA recommend embedding sustainability into the curricula of GI endoscopy.
22 ESGE-ESGENA recommend conducting research into the environmental impact of GI endoscopy
training. Waste reduction and awareness of the environmental costs during training
are ethically linked to the notion of high quality GI endoscopy.
Several organizations and institutions already advocate integrating consideration
of planetary health into medical and clinical education [4 ]
[163 ]. Recently, the Association for Medical Education in Europe has developed a consensus
statement to promote and outline the structural changes required [164 ]. While there are no data on the specific impact of training and educational activities
of GI endoscopy, it is evident that it is associated with considerable environmental
costs. The lack of research and awareness of this dimension of endoscopic practice
argues for action by dedicated professional societies. Incorporating sustainability
in endoscopy training is likely to influence the everyday practice of current and
future GI endoscopists by optimizing resource utilization [19 ]. Raising awareness has been shown to be effective in other disciplines such as laparoscopic
pediatric surgery, where giving individual surgeons a monthly report card that detailed
the utilization and cost of disposable, high cost surgical supplies reduced the use
of disposable trocars by 56 % [165 ]. Recommendations on environmentally friendly training alternatives, correct use
and disposal of GI endoscopy devices [101 ], and overall attention to environmental issues can contribute to the ethical mindset
of developing endoscopists. The incorporation of sustainability into the curricula
of GI endoscopy requires the allocation of dedicated material, human, and time resources
for trainers and trainees.
4.4.2 Reducing the carbon footprint during training and educational activities
23 ESGE-ESGENA recommend that GI endoscopy training should be undertaken in structured,
auditable programs and take into account local availability of endoscopy simulators
and on-site/off-site teaching modules. Adoption of teaching strategies that shorten
the learning curve and ensure safe and efficient procedures is essential to reduce
unnecessary waste during training.
24 ESGE-ESGENA suggest that virtual training and online educational modalities can reduce
the environmental impact of GI endoscopy.
High quality training programs for fellows are an essential part of health care systems
but incur significant material costs, due to potential prolongation of procedure time
and hospitalization [166 ]
[167 ], use of additional materials and instruments, or the need for dedicated spaces and
equipment such as simulators [168 ]. While the structure and objectives of GI endoscopy training programs are highly
variable across health care systems, strategies that reduce skill acquisition time
and accelerate the learning curve are most likely to reduce the carbon footprint associated
with training activities. Simulator training has been shown to be beneficial, especially
in early skill acquisition, and may reduce procedure time and costs when trainees
transition to procedures involving patients [169 ]. There is no consensus on the optimal type of simulator, and existing models offer
different advantages and disadvantages from an ecological standpoint (e. g., reusability,
need for explanted organs or live animals, electricity usage, etc.) [169 ].
Educational activities such as courses, congresses, and workshops contribute to the
environmental footprint mainly due to transport-associated CO2 emissions, redundant paper-based documentation, and avoidable items (e. g., leaflets,
programs, advertisements, bags, cards, etc.) [170 ]. A recent life cycle assessment study concluded that the environmental impact of
a virtual conference would be significantly less (4 tons CO2 equivalent) than that of a traditional international face-to-face conference (192
tons CO2 equivalent) [171 ]. In this sense, live endoscopy events are valuable educational activities that show
a real-time approach to a clinical case by experts and minimize travel needs [172 ]. Adopting virtual/hybrid formats and electronic documentation where possible can
contribute to the reduction of the carbon footprint.
Finally, responsibility in the choice of trainers for educational events could also
reduce travel by encouraging the participation of local rather than foreign experts
when local competence is available.
4.5 Green quality
4.5.1 Reducing the environmental impact of GI endoscopy by adherence to quality guidelines
25 ESGE-ESGENA suggest that the implementation of and adherence to quality measures
for GI endoscopy can reduce its environmental impact.
Our search did not find any study that directly assessed the impact of adhering to
endoscopy quality guidelines on environmental outcomes. ESGE has been promoting quality
in GI endoscopy since 2013 [173 ], and it is conceivable that adherence to key performance measures (KPMs) does not
only improve patient outcomes [173 ], but also has a beneficial effect on the environment. Many of the ESGE KPMs focus
on doing less yet doing it better . Thus, compliance with the following endoscopy service [41 ] and individual KPMs is expected to translate into a reduction in environmental impact:
Appropriateness, as previously mentioned, increases the yield of endoscopy and reduces
the number of unnecessary procedures [36 ]
[37 ].
Adequate fulfillment of KPMs for pre-endoscopy (i. e., rate of adequate bowel preparation
> 90 % [174 ] and correct instructions for fasting > 95 % [175 ]) and for completeness of procedures (i. e., cecal intubation rate > 90 % [174 ], bile duct cannulation > 90 % [176 ], etc.), followed by proper management and identification of pathology, reduces the
number of repeated procedures and allows adequate follow-up intervals. Standardized
photo and video documentation facilitates referral and planning of therapeutic intervention,
and potentially avoids repeated diagnostic procedures. The use of artificial intelligence
(AI) during routine colonoscopy has the potential to improve the quality of endoscopy,
particularly to assure a procedure’s completeness [177 ]. Recent technological developments indeed enable automated assessment of bowel preparation
and blind spots during endoscopy [178 ]. This is an additional effect that needs to be considered when calculating the cost–effectiveness
of AI implementation in daily practice.
Adequate endoscopist and staff training. Adherence to guidelines only translates into
patient benefits if the endoscopist KPMs are met. These criteria include a high polyp
detection rate and ability to remove polyps with regard to screening colonoscopies,
or sufficient inspection time and appropriate biopsy sampling for specific conditions.
Systematic electronic reporting. The first publication of the ESGE Quality Improvement
Committee was on the prerequisites of electronic reporting systems and the need to
develop these for measuring quality [179 ]. To facilitate quality assurance and, as a secondary effect, reduce endoscopy’s
carbon footprint, it is pivotal that quality assurance and automated guideline recommendations
are incorporated into GI endoscopy reporting systems.
Periodic inspection, calibration, and maintenance of facilities and equipment, especially
decontamination and reprocessing circuits, are mandatory for energy-efficient service
[41 ].
4.5.2 Sustainability as a new domain of high quality GI endoscopy
26 ESGE-ESGENA recommend including sustainability as a quality domain for GI endoscopy.
Sustainability can be considered a part of quality health care [13 ]. Indeed, several health care organizations have already included sustainability
as a critical domain of their conceptual quality framework [13 ]. Recently, the implementation of quality improvement in gastroenterology has been
proposed to obtain a more environmentally sustainable delivery of endoscopy by the
National Health Service in the United Kingdom [13 ]
[46 ]. The process of developing environmental KPMs in endoscopy is beyond the scope of
this document. Nonetheless, ESGE-ESGENA acknowledge that this is an unmet need that
should be addressed in the coming years. Potential KPMs to be considered in the future
are CO2 emissions; waste; energy and water expended per endoscopy procedure [22 ]; mass of recycled and of total waste; renewable energy as a percentage of total
energy used in the GI endoscopy unit, etc.
4.6 Green research and guidelines
4.6.1 Defining the roadmap for sustainable research in GI endoscopy
27 ESGE-ESGENA should encourage and fund research into “green and sustainable” GI endoscopy.
28 ESGE-ESGENA recommend conducting high quality research to quantify and minimize the
environmental impact of GI endoscopy.
29 ESGE-ESGENA recommend incorporating the principles of sustainability into every GI
endoscopy research project. The study design should consider the environmental impact
of the research.
The task of minimizing the environmental impact of GI endoscopy starts with improving
our understanding of the ecological impact of all its practices, procedures and devices.
Research addressing these questions with regard to GI endoscopy is currently anecdotal
[47 ]. Moreover, it is frequently overlooked that research activities themselves have
a substantial carbon footprint. The Sustainable Clinical Trials Group has shown that
RCTs generate hundreds of tonnes of CO2
[180 ]. As an example, ClinicalTrials.gov has about 350 000 registered trials, which would
generate CO2 emissions of an estimated 27.5 million tonnes, almost equal to the total CO2 emission of Switzerland (8.7 million population) in 2020 [181 ]
[182 ]. Many of these emissions come from travel and are probably preventable [180 ]. A pertinent and thorough study design increases scientific validity and may also
reduce the carbon footprint by increasing research efficiency [181 ].
ESGE-ESGENA should actively promote and support research that will allow us to understand
the carbon footprint of GI endoscopy and help identify ways in which this impact can
be minimized. To achieve this goal, ESGE-ESGENA favor not only including the concept
of sustainability into every GI endoscopy research project ([Table 7 ]) [181 ]
[183 ]
[184 ]
[185 ], but also the performance of research specifically focused on environmental outcomes.
While medico-economic dimensions may now be incorporated into research protocols,
medico-ecological ones are not currently considered [186 ]. However, ecological impact should become a criterion [11 ]
[186 ]
[187 ]
[188 ] in the choice of research strategy [85 ]
[188 ]
[189 ]
[190 ]. A research agenda focused on the most urgent topics is proposed in [Table 8 ].
Table 7
Actions for reducing the environmental impact of GI endoscopy research [164 ]
[166 ]
[167 ]
[168 ].
Research phase
Action
Conception and rationale
Acknowledge sustainability as a core element of every research project.
Review the evidence systematically and check public study registries to avoid overlapping
research.
Balance the pertinence and strategic relevance of the project within a multidisciplinary
team. Involve patients and clinicians to define outcomes.
Design
Estimate an “efficient” sample size.
Design a statistical analysis plan before the study outset.
Involve methodologists.
Consider including environmental parameters as primary or secondary outcomes.
Take into account the environmental impact of the project.
Carefully consider the requirement for human and material resources.
Minimize travel requirement of the research team and the study population. Encourage
public transport.
Restrict visits and complementary tests to what is strictly necessary for study purposes.
Consider replacing on-site visits with phone or virtual visits.
Consider the pertinence of answering more than one research question (e. g., factorial
design or including an observational phase after a randomized controlled trial).
Reduce bureaucracy where possible.
Data collection, recruitment, and monitoring
Avoid unnecessary data collection.
Use paperless web-based case report forms and databases.
Use systematic, electronic, and centralized systems for auditing and monitoring the
study.
Avoid unnecessary monitoring visits.
Consider conducting a carbon audit.
Transfer eco-friendly attitudes (Reduce-Reuse-Recycle) from home to the research project.
Reporting
Discuss the potential environmental impact of the results and raise awareness when
possible.
Disseminate the results rapidly to avoid overlapping research.
Ensure that the information provided is reproducible and usable to other researchers.
Limit the number of on-site congresses where research is presented.
Table 8
Environmental research priorities in gastrointestinal (GI) endoscopy.
1
Strategies to reduce unnecessary GI endoscopic procedures and interventions and to
lengthen follow-up intervals.
2
Define environmental outcomes related to the field of GI endoscopy.
3
Quantify the environmental impact of reusable GI endoscopes and accessories and identify
strategies to reduce their carbon footprint.
4
Quantify the environmental impact of single-use GI endoscopes, and single-use accessories,
and identify strategies to reduce their carbon footprint.
5
Quantify the environmental impact of GI endoscope reprocessing and identify strategies
to minimize its carbon footprint.
6
Identify the carbon footprint of all types of GI endoscopic procedures at a per-procedure
level.
7
Develop strategies for effectively reducing, reusing, and recycling all GI endoscopy-related
equipment and waste.
8
Environmental impact of activities and practices related to training in GI endoscopy.
9
Define environmental key performance measures for green quality.
10
Telemedicine in GI endoscopy.
4.6.2 Incorporating sustainability when grading the strength of recommendations
30 ESGE-ESGENA recommend taking into account environmental impact when grading the strength
of recommendations in GI endoscopy guidelines.
31 ESGE-ESGENA suggest defining specific PICO (population/problem, intervention, comparison,
outcome) questions to evaluate the environmental impact of guideline recommendations.
In the absence of evidence, ESGE-ESGENA recommend highlighting the need for research
to examine the environmental impact of the GI endoscopy guideline.
Many guidelines in all fields of medicine fail to consider resource utilization and
the potential clinical and environmental harms that can derive from their recommendations
[191 ]. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system,
which is currently used by most GI endoscopy guidelines, does not directly cite sustainability.
However, it places resource use as a binding domain that contributes to the strength
of recommendation (the more resource consumed, the less likely a strong recommendation
is made) [192 ]. The recently established Cochrane Sustainable Health care group aims to reduce
medical excess and underpin a needed shift towards an evidence-based synthesis process
that weighs and prioritizes the environmental impact of medical actions [191 ]. Increased attention to all steps of the evidence chain is required to adequately
balance the multifaceted effects of an intervention. While acknowledging that there
is minimal evidence on how to introduce the environmental impact of endoscopy into
GI endoscopy guidelines, ESGE-ESGENA support that a change in mindset is required
during the guideline development process in order to achieve sustainable health care.
4.7 Industry, health insurers, and health care providers
4.7.1 Encouraging companies to declare the environmental impact of their GI endoscopy
products and to manufacture environmentally friendly devices
32 ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the
environmental impact of their value chain.
33 ESGE-ESGENA recommend that GI endoscopy companies manufacture environmentally friendly
materials and devices.
34 ESGE-ESGENA recommend against planned obsolescence of GI endoscopy materials and
devices.
Currently, most GI endoscopy companies do not provide transparent, audited, and easy
accessible information about the potential environmental impact of their products
and practices. ESGE-ESGENA encourage GI endoscopy companies and manufacturers to adhere
to the conceptual and legal frameworks developed by the EU and the United Nations
[193 ]
[194 ]. The European Green Deal, launched by the European Commission, includes a set of
policies aimed at developing a more sustainable and environmentally friendly industrial
model [193 ]. This strategy seeks to achieve a resource-efficient and competitive economy and
advocates low-emission technologies, sustainable products, and services with no net
GHG emission by 2050. Likewise, the United Nations Global Compact calls upon companies
to align financial strategies and operations with universal principles on human rights,
labor, anticorruption, and the environment; and to take actions to advance societal
goals [195 ]. The United Nations code declares that companies should support a precautionary
approach to environmental challenges, undertake initiatives to promote greater environmental
responsibility, and encourage the development and diffusion of environmentally friendly
technologies [194 ].
Ecological standards must apply to a product’s total life cycle, from research and
innovation to the extraction of raw materials, material formulation, manufacturing,
packaging (often unnecessarily bulky and environmentally harmful [196 ]), distribution, usage, and waste disposal. ESGE-ESGENA encourage GI endoscopy companies
to implement carbon offsetting programs, which enable companies to compensate for
the carbon footprint secondary to their activities by supporting projects that reduce
emissions elsewhere [197 ].
Planned obsolescence (i. e., designing and producing a product with an artificially
limited lifespan) occurs in the health care industry and conflicts with sustainability,
ethical principles, and the concept of a circular economy [198 ]. The optimal lifespan of high-tech devices, such as GI endoscopes, video processors,
or electrosurgical units, depends on several factors such as national and local regulations,
manufacturers’ policies and amenability to technical maintenance. A minimum lifespan
of 7–10 years is expected for endoscopes and devices of similar complexity [199 ]. Thus, replacing newer-generation devices before this timeframe seems only justified
if new technologies impact clinically relevant outcomes or for research purposes.
Finally, expiry dates of GI endoscopy accessories should be based on transparent and
audited scientific evidence and not driven by commercial interests.
4.7.2 Advocating environmentally preferable purchasing
35 ESGE-ESGENA recommend that governments, health insurers, and health care providers
align with environmentally preferable purchasing strategies (“green purchasing”),
including choosing materials and supplies with a low carbon footprint.
Governments, health insurers, and health care providers may also contribute to a more
sustainable future by instituting environmentally preferable purchasing programs (i. e.,
purchasing products or services whose environmental impact has been assessed and found
to be less damaging to the environment and human health when compared to competing
alternatives). This has been termed “green public procurement” or “green purchasing”
by the EU and promotes the policy that Europe’s public authorities, including hospitals,
use their purchasing power to choose environmentally friendly goods and services.
This initiative demands the inclusion of transparent and verifiable environmental
criteria for medical products in the public procurement process. Several European
countries have already developed national guidelines to achieve this goal [193 ].
4.8 Policymakers, governments, and patients
4.8.1 Engaging policymakers and governments
36 ESGE-ESGENA recommend that policymakers and governments take immediate action in
the path towards environmentally sustainable GI endoscopy.
Policymakers, funding bodies, and governments play a crucial role in facilitating
the transition towards green endoscopy. Areas of future regulation and policymaker
engagement include:
Mandating assessments of environmental impact as part of the EU medical device regulation
approval and evaluation process.
Encouragement of environmentally friendly GI endoscopy device alternatives by reimbursement
incentives and penalties for less advantageous options.
Promoting research grant initiatives for green endoscopy research projects by the
EU, national or regional public funders, and policymakers.
Inclusion of green endoscopy initiatives as part of local, regional, or national quality
improvement programs in GI endoscopy.
Policymaker-sponsored training programs for endoscopy managers, endoscopists, and
patient organizations, to educate about green endoscopy alternatives and incentives.
Educational programs for patients and citizens focused on promoting health, environmental
sustainability, and rational use of health care resources.
4.8.2 Raising patient awareness and promoting patient empowerment
37 ESGE-ESGENA recommend development of “Choosing Wisely” campaigns for GI endoscopy,
discouraging overuse and overtreatment, and thus contributing to lower waste related
to GI endoscopy, together with patients and patient organizations.
38 ESGE-ESGENA suggest that patient empowerment programs and a healthy lifestyle can
reduce the need for GI endoscopy procedures in the long term.
Data from the United Kingdom indicate that most patients (82 %) are concerned about
climate change. Nevertheless, only a quarter think that the health care system significantly
contributes to climate change and do not identify health care environmental sustainability
as a priority [200 ]. Patients and individuals undergoing GI endoscopy for disease prevention purposes
are to be encouraged to reduce waste and take environmentally conscious action in
the following ways:
Choose public over private transport. Favoring public transport can dramatically impact
GHG emissions [201 ] and is feasible for most patients undergoing GI endoscopy, except for fragile or
unfit patients who may require individual vehicles.
Choose non-fossil fuel transport.
Request “green endoscopy” information from GI endoscopy providers and choose those
who provide such a service.
Be aware of patient empowerment, defined by the World Health Organization as “a process
through which people gain greater control over decisions and actions affecting their
health” [202 ]. Patient empowerment is promoted by the EU and positively impacts health [203 ]
[204 ]. Patients should be conscious about the usage of GI endoscopy services related to
medical needs, pay attention to, and engage in “Choosing Wisely” campaigns against
overusage of endoscopy.
Primary prevention can also reduce the need for GI endoscopy in the long run. Compelling
evidence indicates that a healthy lifestyle reduces the risk of several GI diseases
that often demand endoscopy, such as gastroesophageal reflux disease, functional dyspepsia,
colorectal cancer, and metabolic-associated fatty liver disease.
Be conscious of absolute benefits and harms of GI endoscopy services related to single-use
or reusable equipment.
