WEO position statement on hygiene in digestive endoscopy: Focus on endoscopy units in Asia and the Middle East

Recent Advancement and Future Perspective of Per Oral Endoscopic Myotomy

Per oral endoscopic myotomy (POEM) has emerged as a preferred approach for the treatment of idiopathic achalasia and various esophageal motility disorders, offering a minimally invasive alternative to traditional laparoscopic Heller's myotomy. Over the past decade, POEM has solidified its status as the primary therapeutic choice in these conditions through constant improvements. Its evolution has been marked by continuous progress, driven by the integration of innovative technologies and sophisticated techniques. Notable advancements in the techniques include the advent of shorter myotomies and sling fiber-preserving gastric myotomies. The introduction of novel image-enhanced endoscopic techniques, such as red dichromatic imaging and much safer bipolar devices, promises to enhance safety and reduce the technical demands of the POEM procedure. Furthermore, significant strides have been made in understanding gastroesophageal reflux (GERD) following POEM, enabling the differentiation of "true reflux" from acidification resulting from fermentation through manual pH tracing assessment. This distinction aids in identifying cases necessitating treatment with proton pump inhibitors. Other treatment strategies of post-POEM GERD have expanded to the incorporation of NOTES fundoplication and device-assisted fundoplication if the necessity arises. This comprehensive review delves into recent developments in POEM, encompassing technical variations, the assessment and management of post-POEM reflux, outcomes in special populations, and future prospects. By exploring these facets, we aim to provide a comprehensive overview of the current state of POEM, shedding light on its evolution and the promising directions it is poised to take in the field of third-space endoscopy.

Recommendations and guidelines for endoscope reprocessing: Current position statement of digestive endoscopic society of Taiwan

Reprocessing of gastrointestinal (GI) endoscopes and accessories is an essential part of patient safety and quality control in GI endoscopy centers. However, current endoscopic reprocessing guidelines or procedures are not adequate to ensure patient-safe endoscopy. Approximately 5.4 % of the clinically used duodenoscopes remain contaminated with high-concern microorganisms. Thus, the Digestive Endoscopy Society of Taiwan (DEST) sets standards for the reprocessing of GI endoscopes and accessories in endoscopy centers. DEST organized a task force working group using the guideline-revision process. These guidelines contain principles and instructions of step-by-step for endoscope reprocessing. The updated guidelines were established after a thorough review of the existing global and local guidelines, systematic reviews, and health technology assessments of clinical effectiveness. This guideline aims to provide detailed recommendations for endoscope reprocessing to ensure adequate quality control in endoscopy centers.

The Effectiveness of Drying on Residual Droplets, Microorganisms, and Biofilms in Gastrointestinal Endoscope Reprocessing: A Systematic Review

BACKGROUND

Despite endoscope reprocessing, residual droplets remain in gastrointestinal endoscope working channels. Inadequate drying of gastrointestinal endoscope working channels may promote microbial reproduction and biofilm formation, increasing the risk of infection in patients. This review was designed to provide the current status of gastrointestinal endoscope drying, emphasize the importance of gastrointestinal endoscope drying, and evaluate the effectiveness of different drying methods of gastrointestinal endoscope in reducing residual droplets and microbial growth risk.

METHODS

A systematic review was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) reporting checklist. The PubMed, Web of Science, Medline, EMBASE, EBSCO, CNKI, CQVIP, and Wanfang Data databases were searched from 2010 to 2020 to identify eligible articles focused on methods of gastrointestinal endoscope drying and the status of endoscope drying. The following key points were analyzed: type of intervention, amount of residual droplets, major microbial types, and effectiveness of biofilm intervention. JBI quality assessment tool was used to determine bias risk for inclusion in the article.

RESULTS

This review included twelve articles. Two of the articles reported lack of drying of gastrointestinal endoscopes while the other ten reported residual droplets, microbial growth, and biofilm formation after different methods of drying. Four articles reported 0 to 4.55 residual droplets; four articles reported that the main microbial types were cocci and bacilli, most commonly Staphylococcus, Escherichia coli, Bacillus maltophilia, and Pseudomonas aeruginosa; and two reported that drying could effectively reduce biofilm regeneration. The type of intervention is as follows: automatic endoscopy reprocessor (AER), manual compressed air drying, and the Dri-Scope Aid for automatic drying and drying cabinet.

CONCLUSIONS

While endoscope reprocessing may not always be effective, an automatic endoscope reprocessor plus the Dri-Scope Aid with automatic drying over 10 min or storage in a drying cabinet for 72 h may be preferred.

Non-tuberculous Mycobacterial Pseudo-outbreak of an Intestinal Culture Specimen Caused by a Water Tap in an Endoscopy Unit

Objective Gastrointestinal lesions of non-tuberculous mycobacteria (NTM) are regarded as opportunistic infections. A large number of positive specimens of NTM were identified in an intestinal fluid culture in the endoscopy unit and it was considered to be a pseudo-outbreak. Methods We reviewed the hospital, laboratory, and colonoscopy records of 263 consecutive patients whose intestinal fluids were analyzed for a mycobacterial culture by colonoscopy at St. Marianna University Hospital, between January 2009 and December 2018. The endoscopy reprocessing procedures were reviewed and samples of water used in the endoscopy unit were cultured. Results An intestinal fluid culture of 154 (58.6%) patients tested positive for NTM (M. intracellulare; 125 cases, M. gordonae; 14 cases, M. avium; 4 cases, M. abscessus; 3 cases, and 8 other cases). In 182 cases (69.2%), an intestinal mucosal culture was performed simultaneously with a fluid culture and tested positive for NTM in 2 cases. Next, we examined the endoscopy unit for any possible environmental contamination. NTM were detected in the tap water used to prepare the antifoaming solution in the endoscopy unit. The water faucets in the endoscopy unit were considered to be the source of the contamination of NTMs. Conclusion We observed that a large number of cases tested positive due to contaminated water that had been used in an endoscopy unit, thus leading to a pseudo-outbreak of NTM.

Society Guidelines-Where Is the Consensus?

With reports of ongoing duodenoscope contamination and pathogen transmission despite strict adherence to manufacturer reprocessing instructions, professional societies continue to release updated recommendations. Despite general guideline similarities, there are differences. Although adherence to guidelines does not entirely eliminate pathogen contamination or transmission, it is critical to strictly adhere to updated guidelines for maximum risk reduction. In the United States, the Food and Drug Administration and Centers for Disease Control and Prevention continue to offer updates regarding improved duodenoscope reprocessing techniques and endoscope design. This article critically analyzes currently available national and international duodenoscope reprocessing guidelines.

Comparative investigation of reusable and single-use flexible endoscopes for urological interventions

In order to evaluate the technical adaptability of a type of disposable endoscope compared to reusable flexible endoscopes, in vitro and in vivo studies were conducted. A disposable digital ureteroscope ("chip on tip") and two reusable endoscopes were investigated with respect to spatial resolution, geometric distortion in air and water the maximum. Additionally, the clinical performance of the disposable device was tested during clinical procedures (n = 20). The disposable endoscope showed an optical resolution of 6.72 lines/mm at 10 mm distance, similar to the other devices. In comparison, the disposable endoscope showed a barrel-shaped image distortion in air of -24.2%, which is in the middle range, but was best under water (-8.6%). The bendability of 297° (275 µm fiber) and 316° (empty channel, 1.5 F basket) and the maximum irrigation (1 m: 58.1 ml/min, 2 m: 91.9 ml/min) were convincing. Clinically the maneuverability was very good in (13/20), good or satisfactory in (7/20). Visibility was evaluated as very good in (11/20), just in (1/20) either satisfactory or sufficient. The consistency of visibility was not affected in (19/20). In all cases there were no adverse events. The technical examination and clinical application of the disposable endoscope are of equal quality compared to reusable devices. Disposable endoscopes can be an alternative to reusable devices, but economic aspects such as reduction of repair costs, sterilization effort and additional waste must be taken into account.

A Case of Suspicious Allergic Reaction to Peracetic Acid Following Endoscopy

A 43-year-old man with rheumatic arthritis was admitted to our hospital for symptoms of cough, left chest pain, and left elbow pain, and further examination revealed an elevated level of C-reactive protein. On day 2 after admission, he underwent esophagogastroduodenoscopy. On the morning of day 7, he developed a high fever of 39.7°C, several hours after bronchoscopy. On day 13, he underwent colonoscopy. Five minutes after the colonoscopy, he developed a high fever of 39.9°C, accompanied by stridor, indicating a decrease in arterial oxygen saturation level. An intradermal test for peracetic acid which was used for cleaning flexible endoscopy was positive. We suspect that he suffered from an allergic reaction to peracetic acid following the flexible endoscopy. This is the first case reported on suspicious allergic reaction to peracetic acid following a flexible endoscopy procedure.

Fifty years of digestive endoscopy: Successes, setbacks, solutions and the future

Flexible endoscopes became generally available 50 years ago and created a revolution in the practice of gastroenterology. They improved diagnosis enormously, enabled quicker, less invasive, and more cost-effective surgical treatment, while endoscopic screening has prevented many cancer deaths. The new technology stimulated research leading to a better understanding of gastrointestinal pathology, identifying new diseases and clarifying the etiology of others. Better-controlled clinical trials accelerated the use of newer and more effective drugs. National and international endoscopy societies supported nursing input, encouraged research, stimulated specialist journals, and devised guidelines that encouraged audit and quality assurance. Advances in instrument design and the manufacture of new accessories enhanced endoscopic technique, diagnostic ability, patient comfort, and safety. The risk of cross-infection inherent in the use of complex labile equipment that cannot be autoclaved remains a challenge. Endoscopy societies working closely with industry have established rigid protocols for high-level disinfection that minimize the risks, but strict adherence to guidelines and continued vigilance is essential, especially with the increasing prevalence of antibiotic-resistant commensals that can give rise to opportunistic infection. Government health departments have a responsibility to encourage and support research in this area by endoscopists, instrument manufacturers, and the pharmaceutical industry. Current trends suggest that in the future, artificial intelligence will greatly improve endoscopic diagnosis, and that therapeutic endoscopy will expand, encouraging endoscopists to subspecialize.

Enhanced manual cleaning efficacy of duodenoscope in endoscopy units: Results of a multicenter comprehensive quality control program

BACKGROUND

Multiple outbreaks from contaminated duodenoscopes have been reported since 2008. This study assessed results of a multicenter comprehensive quality control (QC) program to enhance manual cleaning efficacy of duodenoscopes in endoscopy units.

METHODS

Digestive Endoscopy Society of Taiwan implemented a QC program with adenosine triphosphate (ATP) testing of patient-used duodenoscopes in 2 rounds of on-site audit in endoscopy units. ATP samples were obtained from 5 different locations of the duodenoscope after manual cleaning. Duodenoscope exceeding ATP benchmark of 200 relative light units indicated inadequate manual cleaning.

RESULTS

During the first round on-site audit, 12 hospitals and 27 patient-used duodenoscopes were analyzed. Distal end outer surface (29.6%), elevator mechanism (51.9%), distal attachment cap (59.3%), elevator wire channel (37.0%), and suction biopsy channel (37.0%) were inadequately cleaned. Overall, 19 (70.4%) duodenoscopes had inadequate manual cleaning, ranging widely from 0%-100% among endoscopy units. During the follow-up on-site audit, 32 patient-used duodenoscopes were analyzed, and 6 (18.8%) had inadequate manual cleaning.

CONCLUSIONS

ATP tests may provide real-time feedback on the cleaning efficacy of patient-used duodenoscopes. Implementing a comprehensive QC program could enhance the efficacy of manual cleaning in endoscopy units.