Perspectives and awareness of endoscopy healthcare professionals on sustainable practices in gastrointestinal endoscopy: results of the LEAFGREEN survey

BACKGROUND

Gastrointestinal (GI) endoscopy is one of healthcare's main contributors to climate change. We aimed to assess healthcare professionals' attitudes and the perceived barriers to implementation of sustainable GI endoscopy.

METHODS

The LEAFGREEN web-based survey was a cross-sectional study conducted by the European Society of Gastrointestinal Endoscopy (ESGE) Green Endoscopy Working Group. The questionnaire comprised 39 questions divided into five sections (respondent demographics; climate change and sustainability beliefs; waste and resource management; single-use endoscopes and accessories; education and research). The survey was available via email to all active members of the ESGE and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) in March 2023.

RESULTS

407 respondents participated in the survey (11% response rate). Most participants (86%) agreed climate change is real and anthropogenic, but one-third did not consider GI endoscopy to be a significant contributor to climate change. Improvement in the appropriateness of endoscopic procedures (41%) and reduction in single-use accessories (34%) were considered the most important strategies to reduce the environmental impact of GI endoscopy. Respondents deemed lack of institutional support and knowledge from staff to be the main barriers to sustainable endoscopy. Strategies to reduce unnecessary GI endoscopic procedures and comparative studies of single-use versus reusable accessories were identified as research priorities.

CONCLUSIONS

In this survey, ESGE and ESGENA members acknowledge climate change as a major threat to humanity. Further improvement in sustainability beliefs and professional attitudes, reduction in inappropriate GI endoscopy, and rational use of single-use accessories and endoscopes are critically required.

Environmental impact of small-bowel capsule endoscopy

INTRODUCTION

The environmental impact of endoscopy, including small-bowel capsule endoscopy (SBCE), has gained attention due to its contribution to the global carbon footprint. This study aimed to evaluate the greenhouse gas (GHG) emissions (kgCO2e) of SBCE, including devices life cycle and capsule journey.

METHODS

SBCE devices (3 brands) were evaluated using life cycle assessment methodology (ISO 14040), including patient travelling, bowel preparation, capsule examination and video recording. A survey was conducted on 120 patients undergoing a SBCE to gather data on their transportation, activities during the procedure, and awareness of pollution generated and on 87 physicians reading capsules.

RESULTS

For the 3 different capsules, the weight was 4 g (3.9-5.2% of total), while 43 to 119 g were attributed for packaging (9-97%) including 5 g of deactivation magnets (4-6%) and 11 to 50 g for instruction forms (40%). A full SBCE generated between 19 and 20 kgCO2e, including 0.04 kgCO2e (0.2%) for the capsule itself and 18 kgCO2e related to patient travelling (94.7%). Capsule retrieval would add 0.98 kgCO2e using dedicated devices. Capsule deconstruction revealed components (e.g. Neodymium) that are prohibited from environmental disposal. 76% of patients were not aware of the illegal nature of flushing capsules, and 63% would be willing to retrieve it. Data storage and physician impact were negligible.

CONCLUSION

The GHG emission of SBCE is mainly determined by patient travelling. The capsule device itself has a comparably low carbon footprint. Considering capsule components disposal is illegal, retrieval of the capsule seems crucial but increasing device-related emissions.

Western outcomes of circumferential endoscopic submucosal dissection for early esophageal squamous cell carcinoma

BACKGROUND AND AIMS

Circumferential endoscopic submucosal dissection (cESD) in the esophagus has been reported to be feasible in small Eastern case series. We assessed the outcomes of cESD in the treatment of early esophageal squamous cell carcinoma (ESCC) in Western countries.

METHODS

We conducted an international study at 25 referral centers in Europe and Australia using prospective databases. We included all patients with ESCC treated with cESD before November 2022. Our main outcomes were curative resection according to European guidelines and adverse events.

RESULTS

A total of 171 cESDs were performed on 165 patients. En bloc and R0 resections rates were 98.2% (95% confidence interval [CI], 95.0-99.4) and 69.6% (95% CI, 62.3-76.0), respectively. Curative resection was achieved in 49.1% (95% CI, 41.7-56.6) of the lesions. The most common reason for noncurative resection was deep submucosal invasion (21.6%). The risk of stricture requiring 6 or more dilations or additional techniques (incisional therapy/stent) was high (71%), despite the use of prophylactic measures in 93% of the procedures. The rates of intraprocedural perforation, delayed bleeding, and adverse cardiorespiratory events were 4.1%, 0.6%, and 4.7%, respectively. Two patients died (1.2%) of a cESD-related adverse event. Overall and disease-free survival rates at 2 years were 91% and 79%.

CONCLUSIONS

In Western referral centers, cESD for ESCC is curative in approximately half of the lesions. It can be considered a feasible treatment in selected patients. Our results suggest the need to improve patient selection and to develop more effective therapies to prevent esophageal strictures.

Curative criteria for endoscopic treatment of gastric cancer

Endoscopic treatment, particularly endoscopic submucosal dissection, has become the primary treatment for early gastric cancer. A comprehensive optical assessment, including white light endoscopy, image-enhanced endoscopy, and magnification, are the cornerstones for clinical staging and determining the resectability of lesions. This paper discusses factors that influence the indication for endoscopic resection and the likelihood of achieving a curative resection. Our review stresses the critical need for interpreting the histopathological report in accordance with clinical guidelines and the imperative of tailoring decisions based on the patients' and lesions' characteristics and preferences. Moreover, we offer guidance on managing complex scenarios, such as those involving non-curative resection. Finally, we identify future research avenues, including the role of artificial intelligence in estimating the depth of invasion and the urgent need to refine predictive scores for lymph node metastasis and metachronous lesions.

Crossing barriers: the burden of inflammatory bowel disease across Western Europe

An estimated 2.5-3 million individuals (0.4%) in Europe are affected by inflammatory bowel disease (IBD). Whilst incidence rates for IBD are stabilising across Europe, the prevalence is rising and subsequently resulting in a significant cost to the healthcare system of an estimated 4.6-5.6 billion euros per year. Hospitalisation and surgical resection rates are generally on a downward trend, which is contrary to the rising cost of novel medication. This signifies a large part of healthcare cost and burden. Despite publicly funded healthcare systems in most European countries, there is still wide variation in how patients receive and/or pay for biologic medication. This review will provide an overview and discuss the different healthcare systems within Western Europe and the barriers that affect overall management of a changing IBD landscape, including differences to hospitalisation and surgical rates, access to medication and clinical trial participation and recruitment. This review will also discuss the importance of standardising IBD management to attain high-quality care for all patients with IBD.

Targeted intervention to achieve waste reduction in gastrointestinal endoscopy

OBJECTIVE

Endoscopy is healthcare's third largest generator of medical waste in hospitals. This prospective study aimed to measure a single unit's waste carbon footprint and perform a pioneer intervention towards a more sustainable endoscopy practice. The relation of regulated medical waste (RMW; material fully contaminated with blood or body fluids or containing infectious agents) versus landfill waste (non-recyclable material not fully contaminated) may play a critical role.

DESIGN

In a four-stage prospective study, following a 4-week observational audit with daily weighing of both waste types (stage 1), stage 2 consisted of a 1-week intervention with team education of waste handling. Recycling bins were placed in endoscopy rooms, landfill and RMW bins were relocated. During stages 3 (1 month after intervention) and 4 (4 months after intervention), daily endoscopic waste was weighed. Equivalence of 1 kg of landfill waste to 1 kg carbon dioxide equivalent (CO_2e) and 1 kg of RMW to 3kgCO_2e was assumed. Paired samples t-tests for comparisons.

RESULTS

From stage 1 to stage 3, mean total waste and RMW were reduced by 12.9% (p=0.155) and 41.4% (p=0.010), respectively, whereas landfill (p=0.059) and recycling waste increased (paper: p=0.001; plastic: p=0.007). While mean endoscopy load was similar (46.2 vs 44.5, p=0.275), a total decrease of CO_2e by 31.6% (138.8kgCO_2e) was found (mean kgCO_2e109.7 vs 74.9, p=0.018). The annual reduction was calculated at 1665.6kgCO_2e. All these effects were sustained 4 months after the intervention (stage 4) without objections by responsible endoscopy personnel.

CONCLUSION

In this interventional study, applying sustainability measures to a real-world scenario, RMW reduction and daily recycling were achieved and sustained over time, without compromising endoscopy productivity.

Exploring the Ways of “The Great Imitator”: A Case Report of Syphilitic Hepatitis

Introduction

Syphilis is a chronic infection caused by Treponema pallidum. Manifestations of this disease are vast, and syphilitic hepatitis is a rarely depicted form of secondary syphilis.

Case Presentation

We report the case of a 63-year-old man with worsening jaundice, maculopapular rash and perianal discomfort. Proctological examination with anoscopy revealed a perianal gray/white area with millimetric pale granules along the anal canal. Liver function tests showed a mixed pattern. Venereal Disease Research Laboratory, T. pallidum hemagglutination assay and IgM fluorescent treponemal antibody absorbance were positive. The patient was successfully treated with a single dose of penicillin G.

Discussion/Conclusion

Syphilitic hepatitis is scarcely reported in the literature. Secondary syphilis with mild hepatitis rarely leads to hepatic cytolysis and jaundice. Many signs of secondary syphilis including syphilitic hepatitis may be linked to immune responses initiated during early infection. Over the past decades, evidence has emerged on the importance of innate and adaptive cellular immune responses in the immunopathogenesis of syphilis. This report raises awareness to a clinical entity that should be considered in patients at risk for sexually transmitted diseases, who present with intestinal discomfort or liver dysfunction, as it is a treatable and fully reversible condition.