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Der Gastroenterologe : Zeitschrift Fur... 2022Clinically relevant infections triggered by the use of flexible endoscopes and respective consumables have become the focus of clinical and scientific interest in the... (Review)
Review
Clinically relevant infections triggered by the use of flexible endoscopes and respective consumables have become the focus of clinical and scientific interest in the literature. Endoscopy-associated infections can be assigned to one of two groups: (i) endogenous infections are triggered by the spread of the patient's own local flora and (ii) exogenous infections result from transmission of contaminated material or endoscopes. The number of reported infectious complications in flexible endoscopy is low but likely underestimated due to inadequate surveillance strategies and lack of clinical symptoms. To prevent exogenous infections, single-use endoscopes were brought to the market. Single-use bronchoscope have been part of routine clinical care for years, while single-use duodenoscopes have only recently been approved. The increased patient safety and economic costs were clearly evaluated for the single-use bronchoscopes, but this still needs to be studied for single-use duodenoscopes. The use of single-use endoscopes-at first glance-represents an additional financial burden on the healthcare system. However, in addition to the material costs of disposable endoscopes, the costs that are avoided by them (e.g., prolonged hospitalization, intensive care treatment, and follow-up interventions) must also be included in the overall calculation.
PubMed: 35018195
DOI: 10.1007/s11377-021-00581-9 -
VideoGIE : An Official Video Journal of... Aug 2023Duodenal polyps have a reported incidence of 0.3% to 4.6%. Sporadic, nonampullary duodenal adenomas (SNDAs) comprise less than 10% of all duodenal polyps, and ampullary... (Review)
Review
BACKGROUND AND AIMS
Duodenal polyps have a reported incidence of 0.3% to 4.6%. Sporadic, nonampullary duodenal adenomas (SNDAs) comprise less than 10% of all duodenal polyps, and ampullary adenomas are even less common. Nonetheless, the incidence continues to rise because of widespread endoscopy use. Duodenal polyps with villous features or those that are larger than 10 mm may raise concern for malignancy and require removal. We demonstrate endoscopic resection of SNDAs and ampullary adenomas using some of our preferred techniques.
METHODS
The duodenum has several components that can make EMR of duodenal polyps technically challenging. Not only does the duodenum have a thin muscle layer, but it is also highly mobile and vascular, which may explain higher rates of perforation and bleeding of duodenal EMR reported in the literature compared with colon EMR. A standard adult gastroscope with a distal cap is commonly used for duodenal EMRs. Based on the location, however, side-viewing duodenoscopes or pediatric colonoscopes may be used. To prepare for EMR, a submucosal injection is performed for an adequate lift. The polyp is then resected via stiff monofilament snares and subsequently closed with hemostatic clips if feasible. The ampullectomy technique differs slightly from duodenal EMRs and carries the additional risk of pancreatitis. Submucosal injection in the ampulla may not lift well; thus, its utility is debatable. Biliary sphincterotomy should be performed, and based on endoscopist preference, the pancreatic duct (PD) guidewire can be left during resection to maintain access. After resection, a PD stent is placed to minimize pancreatitis risk.
RESULTS
The video shows the aforementioned duodenal EMR techniques. Two clips of ampullectomy are also shown in the video.
CONCLUSIONS
A few common techniques used to perform duodenal EMR and ampullectomy are highlighted in the video. It is important to understand and manage adverse events associated with these procedures and to have established surveillance plans.
PubMed: 37575136
DOI: 10.1016/j.vgie.2023.05.006 -
Khirurgiia 2020One of significant achievements of modern endoscopy is development of retrograde biliary stenting for obstructive jaundice. This method ensured widespread application of... (Review)
Review
One of significant achievements of modern endoscopy is development of retrograde biliary stenting for obstructive jaundice. This method ensured widespread application of endoscopic decompression in the treatment of patients with malignant biliary obstruction as preparation before radical surgery and final palliative care. Endoscopic retrograde transpapillary stenting firmly took its place together with antegrade and percutaneous stenting. There are certain advantages of this technique including minimally invasiveness and favorable quality of life. However, this approach is associated with some drawbacks associated with stent occlusion and difficult correction of this complication. The maximum diameter of the plastic stent (PS) is determined by the width of the working channel of the duodenoscope. In this regard, self-expandable metal stents (SEMS) were developed to increase the diameter of bile drainage channel. SEMS are associated with prolonged function. However, there is another problem. It is a germination of SEMS followed by impossible removal of the stent for its subsequent replacement. A further step in development of endoscopic biliary stents was the use of special SEMS coating to exclude tumor or granulation ingrowth. The problem of biliary stent occlusion remains relevant despite some improvement of stenting results. Mechanisms of occlusion of biliary stents and prevention of these events are discussed in this review.
Topics: Cholestasis; Decompression, Surgical; Digestive System Neoplasms; Endoscopy, Digestive System; Humans; Jaundice, Obstructive; Palliative Care; Stents
PubMed: 32500692
DOI: 10.17116/hirurgia202005170 -
Gastrointestinal Endoscopy Clinics of... Oct 2020After outbreaks of duodenoscope-transmitted infection with multidrug-resistant organisms, it has become clear that institutions must optimize their endoscope... (Review)
Review
After outbreaks of duodenoscope-transmitted infection with multidrug-resistant organisms, it has become clear that institutions must optimize their endoscope reprocessing programs. Standard endoscope reprocessing practices may not represent the ideal approach for preventing transmission of infection related to endoscopy. We discuss multiple approaches to enhance and optimize reprocessing, drying, and storage of standard duodenoscopes. The optimal enhanced duodenoscope reprocessing modality remains to be determined. Acknowledging the challenges and limitations in effectively reprocessing duodenoscopes, the FDA issued a safety communiqué recommending transitioning to either single use disposable duodenoscopes or duodenoscopes with innovative designs that allow more effective reprocessing.
Topics: Algorithms; Cross Infection; Disease Transmission, Infectious; Disinfection; Duodenoscopes; Endoscopes; Equipment Contamination; Equipment Design; Humans; Infection Control; Infectious Disease Transmission, Professional-to-Patient
PubMed: 32891225
DOI: 10.1016/j.giec.2020.06.003 -
Clinical Gastroenterology and... Aug 2020
Topics: Cholangiopancreatography, Endoscopic Retrograde; Cross Infection; Duodenoscopes; Humans; Infection Control
PubMed: 32302708
DOI: 10.1016/j.cgh.2020.04.026 -
Gastrointestinal Endoscopy Dec 2021
Topics: Cross Infection; Duodenoscopes; Equipment Contamination; Humans
PubMed: 34607702
DOI: 10.1016/j.gie.2021.08.010 -
Annals of Gastroenterology 2022Despite the standardization and optimization of disinfection protocols, duodenoscope-related infections (DRIs) remain an emerging threat for patients undergoing...
BACKGROUND
Despite the standardization and optimization of disinfection protocols, duodenoscope-related infections (DRIs) remain an emerging threat for patients undergoing endoscopic retrograde cholangiopancreatography (ERCP). Single-use duodenoscopes could represent a potential alternative avenue to circumvent the problem of reprocessing and thus risk of exogenous patient-to-patient transmission. The aim of our study was to test the feasibility and technical success rate of a recently made available single-use duodenoscope.
METHODS
We carried out a thorough and standardized evaluation of the usability, performance and safety of a recently developed single-use duodenoscope in 52 consecutive patients scheduled for ERCP in a single center. Outcomes included performance ratings of the single-use duodenoscopes, adverse events (assessed at 3 days and 1 week), and crossover rate to a reusable duodenoscope.
RESULTS
The ERCP completion rate with a single-use duodenoscope was 90.4%, rising to 94.2% after crossover to reusable duodenoscope. The mean American Society for Gastrointestinal Endoscopy (ASGE) grade was 2.7, with 27 procedures (51.9%) considered as advanced level complexity (ASGE grade 3 & 4). Performance rating found that 94% of the therapeutic treatments were comparable to those using a traditional reusable duodenoscope. Overall satisfaction amounted to 80%. No major adverse events were attributable to the single-use endoscope.
CONCLUSIONS
Single-use duodenoscopes can provide an alternative to avoid the intensive and often inconsistent results of cleaning and disinfection procedures. We confirmed the feasibility, adequate performance characteristics and safety of a recently developed first-generation single-use duodenoscope over a broad range of ERCP procedures, in terms of both indication and complexity.
PubMed: 35784631
DOI: 10.20524/aog.2022.0723 -
World Journal of Gastroenterology Jul 2020Patient-ready duodenoscopes were designed with an assumed contamination rate of less than 0.4%; however, it has been reported that 5.4% of clinically used duodenoscopes... (Review)
Review
BACKGROUND
Patient-ready duodenoscopes were designed with an assumed contamination rate of less than 0.4%; however, it has been reported that 5.4% of clinically used duodenoscopes remain contaminated with viable high-concern organisms despite following the manufacturer's instructions. Visual inspection of working channels has been proposed as a quality control measure for endoscope reprocessing. There are few studies related to this issue.
AIM
To investigate the types, severity rate, and locations of abnormal visual inspection findings inside patient-ready duodenoscopes and their microbiological significance.
METHODS
Visual inspections of channels were performed in 19 patient-ready duodenoscopes using the SpyGlass visualization system in two endoscopy units of tertiary care teaching hospitals (Tri-Service General Hospital and National Taiwan University Hospital) in Taiwan. Inspections were recorded and reviewed to evaluate the presence of channel scratches, buckling, stains, debris, and fluids. These findings were used to analyze the relevance of microbiological surveillance.
RESULTS
Seventy-two abnormal visual inspection findings in the 19 duodenoscopes were found, including scratches ( = 10, 52.6%), buckling ( = 15, 78.9%), stains ( = 14, 73.7%), debris ( = 14, 73.7%), and fluids ( = 6, 31.6%). Duodenoscopes > 12 mo old had a significantly higher number of abnormal visual inspection findings than those ≤ 12 mo old (46 findings 26 findings, < 0.001). Multivariable regression analyses demonstrated that the bending section had a significantly higher risk of being scratched, buckled, and stained, and accumulating debris than the insertion tube. Debris and fluids showed a significant positive correlation with microbiological contamination ( < 0.05). There was no significant positive Spearman's correlation coefficient between negative bacterial cultures and debris, between that and fluids, and the concomitance of debris and fluids. This result demonstrated that the presence of fluid and debris was associated with positive cultures, but not negative cultures. Further multivariate analysis demonstrated that fluids, but not debris, is an independent factor for bacterial culture positivity.
CONCLUSION
In patient-ready duodenoscopes, scratches, buckling, stains, debris, and fluids inside the working channel are common, which increase the microbiological contamination susceptibility. The SpyGlass visualization system may be recommended to identify suboptimal reprocessing.
Topics: Disinfection; Duodenoscopes; Endoscopes; Equipment Contamination; Humans; Taiwan
PubMed: 32774056
DOI: 10.3748/wjg.v26.i26.3767 -
Infection Control and Hospital... Dec 2022Several clinical procedures utilize duodenoscopes, which are processed for reuse after the procedures are completed. However, infection outbreaks due to improper...
OBJECTIVE
Several clinical procedures utilize duodenoscopes, which are processed for reuse after the procedures are completed. However, infection outbreaks due to improper duodenoscope processing occur frequently. To address this, we aimed to assess the contamination rates of duodenoscopes after reprocessing in nonoutbreak settings.
DESIGN AND SETTING
Prospective study in 16 clinical sites in the United States.
METHODS
We sampled and cultured reprocessed duodenoscopes following the FDA/CDC/ASM guideline; "Duodenoscope Surveillance Sampling and Culturing - Reducing the Risks of Infection." High-concern (HC) organisms were those highly associated with disease, including gram-negative rods, , β-hemolytic , spp, and yeasts. We evaluated duodenoscopes with ≥1 CFU of organisms after reprocessing. The reprocessing environments were also sampled and cultured.
RESULTS
We assessed 859 newer-model (NM) duodenoscopes (TJF-Q180V) and 850 older-model (OM) duodenoscopes (TJF-160F/VF); of these, 35 NM samples (4.1%) and 56 OM samples (6.6%) were contaminated with HC organisms. We detected and classified the HC organisms as gastrointestinal (45.4%), human origin (16.7%), environmental (24.1%), waterborne (13.0%), and unidentified (0.9%).
CONCLUSIONS
We detected an overall HC contamination rate of 5.3% in nonoutbreak settings. Although the relationship between endoscopic contamination and the occurrence of infections remains unclear, attempts should continue to be made to further reduce contamination rates. Additional improvements to the manufacturer's instructions for use, human factors during the reprocessing procedure, ongoing training programs, cleanliness of reprocessing environments, and the design of the distal end of the duodenoscope should be considered.
Topics: Humans; Duodenoscopes; Prospective Studies; Equipment Contamination; Disease Outbreaks; Gram-Negative Bacteria; Disinfection
PubMed: 35300743
DOI: 10.1017/ice.2021.525 -
Gut Mar 2024Contaminated duodenoscopes caused several hospital outbreaks. Despite efforts to reduce contamination rates, 15% of patient-ready duodenoscopes are still contaminated... (Review)
Review
OBJECTIVE
Contaminated duodenoscopes caused several hospital outbreaks. Despite efforts to reduce contamination rates, 15% of patient-ready duodenoscopes are still contaminated with gastrointestinal microorganisms. This study aimed to provide an overview of duodenoscope contamination over time, identify risk factors and study the effects of implemented interventions.
DESIGN
Duodenoscope culture sets between March 2015 and June 2022 at a Dutch tertiary care centre were analysed. Contamination was defined as (1) the presence of microorganisms of oral or gastrointestinal origin (MGO) or (2) any other microorganism with ≥20 colony-forming units/20 mL (AM20). A logistic mixed effects model was used to identify risk factors and assess the effect of interventions, such as using duodenoscopes with disposable caps, replacing automated endoscope reprocessors (AER) and conducting audits in the endoscopy department.
RESULTS
A total of 404 culture sets were analysed. The yearly contamination rate with MGO showed great variation, ranging from 14.3% to 47.5%. Contamination with AM20 increased up to 94.7% by 2022. For both MGO and AM20, the biopsy and suction channels were the most frequently contaminated duodenoscope components. The studied interventions, including audits, AER replacement and implementation of duodenoscopes with disposable caps, did not show a clear association with contamination rates.
CONCLUSION
Duodenoscope contamination remains a significant problem, with high contamination rates despite several interventions. Reprocessing the biopsy and suction channels is especially challenging. Changes in the design of reusable duodenoscopes, such as enabling sterilisation or easily replaceable channels, are necessary to facilitate effective duodenoscope reprocessing and to eliminate the risk of duodenoscope-associated infections.
Topics: Humans; Cholangiopancreatography, Endoscopic Retrograde; Cross Infection; Duodenoscopes; Magnesium Oxide; Retrospective Studies; Tertiary Care Centers
PubMed: 38182137
DOI: 10.1136/gutjnl-2023-330355