The Centers for Disease Control and Prevention Guidance on Flexible Gastrointestinal Endoscopes: Lessons Learned from Outbreaks, Infection Control.

Flexible endoscopes require cleaning, high-level disinfection, and sterilization between each patient use to reduce risk of transmitting pathogens. Public health investigations have identified concerns, including endoscope damage, mishandling, and reprocessing deficiencies, placing patients at risk for transmission of bacterial, viral, and other pathogens. Findings from outbreak investigations and other studies have led to innovations in endoscope design, use, and reprocessing, yet infection risks related to contaminated or damaged endoscopes remain. Strict adherence to infection control guidelines and manufacturer instructions for use, utilization of supplemental guidance, and training and oversight of reprocessing personnel, reduce risk of pathogen transmission by flexible endoscopes.

Clinical utility of novel ultrathin single-balloon enteroscopy: a feasibility study.

BACKGROUND: The advent of balloon-assisted enteroscopy (BAE) has facilitated the examination of the entire digestive tract. However, using a rigid sliding tube during the procedure reduces patient acceptance. This study evaluated the clinical application of a newly developed ultrathin single-balloon enteroscope for BAE. METHODS: 28 outpatients underwent enteroscopy with a novel ultrathin single-balloon enteroscope. None of the subjects required therapeutic procedures, such as balloon dilation or hemostasis. The insertability, efficacy, and safety of the ultrathin single-balloon endoscope were evaluated retrospectively. RESULTS: 7 patients underwent transoral enteroscopy and 21 patients underwent transanal enteroscopy under conscious sedation. No adverse events related to the procedure were reported in any patients. Targeted observation and/or targeted biopsy were achieved in all procedures. All transoral procedures allowed evaluation of the jejunum beyond the ligament of Treitz. All transanal procedures allowed intubation of the terminal ileum, despite several patients having severe stenosis of the colon and ileum. CONCLUSION: A novel ultrathin single-balloon enteroscope showed adequate insertability and safety for outpatient surveillance enteroscopy under conscious sedation.

Procedures in endoscope reprocessing and monitoring: an Italian survey.

BACKGROUND: The high diffusion of endoscopes worldwide and the need for effective reprocessing methods requested the development of guidelines and implementation of surveillance procedures at local level. STUDY DESIGN: In order to collect data on everyday's practice and adherence to available guidelines, endoscopy units from different public institutions were surveyed using a dedicated questionnaire. METHODS: Between July and November 2015 a survey was carried in 12 main hospitals from 10 different Italian regions, involving 22 endoscopy units. The state of the art of national and international guidelines was investigated to compare the protocols adopted at local level. RESULTS: In all the surveyed hospitals, the reprocessing activity is based on pre-established protocols in adherence with principal guidelines. Enzymatic detergents, which are recommended by the international guidelines, are used in 55.6% of units and peracetic acid is currently the most widely used chemical disinfectant. Discrepancies were observed in the application of periodic quality controls. CONCLUSION: Updated guidelines are generally applied in reprocessing practice. Quality controls may represent a critical issue to improve effectiveness and surveillance. The whole of acquired data can promote a positive trend towards the application of best practices.

National Endoscopy Quality Improvement Program Remains Suboptimal in Korea.

BACKGROUND/AIMS: We evaluated the characteristics of the National Cancer Screening Program (NCSP) and opinions regarding the National Endoscopy Quality Improvement Program (NEQIP). METHODS: We surveyed physicians performing esophagogastroduodenoscopy and/or colonoscopy screenings as part of the NCSP via e-mail between July and August in 2015. The 32-item survey instrument included endoscopic capacity, sedation, and reprocessing of endoscopes as well as opinions regarding the NEQIP. RESULTS: A total of 507 respondents were analyzed after the exclusion of 40 incomplete answers. Under the current capacity of the NCSP, the typical waiting time for screening endoscopy was less than 4 weeks in more than 90% of endoscopy units. Performance of endoscopy reprocessing was suboptimal, with 28% of respondents using unapproved disinfectants or not knowing the main ingredient of their disinfectants and 15% to 17% of respondents not following reprocessing protocols. Agreement with the NEQIP was optimal, because only 5.7% of respondents did not agree with NEQIP; however, familiarity with the NEQIP was suboptimal, because only 37.3% of respondents were familiar with the NEQIP criteria. CONCLUSIONS: The NEQIP remains suboptimal in Korea. Given the suboptimal performance of endoscopy reprocessing and low familiarity with the NEQIP, improved quality in endoscopy reprocessing and better understanding of the NEQIP should be emphasized in Korea.

Fecal microbiota transplant by push enteroscopy to treat diarrhea caused by Clostridium difficile.

Clostridium difficile is the major etiological agent of pseudomembranous colitis and is found in up to 20% of adult inpatients. The recommended treatment is antibiotic therapy with metronidazole and/or vancomycin. However, the recurrence rate may reach up to 25% and it increases in each episode. The newest alternative to treat diarrhea due to recurrent Clostridium difficile is fecal microbiota transplantation. The procedure was performed in 12 patients, with a 6-month follow-up on 10 of them. Of the ten cases, bacterial recurrence was diagnosed in only one patient, after a course of antibiotic to treat urinary tract infection, without presenting with diarrhea. The particularity of our study, besides being an unprecedented event in South America, is the way to perform the infusion of fecal microbiota by enteroscopy.

[Hygiene in endoscopy in clinic and practice 2013 in comparison with 2003--structure and process quality]. / Struktur- und Prozessqualität bei der Aufbereitung flexibler Endoskope in Klinik und Praxis in Frankfurt am Main--2013 im Vergleich zu 2003.

BACKGROUND: Endoscopy is an important part of modern medical diagnostics and therapy. The invasive procedures are however associated with a risk to transmit infections. Against this background the KRINKO has published the "Hygienic requirements for the reprocessing of flexible endoscopes and endoscopic accessories" in 2002 and has updated these recommendations in 2012. In 2003 and 2013 all gastroenterological facilities in Frankfurt am Main using flexible endoscopes were monitored for compliance with the recommendations. METHODS: The inspections were performed after prior notice by a staff member of the health authority using a checklist which had been developed on the basis of the current KRINKO recommendations. RESULTS: In both years all institutions performing endoscopic procedures were visited: 2003 15 hospitals and 23 practices; 2013 14 clinics and 10 practices. In 2013 (data for 2003 in brackets) 100 % (93 %) of the hospitals and 60 % (22 %) of practices reprocessed their endoscopes by automated methods. The appropriate reprocessing and filling of water bottles for rinsing the scope channels with sterile water and the sterilisation of accessories were satisfactorily performed in 2003 and 2013 by all hospitals. However in 2013 only 90 % (2003: 74 %) of the practices correctly reprocessed water bottles and 80 % (52 %) used sterile water for filling the bottle. In 2013 100 % (2003: 57 %) of the practices correctly sterilised accessory instruments, while 2 practices used disposable, i. e., single-use materials. In 2013 all institutions performed microbiological tests according to KRINKO recommendations, while in 2003 all hospitals but only 43 % of the practices could present such tests. DISCUSSION: While the gastroenterological departments of Frankfurt hospitals already complied with the KRINKO recommendations in 2003, the inspection of several practices in 2003 had revealed considerable shortcomings in the implementation of these recommendations. Subsequently the practices have improved their hygiene management.

The use of rapid indicators for the detection of organic residues on clinically used gastrointestinal endoscopes with and without visually apparent debris.

BACKGROUND: Outbreaks of multidrug-resistant organisms have been linked to endoscope reprocessing lapses. Meticulous manual cleaning before high-level disinfection (HLD) is essential in reducing residual contamination that can interfere with HLD. Current reprocessing guidelines state that visual inspection is sufficient to confirm adequate cleaning. OBJECTIVE: Our aim was to evaluate contamination of clinically used endoscopes, using visual inspection and rapid indicator tests before and after manual cleaning. A second objective was to determine which rapid indicator instruments and methods could be used for quality improvement initiatives in endoscope reprocessing. DESIGN: Clinical use study of endoscope reprocessing effectiveness. SETTING: Tertiary care teaching hospital with an inpatient endoscopy center. METHODS: Researchers sampled endoscopes used for gastrointestinal procedures before and after manual cleaning. The external surfaces and 1 channel of each endoscope were visually inspected and tested with rapid indicators to measure protein, blood, and adenosine triphosphate (ATP) contamination levels. RESULTS: Multiple components were sampled during 37 encounters with 12 unique endoscopes. All bedside-cleaned endoscopes had high levels of ATP and detectable blood or protein, whether or not any residue was visible. Although there was no visible residue on any endoscopes after manual cleaning, 82% had at least 1 positive rapid indicator test. CONCLUSIONS: Relying solely on visual inspection of endoscopes prior to HLD is insufficient to ensure reprocessing effectiveness. For quality assurance initiatives, tests of different endoscope components using more than 1 indicator may be necessary. Additional research is needed to validate specific monitoring protocols.

Accuracy of diagnosing gastroesophageal reflux disease by GerdQ, esophageal impedance monitoring and histology.

OBJECTIVE: To assess the performance of self-assessment gastroesophageal reflux disease questionnaire (GerdQ), 24-h impedance monitoring, proton pump inhibitor (PPI) test and intercellular space of esophageal mucosal epithelial cells in the diagnosis of gastroesophageal reflux disease (GERD). METHODS: Patients with symptoms suspected of GERD were administered the GerdQ and underwent endoscopy (measurement of intercellular space in the biopsy specimen sampling at 2 cm above the Z-line) and 24-h impedance pH monitoring, together with a 2-week experimental treatment with esomeprazole. RESULTS: A total of 636 patients were included for the final analysis, including 352 with GERD. The sensitivity and specificity of GerdQ and 24-h impedance monitoring for diagnosing GERD were 57.7% and 48.9%, and 66.4% and 43.3%, respectively. The sensitivity of 24-h impedance pH monitoring increased to 93.7%. The sensitivity and specificity of dilated intercellular spaces (DIS) (≥0.9 µm) for diagnosing GERD were 61.2% and 56.1%, respectively, whereas those for PPI test were 70.5% and 44.4%. CONCLUSIONS: GerdQ score or PPI test alone cannot accurately diagnose GERD in a Chinese population suspected of GERD. A definitive diagnosis of GERD still depends on endoscopy or 24-h pH monitoring. 24-h impedance pH monitoring may increase the sensitivity for diagnosing GERD by 20%; however, when used alone, it results in poor specificity in patients without acid suppressive therapy.

Estudio comparativo entre un colonoscopio con tecnología RIT (“responsive insertion technology”) y un colonoscopio de rigidez variable convencional / Comparative study of a responsive insertion technology (RIT) colonoscope versus a variable-stiffness colonoscope

Introducción y objetivos: la casa Olympus ha desarrollado recientemente un nuevo endoscopio prototipo, denominado XCFQ180AY2L con tecnología RIT. Esta tecnología supone la incorporación, además de la función de rigidez variable ya conocida, de un segmento con flexión pasiva (PB, de sus siglas en inglés passive bending section) contiguo al segmento móvil del endoscopio, y un tubo de inserción que optimiza la transmisión de la fuerza desde los mandos al extremo distal del aparato (HFT, de sus siglas en inglés high force transmission tube). El objetivo del estudio es comprobar si el uso de este prototipo facilita el procedimiento de inserción del colonoscopio, incrementando la tasa de colonoscopias completas y/o disminuyendo el tiempo de intubación. Material y métodos: estudio observacional y unicéntrico en el que se incluyó de forma prospectiva a 305 pacientes comparando la proporción de colonoscopias completas, los tiempos medios de intubación cecal e ileal, y la necesidad de recibir maniobras específicas durante la colonoscopia, en función del colonoscopio utilizado: el colonoscopio prototipo XCF-Q180AY2L o un colonoscopio convencional, del tipo CFH180AL o CFQ160L, usados como control. Todos los procedimientos fueron realizados bajo sedación con propofol intravenoso. El estudio incluyó finalmente a 288 pacientes y no se observó ninguna complicación. Resultados: la tasa de colonoscopias completas fue del 100 % en ambos grupos. La ileoscopia se realizó en el 98,95 % de los casos. El tiempo medio de intubación fue menor en el grupo del prototipo (4,31 min, DE 2,63 min) que en el grupo control (4,66 min, DE 2,52 min) (p < 0,05). En el grupo del prototipo se utilizó menos la función de rigidez variable (p < 0,05), se necesitó menor número de rectificaciones cuando fue necesario hacer esta maniobra (p < 0,01), y se obtuvo una menor sensación de dificultad al pasar el sigma (p < 0,01). Conclusión: la conclusión fue que el colonoscopio prototipo (XCF-Q180AY2L) facilitó la inserción del colonoscopio, y disminuyó muy ligeramente el tiempo de inserción cecal (AU)

Background and objectives: recently, Olympus developed a new prototype (XCF-Q180AY2L) with responsive insertion technology (RIT), which besides the still known variable stiffness technology, included a passive bending section and a new high force insertion tube. Our objective was to investigate whether the use of this prototype could ease colonoscope insertion, increasing the cecal intubation rate, and/or shortening the cecal intubation time. Material and methods: the study was designed as a prospective observational study in 305 consecutive patients from a colo-rectal cancer screening program. We compared colonoscopies performed with conventional colonoscopes (CFH180AL/CFQ160L) with those performed with the prototype XCF-Q180AY2L. End points were mean cecal and terminal ileal intubation times, cecum intubation rate, and need for specific maneuvers. All colonoscopies were performed under sedation with intravenous propofol. Finally, 288 patients were included. Results: no complications were observed. Complete cecal intubation rate was 100 % in both groups. The ileum could be reached in 98.95 % of cases. Mean time required to reach the cecum was shorter in the prototype endoscope group (4.31 min, SD 2.63 min) than in the conventional endoscope group (4.66 min, SD 2.52 min) (p < 0.05). Compared with the standard colonoscope group, we observed in the prototype group less subjective sensation of difficulty in the passage of the sigma (p < 0.01), fewer maneuvers when it proved necessary to straighten the scope (p < 0.01), and less frequent need to modify the stiffness of the endoscope (p < 0.05). Conclusion: we concluded that the prototype endoscope (XCFQ180AY2L) facilitated colonoscope insertion, requiring slightly less time to reach the cecum than a standard colonoscope (AU)

Steady progress seen in endoscopic surgery on major salivary glands.

INTRODUCTION: The objective of this study was to investigate the development in sialendoscopy (SE) in East Denmark. Data were compared with previously published data to assess the learning curve. MATERIAL AND METHODS: In this retrospective consecutive study, all patients who had SE performed at Hillerød Hospital from November 2009 to April 2011 were included. Data were extracted from medical records and interviews. Two surgeons performed all SEs. Z-test and Fisher's exact test were used for statistical analysis. RESULTS: A total of 118 patients met the inclusion criteria. In all, 156 diagnostic and 139 therapeutic SEs were performed. The median age was 44 years (3-85 years) and the female-to-male-ratio was 1.81. A total of 96% of patients had pre-operative ultrasound performed (the positive predictive value for detection of stone was 0.82, 95% confidence interval 0.70-0.90. Indication for SE was recurrent or chronic swelling, pain, identified stone or recurrent infections. The only exclusion criterion was neoplasms. The success rate of diagnostic SE was 98%, and the therapeutic SE success rate was 67%. Total or partial relief from symptoms was obtained in 77% of patients which was a significant improvement (Z-test: p < 0.001). No serious persistent complications occurred. CONCLUSION: SE is a safe and effective treatment for benign obstructive disease of the major salivary glands. The surgeon's results improve significantly over time. Updated equipment and an experienced surgeon yielded patient symptom relief in 77% of cases. FUNDING: not relevant. TRIAL REGISTRATION: This study was approved by the Danish Committee on Biomedical Research Ethics and the Danish Data Protection Agency.

'Short' double-balloon enteroscope endoscopic retrograde cholangiopancreatography in patients with a surgically altered upper gastrointestinal tract.

BACKGROUND: Endoscopic retrograde cholangiopancreatography (ERCP) remains a challenge for endoscopists in patients with surgically altered anatomy of the upper gastrointestinal tract. Double-balloon enteroscopes (DBEs) have revolutionized the ability to access the small bowel. The indication for its therapeutic use is expanding to include ERCP for patients who have undergone small bowel reconstruction. Most of the published experiences in DBE-assisted ERCP have used conventional double-balloon enteroscopes that are 200 cm in length, which do not permit use of the standard ERCP accessories. The authors report their experience with DBE-assisted ERCP using a 'short' DBE in patients with surgically altered anatomy. METHODS: A retrospective review of patients with previous small bowel reconstruction who underwent ERCP with a 'short' DBE at the Centre for Therapeutic Endoscopy and Endoscopic Oncology (Toronto, Ontario) between February 2007 and November 2008 was performed. RESULTS: A total of 20 patients (10 men) with a mean age of 57.9 years (range 26 to 85 years) underwent 29 sessions of ERCP with a DBE. Six patients underwent Billroth II gastroenterostomy, seven patients Roux-en-Y hepaticojejunostomy, five patients Roux-en-Y gastrojejunostomy, one patient Roux-en-Y esophagojejunostomy and one patient a Whipple's operation with choledochojejunostomy. Some patients (n=12 [60%]) underwent previous attempts at ERCP in which the papilla of Vater or bilioenteric anastomosis could not be reached with either a duodenoscope or pediatric colonoscope. All procedures were performed with a commercially available DBE (working length 152 cm, distal end diameter 9.4 mm, channel diameter 2.8 mm). The procedures were performed under conscious sedation with intravenous midazolam, fentanyl and diazepam, except in one patient in whom general anesthesia was administered. Either the papilla of Vater or bilioenteric anastomosis was reached in 25 of 29 cases (86.2%) in a mean duration of 20.8 min (range 5 min to 82 min). Bile duct cannulation was successful in 24 of 25 cases in which the papilla or bilioenteric anastomosis was reached. Therapeutic interventions were successful in 15 patients (24 procedures) including sphincterotomy (n=7), stone extraction (n=9), biliary dilation (n=8), stent placement (n=9) and stent removal (n=8). The mean total duration of the procedures was 70.7 min (range 30 min to 117 min). There were no procedure-related complications. CONCLUSION: DBEs enable successful diagnostic and therapeutic ERCP in patients with a surgically altered anatomy of the upper gastrointestinal tract. It is a safe, feasible and less invasive therapeutic option in this group of patients. Standard 'long' DBEs have limitations of long working length and the need for modified ERCP accessories. 'Short' DBEs are equally as effective in reaching the target limb as standard 'long' DBEs, and overcomes some limitations of long DBEs to result in high success rates for endoscopic therapy.