Sustainability of Single-Use Endoscopes


      Interest in single-use, disposable endoscopes has been growing due to concerns about infection transmission with reusable endoscopes. Yet valid concerns remain about the sustainability of single-use endoscopes in the form of long-term economic, environmental, and social consequences, even with the assumption that single-use endoscopes eliminate infection risk completely, are technically equivalent, and are cost-neutral to patients and hospitals when compared with reusable endoscopes. Economic sustainability extends beyond the per unit cost of single-use endoscopes to the concept of economic growth without adverse effects on the environment and society. Environmental sustainability is responsibly interacting with the planet to protect and conserve natural resources to support health and well-being, now and in the future. Environmental sustainability is influenced by all stages in the life cycle of an endoscope including manufacturing, transport, use, and disposal, most of which remains obscured to hospitals and physicians. Social sustainability, the recognition of and a commitment to, ensure that new medical devices are available to all patients and that the manufacture, use, and disposal of medical devices does not harm others, particularly vulnerable populations. Physicians and hospitals deliberating the adoption of single-use endoscopes should carefully consider the full extent of sustainability and long-term consequences in their discussions.


      To read this article in full you will need to make a payment
      AGA Member Login
      Login with your AGA username and password.
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • American Medical Association
        AMA Code of Medical Ethics’ Opinion on Physician Stewardship.
        AMA Journal of Ethics. 2015; 17: 1044-1045
        • Peter G
        Peterson Foundation. Why Are Americans Paying More for Healthcare?.
        Peter GPeterson Foundation. 2020;
        • Shrank WH
        • Rogstad TL
        • Parekh N.
        Waste in the US Health Care System: Estimated Costs and Potential for Savings.
        JAMA. 2019; 322: 1501-1509
        • Eckelman MJ
        • Sherman J.
        Environmental Impacts of the U.S. Health Care System and Effects on Public Health.
        PloS One. 2016; 11e0157014
        • Meadows DH
        • Meadows D
        • Randers J
        • Behrens III WW
        The Limits to Growth : A Report for the Club of Rome's Project on the Predicament of Mankind.
        1st ed. Universe Books, New York1972
        • World Commission on Environment and Development
        Our Common Future.
        1st ed. Oxford University Press, Oxford1987
        • Harper G
        • Sommerville R
        • Kendrick E
        • Driscoll L
        • Slater P
        • Stolkin R
        • et al.
        Recycling lithium-ion batteries from electric vehicles.
        Nature. 2019; 575: 75-86
        • Grand View Research
        Electric Vehicle Market Size, Share & Trends Analysis Report By Product (Battery Electric Vehicles (BEV), Plug-in Hybrid Electric Vehicles (PHEV)), By Region (North America, Europe, APAC, LATAM, MEA).
        And Segment Forecasts. 2020; (2020 - 2027)
      1. United Nations Department of Economic and Social Affairs. The 17 Goals. United Nations Department of Economic and Social Affairs 2021.

      2. U.S. Food and Drug Administration. The FDA Continues to Remind Facilities of the Importance of Following Duodenoscope Reprocessing Instructions: FDA Safety Communication 2019.

        • Ofstead CL
        • Heymann OL
        • Quick MR
        • Eiland JE
        • Wetzler HP.
        Residual moisture and waterborne pathogens inside flexible endoscopes: Evidence from a multisite study of endoscope drying effectiveness.
        American Journal of Infection Control. 2018; 46: 689-696
      3. U.S. Food and Drug Administration. 522 Postmarket Surveillance Study PS150003 /PSS001 2017.

        • Ofstead CL
        • Dirlam Langlay AM
        • Mueller NJ
        • Tosh PK
        • Wetzler HP
        Re-evaluating endoscopy-associated infection risk estimates and their implications.
        American Journal of Infection Control. 2013; 41: 734-736
      4. U.S. Food and Drug Administration. FDA recommends health care facilities and manufacturers begin transitioning to duodenoscopes with disposable components to reduce risk of patient infection. Food and Drug Administration 2020.

      5. American Society for Gastrointestinal Endoscopy. Transmission of Multi-Drug Resistant Bacteria via ERCP 2019.

      6. National Quality Forum. Serious Reportable Events in Healthcare 2011 2011.

        • Crandall M
        • Duncan T
        • Mallat A
        • Greene W
        • Violano P
        • Christmas AB
        • et al.
        Prevention of fall-related injuries in the elderly: An Eastern Association for the Surgery of Trauma practice management guideline.
        The Journal of Trauma and Acute Care Surgery. 2016; 81: 196-206
        • US Preventive Services Task Force
        • Grossman DC
        • Curry SJ
        • Owens DK
        • Barry MJ
        • Caughey AB
        • et al.
        Interventions to Prevent Falls in Community-Dwelling Older Adults: US Preventive Services Task Force Recommendation Statement.
        JAMA. 2018; 319: 1696-1704
        • Mu Y
        • Edwards JR
        • Horan TC
        • Berrios-Torres SI
        • Fridkin SK.
        Improving risk-adjusted measures of surgical site infection for the national healthcare safety network.
        Infection Control and Hospital Epidemiology. 2011; 32: 970-986
        • Tartari E
        • Weterings V
        • Gastmeier P
        • Rodríguez Baño J
        • Widmer A
        • Kluytmans J
        • et al.
        Patient engagement with surgical site infection prevention: an expert panel perspective.
        Antimicrobial Resistance and Infection Control. 2017; 6: 45
        • Ulger F
        • Esen S
        • Dilek A
        • Yanik K
        • Gunaydin M
        • Leblebicioglu H.
        Are we aware how contaminated our mobile phones with nosocomial pathogens?.
        Annals of Clinical Microbiology and Antimicrobials. 2009; 8
        • Shakir IA
        • Patel NH
        • Chamberland RR
        • Kaar SG.
        Investigation of cell phones as a potential source of bacterial contamination in the operating room.
        The Journal of Bone and Joint Surgery American Volume. 2015; 97: 225-231
      7. Ofstead CL, Eiland JE, Adams SJ. A Glimpse at the True Cost of Reprocessing Endoscopes: Results of a Pilot Project 2017.

        • Larsen S
        • Kalloo A
        • Hutfless S.
        The hidden cost of colonoscopy including cost of reprocessing and infection rate: the implications for disposable colonoscopes.
        Gut. 2020; 69: 197-200
        • Terjesen CL
        • Kovaleva J
        • Ehlers L.
        Early Assessment of the Likely Cost Effectiveness of Single-Use Flexible Video Bronchoscopes.
        PharmacoEconomics - Open. 2017; 1: 133-141
        • Sohrt A
        • Ehlers L
        • Udsen FW
        • Mærkedahl A
        • McGrath BA.
        Cost Comparison of Single-Use Versus Reusable Bronchoscopes Used for Percutaneous Dilatational Tracheostomy.
        PharmacoEconomics - Open. 2019; 3: 189-195
        • Barakat M
        • Ghosh S
        • Banerjee S.
        Cost Utility Analysis Comparing Duodenoscope Reprocessing/Sterilization, Novel Duodenoscopes with Disposable Endcaps and Fully Disposable Duodenoscopes.
        Gastrointestinal Endoscopy. 2020; 91: AB67
        • Bang JY
        • Sutton B
        • Hawes R
        • Varadarajulu S.
        Concept of disposable duodenoscope: at what cost?.
        Gut. 2019; 68: 1915-1917
        • Melnick G
        • Fonkych K.
        Regulating Out-Of-Network Hospital Emergency Prices: Problem And Potential Benchmarks.
        Health Affairs Blog. 2020;
      8. Ambu A/S. aScopeTM Duodeno Coding and Payment Guide: Medicare Outpatient Transitional Pass-Through Payments. Ambu A/S 2020.

        • BostonScientific
        Boston Scientific Receives Medicare Transitional Pass-Through Payment for the EXALTTM Model D Single-Use Duodenoscope.
        Boston Scientific. 2020;
        • Gustafson T.
        Transitional Pass-Through Payments.
        ASC Focus. 2015; : 8-9
        • Kovaleva J
        • Peters FTM
        • van der Mei HC
        • Degener JE.
        Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy.
        Clinical Microbiology Reviews. 2013; 26: 231-254
        • Dyrda L.
        GI endoscopies make up 68% of all endoscopies in U.S.: 5 market trends.
        GI & Endoscopy. 2019;
      9. Grand View Research. Disposable Endoscopes Market Size, Share & Trends Analysis Report By Application (Bronchoscopy, Proctoscopy, Arthroscopy), By End-use (Hospitals, Diagnostic Centers, Clinics), And Segment Forecasts, 2020 - 2027. Grand View Research 2020.

      10. GlobalData Healthcare. Disposable endoscopes set to disrupt the reusable endoscopes market 2021.

        • Liu H
        • Mattke S
        • Predmore ZS.
        Medicare Coverage of Anesthesia Services During Screening Colonoscopies for Patients at Low Risk of Sedation-Related Complications.
        JAMA Internal Medicine. 2015; 175: 1848
        • Krigel A
        • Chen L
        • Wright JD
        • Lebwohl B.
        Substantial Increase in Anesthesia Assistance for Outpatient Colonoscopy and Associated Cost Nationwide.
        Clinical Gastroenterology and Hepatology : The Official Clinical Practice Journal of the American Gastroenterological Association. 2019; 17: 2489-2496
        • Childers CP
        • Maggard-Gibbons M.
        Estimation of the Acquisition and Operating Costs for Robotic Surgery.
        JAMA. 2018; 320: 835-836
        • ARUP Laboratories
        Healthcare's climate footprint.
        ARUP Laboratories. 2019;
        • Association of American Medical Colleges
        Hospitals race to save patients — and the planet.
        AAMC. 2019;
        • Pohl H
        • von Renteln D.
        Environmental Impact of Disposable Endosopic Equipment and Endoscopes - A Volumetric Analysis.
        ESGE Days. 2020;
        • Horwood J
        • Brennan F
        • Morris D
        • Torkington J.
        The globalised supply chain of the suture: industry and healthcare organisations’ responsibility to sustainable healthcare.
        The Bulletin of the Royal College of Surgeons of England. 2020; 102: 194-196
        • International Energy Agency
        International Energy Agency, 2018
        • International Energy Agency
        United States.
        International Energy Agency, 2018
      11. Ambu A/S. Sustainability report 2019/20. 2020.

      12. Boston Scientific. Climate Change. Boston Scientific 2021.

        • Donahue M.
        Report: Waste Incineration: A Dirty Secret in How States Define Renewable Energy.
        Institute for Local Self-Reliance. 2018;
        • U.S. Environmental Protection Agency
        Energy Recovery from the Combustion of Municipal Solid Waste (MSW).
        US Environmental Protection Agency, 2021
      13. U.S. Food and Drug Administration. Safety assessment of di (2-ethylhexyl) phthalate (DEHP) released from PVC medical devices. Rockville, MD, Sept 2001.

        • Vlasselaers D
        • Milants I
        • Desmet L
        • Wouters PJ
        • Vanhorebeek I
        • van den Heuvel I
        • et al.
        Intensive insulin therapy for patients in paediatric intensive care: a prospective, randomised controlled study.
        Lancet (London, England). 2009; 373: 547-556
      14. U.S. Consumer Product Safety Commission. Prohibition of Children's Toys and Child Care Articles Containing Specified Phthalates. US Consumer Product Safety Commission 2017.–Standards/Rulemaking/Final-and-Proposed-Rules/Prohibition-of-Childrens-Toys-and-Child-Care-Articles-Containing-Specified-Phthalates.

      15. Ambu A/S. Corporate Social Responsibility 2021.

        • Markman A.
        Why people aren't motivated to address climate change.
        Harvard Bus Rev. 2018;
        • Amnesty International
        Exposed: Child labour behind smart phone and electric car batteries.
        Amnesty International. 2016;
      16. Business & Human Rights Resource Centre. Lawsuit against Apple, Google, Tesla, and others (re child labour, DRC). Business & Human Rights Resource Centre 2019.

        • Ross A.
        Send in the troops: Congo raises the stakes on illegal mining.
        Reuters. 2019;
      17. Ambu A/S. Ambu: Sustainability Report. Ambu A/S 2020.

        • Carreyrou J.
        Surgical Robot Examined in Injuries.
        Wall Street Journal. 2010;
      18. Waste Dive. Nearly 80% of US incinerators located in marginalized communities, report reveals. Waste Dive 2019.

        • Gaia
        Failing Incinerators.
        Gaia. 2021;