Processamento endoscópico: quais são os gaps na prática clínica? / Endoscopic processing: what are the gaps in clinical practice?

Objetivo: Identificar na prática clínica gaps que interferem na efetividade do processamento endoscópico. Método: Revisão integrativa de artigos publicados entre 2008­2020, identificados em bases de dados por meio de descritores controlados em Ciências da Saúde, adotando-se a estratégia PICO. Os gaps identificados foram classificados segundo nível de evidência (IA, IB, IC, II). Resultados: Foram encontrados 18 artigos registrando 64 gaps, 26,6% no nível de evidência IA e 40,6% IB, predominando: ausência/inadequação da secagem (55,5%), limpeza manual sem escovação dos canais/escovas inapropriadas (50%), omissão do teste de vedação (38,8%), inadequações no armazenamento (33,3%) e no uso da solução desinfetante (27,7%), tempo de imersão ou monitorização da concentração mínima eficaz, ausência de pré-limpeza (16,6%), transporte incorreto para a sala de processamento (11,1%). Conclusão: As diretrizes fortemente recomendadas por entidades internacionais e nacional têm sido descumpridas, representando aspectos críticos no processamento dos endoscópios que implicam em potenciais falhas na segurança do paciente.

Objective: This paper aimed to identify gaps in clinical practice that interfere with the effectiveness of endoscopic processing. Method: Integrative review of articles published between 2008 and 2020, identified in databases through controlled descriptors in Health Sciences, adopting the PICO strategy. The identified gaps were classified according to the level of evidence (IA, IB, IC, II). Results: Eighteen articles were found, recording 64 gaps, 26.6% at the level of evidence IA and 40.6% IB, predominating: absence/inadequate drying (55.5%), manual cleaning without brushing the inappropriate channels/brushes (50%), omission of the sealing test (38.8%), inadequate storage (33.3%) and use of the disinfectant solution (27.7%), time of immersion or monitoring of the minimum effective concentration, absence of pre-cleaning (16.6%), incorrect transportation to the processing room (11.1%). Conclusion: It was concluded that guidelines strongly recommended by international and national entities have been breached, representing critical aspects in the processing of endoscopes that imply potential failures in patient safety.

A prática do processamento de gastroscópios, colonoscópios e duodenoscópios nos serviços de saúde intra - hospitalares / The practice of processing gastroscopes, colonoscopes and duodenoscopes in intra-hospital health services

Procedimentos endoscópicos representam um importante recurso diagnóstico e terapêutico amplamente utilizado nos serviços de saúde. Entretanto, durante o exame, ao entrar em contato com o trato gastrointestinal, o endoscópio se torna altamente contaminado pela microbiota humana. Portanto, a limpeza meticulosa e desinfecção desse equipamento é extremamente crítica na prevenção de infecção e segurança do seu uso. Diante disso, objetivou-se avaliar a prática do processamento de gastroscópios, colonoscópios e duodenoscópios nos serviços de saúde intra ­ hospitalares. Tratou-se de um estudo transversal, com apoio da Secretaria de Estado de Saúde de Minas Gerais (SES-MG), realizado em oito serviços de endoscopia intrahospitalares em Belo Horizonte, sendo avaliado o processamento de 22 equipamentos endoscópicos e 60 amostras dos canais dos equipamentos. A coleta de dados ocorreu por meio de entrevista, observação das práticas adotadas, análise microbiológica dos canais de ar/água e, no duodenoscópio acrescentou-se a análise do canal do elevador, somado à aplicação de teste de proteína após a limpeza. A análise dos dados se deu por meio de estatística descritiva, com cálculo de frequências, medidas de tendência central. A maioria dos serviços dispuham de endoscópios com média global de uso de 7,3 anos. As manutenções preventivas ocorriam em média a cada 90 dias. Protocolos de processamento não estavam ao alcance dos profissionais de forma facilitada em 50% (4/8) dos serviços. A auditoria do processo de limpeza é realizada em 62,5% (5/8) dos serviços, por meio de teste adenosina trifosfato (ATP) bioluminescência. Nenhum serviço possuía rotina de vigilância dos pacientes submetidos a procedimentos endoscópicos. Todas as etapas do processamento apresentaram não conformidades com as diretrizes nacionais e internacionais, destacando-se a etapa da limpeza como a de maior desafio, seguida da secagem, pré-limpeza, teste de vedação e armazenamento. Na pré-limpeza, verificou-se que 86,4% (19/22) dos equipamentos não era padronizada a compressa para limpeza externa do equipamento, sendo adotada a gaze. O teste de vedação não foi realizado em 36,4% (8/22) dos equipamentos. Na limpeza, 72,7% (17/22) dos endoscópios não foram imersos em solução detergente e 63,6% (14/22) dos equipamentos, os canais eram friccionados com esvova de tamanho único. Nenhum serviço havia padronização de tempo para a secagem final dos canais. No armazenamento, os armários convencionais em MDF foram encontrados em 37,5% (3/8) dos serviços, sem qualquer ventilação. Quanto ao potencial de contaminação, após o processamento verificou-se um predomínio de Pseudomonas, sendo que 28,5% eram resistentes a carbepenem e 21,4% com perfil intermediário. Serratia marcescens resistente a carbapenem foi isolada em 33,3% das amostras. Em relação aos testes de avaliação da limpeza, 33% (2/6) dos duodenoscópios apresentavam resíduos de proteína no canal do elevador. Conclui-se que as práticas cotidianas do processamento de endoscópios em serviços de saúde não têm sido realizadas conforme as evidências e as recomendações científicas.

Endoscopic procedures are an important diagnosis and therapeutic resource broadly used in health services. However, during the procedure, when contacting the gastrointestinal tract, the endoscope becomes highly contaminated by human microbiota. A thorough cleaning and disinfection of these equipment is of critical importance in the prevention of infection and safety of its use. Therefore, the aim was to evaluate the practice of processing gastroscopes, colonoscopes and duodenoscopes in intra-hospital health services. The study was a crosssectional one, supported by Minas Gerais State Department of Health, performed in eight inhospital endoscopic services in Belo Horizonte. Data collection occurred through interviews, observation of practices, microbiological analysis of air/water channels, and in the duodenoscope, was added analysis of the elevator channel, adding to protein test applications after cleaning. 60 samples from the equipment channels were analyzed. Data analysis was performed using descriptive statistics, with frequency calculation, measures of central tendency. The majority of services had endoscopes with global average use of 7,3 years. Preventive maintenance occurred in an average cicle of 90 days. At pre-cleaning, it was found that 86.4% (19/22) of the endoscopes did not standardized compress for the equipment external cleaning, and gause was adopted. The sealing test was not used at 36.4% (8/22) of the equipment. For cleaning, 63.6% (14/22) of endoscopes did not had compatible brushes for each channel, and 72.7% (17/22) of the equipments were not immersed in a detergent solution. At storage, conventional MDF cabinets were found, at 37.5% (3/8) of services, without any air circulation. Processing protocols at 50% (4/8) of services were not available to professionals in an easy way. All processing steps presented nonconformities with national and international guidelines, highlighting the cleaning stage as the most challenging one, followed by drying, pre-cleaning, sealing test and storage. The cleaning process audit took place at 62.5% (5/8) of services, through adenosine triphosphate (ATP) bioluminescence. As for disinfection, all services monitored the solution with MEC tape. None of the services had a surveillance routine of patients undergoing endoscopic procedures. As for the contamination potential, after processing there was a predominance of Pseudomonas, 28.5% were resistant to carbepenem and 21.4% had an intermediate profile. Serratia marcescens carbapenem resistant, was isolated at 33.3% of the samples. Regarding cleaning validation tests, 33% (2/6) of duodenoscopes showed protein residues in the elevator channel. It is concluded that the daily practices endoscopes processing in health services have not been carried out in accordance with scientific evidence and recommendations.

Adequacy of Reprocessing Gastrointestinal Endoscopes in Korea Hospitals

BACKGROUND: This study was conducted in order to survey the current state of cleaning, disinfection, rinsing, drying, and storage of gastrointestinal endoscopes. METHODS: Eighty hospitals were selected through convenient sampling. Self-reported questionnaire was distributed from September 14 to October 10 in 2015. RESULTS: The response rate was 67.5% (54/80). In 88.9% of the hospitals, reprocessing was performed in a cleaning space separated from the laboratory and 88.9% used an enzymatic cleaner. Disinfectants used were ortho-phthalaldehyde in 63.0%, and paracetic acid in 33.3%. Eighty seven percent of the hospitals used test strips in order to test the effective concentration of disinfectant and in 61.1%, drying was done through passing air and over 70% alcohol. Microbial culture for the quality control of gastrointestinal endoscopes was performed in 77.8%. In the comparison of the adequacy of gastrointestinal endoscope reprocessing, it was observed that gastrointestinal endoscopes were reprocessed more adequately in larger and tertiary care hospitals. CONCLUSION: Gastrointestinal endoscopes were reprocessed in similar manners, but there were differences in the detailed process. It is still necessary to segment reprocessing into stages, to prepare standardized guidelines, and to monitor compliance with the guidelines.

Eficacia del proceso de limpieza y desinfección de los endoscopios en un hospital de nivel III / Efficacy of the cleaning and disinfection processes of endoscopes in a level III hospital

Objetivos: Determinar la eficacia del proceso de limpieza y desinfección de los endoscopios en un hospital de nivel III, y determinar los agentes patógenos más comunes encontrados antes y después del proceso. Material y métodos: Estudio descriptivo tipo serie de casos realizado en agosto, setiembre y octubre del 2010. Se evaluaron 50 ciclos de limpieza y desinfección de endoscopios. Para el aislamiento de microorganismos patógenos se utilizaron medios de cultivos y las pruebas de coagulasa, oxidasa y de pigmentos, medio Agar selectivo (Agar Verde Brillante, Agar Xilosa Lisina Desoxicolato, Agar con Sulfito de Bismuto), y medio Agar Mc Conkey. Resultados: La media del recuento de microorganismos antes del proceso de limpieza y desinfección de los endoscopios fue 835,3 ± 1 114,6 UFC/ml, la mediana 233 UFC/ml. Después del proceso la media fue 236,3 ± 700,7 UFC/ml y la mediana 10 UFC/ml, esta diferencia fue estadísticamente significativa (p= 0,000001). La carga bacteriana antes del proceso fue positiva en 88% y después del proceso en 26%. Se encontró diferencia estadísticamente significativa para Pseudomonas aeruginosa (p=0,006) y Salmonella enterica (p=0,00001). La carga bacteriana después del décimo día de activación del desinfectante fue positiva en 55% y antes del noveno día, 19%. Conclusiones: El proceso de limpieza y desinfección de los endoscopios no es efectivo. Los microorganismos patógenos más frecuentes fueron: Salmonella entérica, Pseudomonas aeruginosa y Escherichia coli. El desinfectante de alto nivel (glutaraldehído al 2%) no es efectivo después del décimo día de haber sido activado. (AU)

Objectives: To determine the efficacy of the cleaning and disinfection processes of endoscopes in a level III hospital, and to determine the most common pathogens found before and after these procedures. Methods: Case series from August to October 2010. A total of 50 cycles of cleaning-disinfection procedures were evaluated. Culture media (Brilliant blue agar, xylose-lisine-deoxycholate, sulfite bismute, Mc Conkey) as well as coagulase and oxidase tests were used. Results: The mean count of bacteria before the procedures was 835.3 ± 1,114.6 UFC/ml; the median count was 233 UFC/ml; respective values after the procedures were 236.3 ± 700.7 UFC/ml and 10 UFC/ml, respectively, a statistical difference was found (p=0.000001). Bacterial load was positive before the procedures in 88%, and 26% after them. A statistical significant difference was found for Pseudomonas aeruginosa (p = 0.006) and Salmonella entérica (p=0.00001). Bacterial load was positive in 55% after 10 days of using the disinfectant and it was 19% after the ninth day. Conclusions: The cleaning-disinfection process is not effective. Salmonella enterica, Pseudomonas aeruginosa and Escherichia coli were the most frequent isolated pathogens. The high level disinfectant (2% glutaraldehyde) is not effective after the tenth day. (AU)

Magnifying Endoscopy for Intestinal Follicular Lymphoma Is Helpful for Prompt Diagnosis

The representative endoscopic features of primary intestinal follicular lymphoma are well known as small whitish polypoid nodules, but a magnified view has only been described in a few case reports. Herein, we report a case with intestinal follicular lymphoma in which magnifying endoscopy with narrow band imaging was helpful for prompt diagnosis. A 57-year-old Japanese woman underwent surveillance esophagogastroduodenoscopy. The endoscopic examination revealed confluent whitish granules in the duodenum, distinct from the nodules or polyps that are typical findings of intestinal follicular lymphoma. Magnifying endoscopy visualized whitish enlarged villi, and narrow band imaging emphasized an elongated and coiled vascular pattern. Based on these features, intestinal follicular lymphoma was highly suspected, and subsequent histological study confirmed the diagnosis. This case demonstrates that magnifying endoscopy with narrow band imaging was useful for the detection and prompt diagnosis of intestinal follicular lymphoma. The pathological features of intestinal follicular lymphoma are also discussed.

A survey of sedated gastrointestinal endoscopy / 中华消化内镜杂志

ObjectiveTo investigate the popularity of the sedated gastrointestinal endoscopy in mainland China.MethodsThe survey on the popularity of the sedated gastrointestinal endoscopy was conducted with questionnaires sent by e-mails or telephones to the GI endoscopy units of three levels of hospitals.ResultsFrom May,2010 to November,2010,169 units from 28 provinces (90.3％ ) were enrolled,including 46 hospitals of grade Ⅲ,91 of grade Ⅱ and 32 of grade Ⅰ.Sedated gastrointestinal endoscopy were performed in 110 (65.1％,110/169) hospitals,i.e.93.5％ (43/46) grade Ⅲ hospitals,68.1％(62/91) grade Ⅱ hospitals and 15.6％ (5/32) grade Ⅰ hospitals.Significant difference was observed between the grade Ⅲ and the grade Ⅱ hospitals (P ＜ 0.05 ),so was between the grade Ⅱ and the grade Ⅰ hospitals ( P ＜ 0.05 ).Propofol was frequently used in sedation in 98 hospitals ( 89.1％ ).The only 9.1％( 10/110)hospitals,which had full-time anesthetists or anesthetic nurses,were all grade Ⅲ hospitals.ConclusionThere has been great progress in the popularity of sedated gastrointestinal endoscopy in mainland China during the past decade.However,it is less frequently pefformed in grade Ⅰ and Ⅱ hospitals.Shortage of full-time anesthetists is still a problem.

Safety and efficacy of single balloon enteroscopy for small intestinal disorders / 中华消化内镜杂志

Objective To evaluate safety and clinical significance of single balloon enteroscopy (SBE) for small intestinal diseases. Methods Data of 83 patients with suspected or known small intestinal diseases, who underwent SBE from March 2009 to July 2010, were reviewed in terms of preparation time,procedure time, detection rate and complication occurrence. Results The 83 patients included 37 cases of digestive tract bleeding, 38 chronic abdominal pain, 1 chronic diarrhea, 2 fever and 5 incomplete ileus. A total of 94 procedures of SBE were performed, including oral route in 46 patients, anal route in 26 and both routes in 11. Excluding 6 cases with endoscopic therapy, the mean procedure time of oral approach was 29.6 ± 10. 3 min, and that of anal route was 57.1 ± 15.6 min. Abnormalities were detected in 57 ( 68.7% )of the 83 patients, with detection rate of 81.1% (30/37) in digestive tract bleeding with unknown reason,57. 8% (22/38) in chronic abdominal pain of unknown reason, 50. 0% (1/2) in fever of unknown reason and 80. 0% (4/5) in incomplete ileus. Peutz-Jeghers syndrome was diagnosed in 6 patients and endoscopic polypectomy was performed, with complicated bleeding in one patient. No other procedure-related complications were observed. Conclusion SBE is well-tolerated and safe for diagnosis of small intestine diseases,with easy manipulatiou, short procedure time, high detection rate and satisfactory location of intestinal hemorrhagic lesions.

Hybrid trans-gastric endoscopic and laparoscopic cholecystectomy in a porcine model / 中华消化内镜杂志

Objective To assess the safety and feasibility of hybrid trans-gastric endoscopic and laparoscopic cholecystectomy in a porcine model.Methods A total of 6 pigs underwent hybrid trans-gastric endoscopic and laparoscopic cholecystectomy from July to October,2010 under general anesthesia.The operation time and complications during the procedure were recorded,as well as post-operative changes of eating habits and weight.Animals underwent autopsies on post-operative days(POD)14 for evaluation of infection,abscesses and adhesion.Results All procedures were successfully performed and all dogs survived.There was no severe complication except for hemorrhage in one porcine,which was successfully managed under laparoscopy.The mean operation time was 87mins(ranging from 69-124 mins).After the operation,there was no change in eating habits or weight.At autopsy on POD 14,no abscess or hemorrhage was found.Sites of gastric closure were found to be completely healed.Conclusion The hybrid approach increases the safety of initial gastric puncture and gastric wall incision,simplifies peroral trans-gastric cholecystectomy,and decreases invasiveness of laparoscopic surgery.It is a bridge between laparoscopic and transluminal surgery.

Feasibility of endoscopic resection-closure for non-intraluminal gastric stromal tumors originating from the muscularis propria layer / 中华消化内镜杂志

Objective To evaluate the feasibility of endoscopic resection and closure for non-intraluminal gastric stromal tumors originating from the muscularis propria layer.Methods Included in the study were 46 patients with gastric submucosal lesions originating from the muscularis propria layer, detected by gastroscopy and endoscopic ultrasonography.The lesions were removed by endoscopic resection and closure, which were further diagnosed as stromal tumor by means of pathologic and immunohistochemical examinations.The patients were followed up with endoscopy for evaluation of therapeutic effect and complications.Results All lesions were successfully removed, with serosa layer remained in 2 cases and full layer resection in other 44, which were all closed by endoscopic clips.Combination managements of acid suppression,gastrointestinal decompression and intravenous antibiotics were applied in all patients.Pathology reports confirmed complete resection of all lesions, with 0.5 to 3.7 cm in diameter.Normal diet was restored in 44 patients 48 ～ 72 h after the procedure.Pneumoperitoneum and focal peritonitis occurred in 2 cases, one of which underwent rupture and was clamped again.The 2 patients recovered after 10-12 days of conservative treatments.Follow-up endoscopy revealed white ulcerous scar in all cases.Conclusion Endoscopic resection and closure therapy is a safe, economic and less invasive treatment for non-intraluminal gastric stromal tumors originating from the muscularis propria layer.