Introduction
Esophagogastroduodenoscopy (EGD) is the routine method for investigating the upper
digestive system [1]
[2]
[3]. Small-caliber gastrointestinal endoscopes have been developed and marketed and
can be inserted transnasally [4]
[5]. Transnasal endoscopy is better tolerated, with high levels of patient comfort and
acceptability and can be safely performed [6]
[7]. However, there are several problems with small-caliber endoscopes. They have technical
difficulties due to greater flexibility but limited optical capabilities. Video image
resolution is inferior to conventional high-resolution endoscopes. Furthermore, image
quality may be impaired when secretions or bubbles are present, as a result of poorer
suction and lavage [8].
On the other hand, repair costs and maintenance of gastrointestinal endoscopy equipment
represent an important share of the total budget of the endoscopy unit. Gastrointestinal
endoscopes are damaged through routine wear and tear during procedures, as well as
use of aggressive cleaning and disinfection processes [9]. However, repair costs of small-caliber versus conventional endoscopes have never
been evaluated. This study evaluated repair costs of small-caliber and conventional
endoscopes in EGD.
Patients and methods
A retrospective analysis of upper gastrointestinal endoscope damage and repair costs
between April 2012 and May 2019 was performed at Toyoshima Endoscopy Clinic, an outpatient
clinic specializingd in endoscopy. This study was approved by the Ethical Review Committee
of the Hattori Clinic [10]. All clinical investigations were conducted according to the ethical guidelines
of the Declaration of Helsinki.
At the time of analysis, the following upper gastrointestinal endoscopes were in use:
Olympus GIF-H260, GIF-XP260N, GIF-HQ290, GIF-H290Z, and GIF-XP290N. Data on repair
costs were obtained from the archive of the invoices of gastrointestinal endoscope
repairs and were then compared to the invoice copies from the service company (Olympus,
Tokyo, Japan).
Endoscopic examination
EGD was used to evaluate patients with abdominal pain, gastrointestinal bleeding and
iron-deficiency anemia, and those who had undergone screening for cancer, polyps,
atrophic gastritis, and physical check-up. EGD was performed for diagnostic (observation
and biopsies), not for therapeutic purposes, such as polypectomy. Conventional endoscopes
(GIF-H260, GIF-HQ290, and GIF-H290Z) were used for transoral EGD. Before starting
, the pharynx of patients was topically anesthetized by gargling with 2 % lidocaine
hydrochloride viscous solution (Xylocaine Viscous 2 %, AstraZeneca Inc., Japan) [11]. Sedation with midazolam and/or pethidine was induced based on the patient’s willingness
[12]
[13]. Small-caliber endoscopes (GIF-XP260N and GIF-XP290N) were used for transnasal EGD
or transoral EGD. The nasal cavity was prepared by spraying three puffs of 0.05 %
naphazoline (Nippon Shinyaku Co., Ltd., Kyoto, Japan), followed by 1 mL of 4 % Xylocaine
delivered as a fine mist using a mucosal atomization device. Furthermore, 3 mL of
Xylocaine Viscous was injected into the nasal cavity. An endoscopic nurse assisted
with every procedure. Use of small-caliber endoscopes was based on patient preference
and better patient tolerability.
Cleaning and disinfection of endoscopes
High-level disinfection was achieved with an automated endoscope re-processor following
manufacturer’s instructions with strong acidic electrolyzed water (Kaigen pharma CO.,
LTD. Osaka, Japan). Both small-caliber and conventional endoscopes were sterilized
using an automated endoscope re-processor. All endoscopes were stored in endoscope
storage cabinets.
Statistical analysis
We compared incidence of damage and repair costs between small-caliber and conventional
endoscopes with use of a Student’s t-test or Welch's t-test or χ-squared test. P < 0.05 was considered statistically significant. Data were analyzed using the Stat
Mate IV software (ATOMS, Tokyo, Japan).
Results
During the study period, 32,223 EGD procedures were performed. Characteristics of
small-caliber and conventional endoscope groups are shown in [Table 1]. Three small-caliber endoscopes and five conventional endoscopes were used for 1,031
procedures and 31,192 procedures, respectively. Duration of use for small-caliber
and conventional endoscopes was 86 ± 61.5 months and 75.8 ± 42.7 months, respectively.
The number of procedures/damage incidence for small-caliber endoscopes and conventional
endoscopes was 344 and 1950, respectively. Damage incidence for small-caliber endoscopes
was significantly higher than that for conventional endoscopes (P = 0.014). Repair costs/procedure for the small-caliber and conventional endoscopes
were $ 5.95 ± $ 132 and $ 2.41 ± $ 115, respectively. Repair costs/procedure for the
small-caliber endoscopes were more than twice those for the conventional endoscope
(P = 0.396).
Table 1
Repair costs for upper gastrointestinal endoscopes.
|
Small-caliber endoscope
|
Conventional endoscope
|
P value
|
|
Procedures performed
|
1,031
|
31,192
|
–
|
|
Endoscopes
|
GIF-XP260N: 2
|
GIF-H260: 2
|
–
|
|
(number)
|
GIF-XP290N: 1
|
GIF-HQ290: 2
|
|
|
|
GIF-H290Z: 1
|
|
|
Duration of endoscope use
|
86 ± 61.5
|
75.8 ± 42.7
|
0.816
|
|
(mean month ± SD)
|
|
|
|
|
Incidents of damage
|
3
|
16
|
0.014
|
|
Procedures/damage incidence
|
344
|
1950
|
|
|
Total repair costs (dollars)
|
6137
|
75081
|
–
|
|
Repair costs/procedure
|
5.95 ± 132
|
2.41 ± 115
|
0.396
|
|
(mean dollar ± SD)
|
|
|
|
SD, standard deviation.
Types of endoscope damage are shown in [Table 2]. The most frequent type of damage was to the rubber coat on the distal bending section.
Table 2
Types of endoscope damage.
|
Endoscope damage
|
Small-caliber endoscope
|
Conventional endoscope
|
|
Occurrences
|
Average repair cost/damage (dollars)
|
Occurrences
|
Average repair cost/damage (dollars)
|
|
Damage to the rubber coat on the distal bending section
|
2
|
1356
|
5
|
2664
|
|
Damage to the scope connector
|
0
|
|
5
|
6492
|
|
Damage to the bending apparatus
|
1
|
3425
|
2
|
3660
|
|
Damage to the external sheath
|
0
|
|
1
|
4773
|
|
Ocular damage
|
0
|
|
1
|
5407
|
|
Water channel damage
|
0
|
|
1
|
5708
|
|
Suction channel damage
|
0
|
|
1
|
6093
|
Discussion
Small-caliber endoscopes had a higher frequency of repair than conventional endoscopes.
Repair costs for small-caliber endoscopes could be twice that of conventional endoscopes.
To the best of our knowledge, this is the first report about repair costs for small-caliber
gastrointestinal endoscopes. Fragility and higher repair costs might have an impact
on the management strategy of an endoscopy unit, such as the decision about purchase
of small-caliber versus conventional endoscopes.
Repair costs/procedures for small-caliber and conventional endoscopes were $ 5.95 ± $ 132
and $ 2.41 ± $ 115, respectively. Repair costs for gastrointestinal endoscopes account
for a significant proportion of the total budget of an endoscopy unit. The doctors
and staff who handle endoscopes should recognize the expensive repair costs and avoid
rough handling.
Damage to the rubber coat on the distal bending section was the most frequent type
of damage. Extreme bending during endoscopic procedures puts the distal bending section
under great mechanical stress, predisposing it to wear and tear [14]. Wear and tear damages occur not only during procedures but also during cleaning
and maintenance. Because small-caliber endoscopes are thin, they break easily.
This study had some limitations. First, it was a retrospective review at a single
institution. Second, patients were not randomized to either the thin endoscope group
or conventional endoscope group; thus, there were background differences.
Conclusion
In conclusion, small-caliber endoscopes are more fragile than conventional endoscopes.
