The environmental impact of small-bowel capsule endoscopy

Abstract

Introduction The environmental impact of endoscopy, including small-bowel capsule endoscopy (SBCE), is a topic of growing attention and concern. This study aimed to evaluate the greenhouse gas (GHG) emissions (kgCO₂) generated by an SBCE procedure.

Methods Life cycle assessment methodology (ISO 14040) was used to evaluate three brands of SBCE device and included emissions generated by patient travel, bowel preparation, capsule examination, and video recording. A survey of 87 physicians and 120 patients was conducted to obtain data on travel, activities undertaken during the procedure, and awareness of environmental impacts.

Results The capsule itself (4 g) accounted for < 6 % of the total product weight. Packaging (43–119 g) accounted for 9 %–97 % of total weight, and included deactivation magnets (5 g [4 %–6 %]) and paper instructions (11–50 g [up to 40 %]). A full SBCE procedure generated approximately 20 kgCO₂, with 0.04 kgCO₂ (0.2 %) attributable to the capsule itself and 18 kgCO₂ (94.7 %) generated by patient travel. Capsule retrieval using a dedicated device would add 0.98 kgCO₂ to the carbon footprint. Capsule deconstruction revealed materials (e. g. neodymium) that are prohibited from environmental disposal; 76 % of patients were not aware of the illegal nature of capsule disposal via wastewater, and 63 % would have been willing to retrieve it. The carbon impact of data storage and capsule reading was negligible.

Conclusion The carbon footprint of SBCE is mainly determined by patient travel. The capsule device itself has a relatively low carbon footprint. Given that disposal of capsule components via wastewater is illegal, retrieval of the capsule is necessary but would likely be associated with an increase in device-related emissions.

Introduction

The environmental impact of endoscopy cannot be neglected [1] [2] [3] [4]. Recent assessments have ranked gastrointestinal (GI) endoscopy as the third highest department for the generation of hazardous healthcare waste [5]. The environmental impact of GI endoscopy has led the European Society of Gastrointestinal Endoscopy (ESGE) to establish sustainable endoscopy practices as a major objective within our field [6]. Although the environmental impact of some endoscopic procedures has already been assessed, there is methodologic heterogeneity across the published studies, which also lack a standardized “cradle-to-grave” approach to carbon footprint reporting [3] [7] [8] [9].

Despite this increasing interest in sustainability, the environmental impact of small-bowel capsule endoscopy (SBCE) has not been explored. Approximately 24 000 SBCE procedures are performed each year in France; a number that is steadily increasing over time [10]; however, only a small proportion of these capsules are retrieved by patients after the procedure. The issue of capsule disposal prompted us to conduct an eco-audit specifically targeting SBCE. Our aim was to evaluate the net greenhouse gas (GHG) emission profile of an SBCE procedure, calculated in kg of carbon dioxide equivalents (kgCO₂). Secondarily, we aimed to assess the contribution of the individual SBCE components to overall GHG emissions and the potential benefits of capsule retrieval and recycling.

Methods

Study design and ethical considerations

Our prospective evaluation study had two phases.

• An eco-audit to quantify the environmental emissions related to single-use products and drugs involved in an SBCE examination.

• A survey of patients and physicians to evaluate:

  • the travel, resources, and waste involved in the SCBE procedure and reading of the capsule data

  • patients’ opinions on climate change and capsule disposal.

The patients and physicians who participated in the survey gave their written informed consent for the study after clear information had been given.

Eco-audit

Aims and scope

From November 2022 to February 2023, an eco-audit was performed following the method proposed by Ashby et al. [11] [12] [13] to quantify environmental emissions related to single-use products and drugs, based on the ISO 14040:2006–3-5 framework.

The primary aim of the study was to estimate the net GHG emissions generated by an SBCE examination ([Fig. 1]), including the capsule and its packaging (manufacturing, transport, use, and disposal), patient travel, and bowel preparation.

Fig. 1 Diagram of the Life Cycle Assessment of a small-bowel capsule endoscopy examination (the term “drug” corresponds to bowel preparation medication).
^a For example kWh, km, kg quantity (materials).
^b For example Granta CES EduPack for Eco Design [13].
^c Calculated as kg of carbon dioxide equivalents.

The secondary aims were to:

• understand the relative contributions made to overall GHG emissions by the variety of materials and processes

• examine the potential benefits of capsule retrieval and recycling

• assess associations between patient characteristics and ecologic concern, transport choices, and knowledge of waste management

• determine the relative contribution to the carbon footprint from service provision factors

• determine the potential additional impacts of adding outpatient clinics surrounding the capsule procedure.

Data inventory and assumptions

To evaluate the carbon footprint of SBCE, the procedural steps from the arrival of the products to their archiving and destruction (end-of-life) were considered as illustrated in [Fig. 1].

Three different brands of endoscopic capsule device were assessed: PillCam SB3 (Medtronic, California, USA), CapsoCam (CapsoVision, California, USA), and NaviCam capsule (AnX Robotica, Texas, USA). All three capsules were dismantled and assessed to determine the weight and material composition of individual components. Detailed product information was found either on labels or through extensive searches to obtain descriptions of the devices (e. g. by referring to CE-marking). In some cases, differential scanning calorimetry, X-ray, and microscopic analysis were performed to identify material components. Whenever materials were not disclosed in the CES EduPack 2022 database (a database on materials), manufacturers were contacted to obtain material information. Transport data pertaining to the manufacturing location and mode of shipment were provided by the manufacturers.

The functional unit of the study was chosen as a single SBCE procedure. The system studied was delimited (system boundary) and included all the steps required for an SBCE procedure, including materials and travel. Energy for the building functioning was excluded from the analysis.

Data were prospectively collected on each device from November 2022 to March 2023 by two medical staff (M.P. and R.G.). The carbon footprint analysis of materials, packaging, and drugs was performed by an independent team of scientists (P-J.C., M.-Q.L.) from the Laboratoire de Génie Électrique et Ferroélectricité (LGEF) Research Laboratory. GHG emissions were expressed as kgCO₂ and water consumption was expressed in liters. The total impact is the sum of each inventory data point multiplied by its specific emission factor: total impact = Σ(inventory data point × emission factor), as presented in [Fig. 1].

For bowel preparation, 1 L of polyethylene glycol with ascorbic acid (PEG-ASC) bowel preparation (Moviprep; Norgine, France) was administered before the procedure, according to each institution’s current protocol. Patient travel, and video data recording and storage were also considered. Data on mode and distance of patient travel were obtained from a patient survey. Water required for toilet flushing during the bowel preparation and the capsule journey was not included in the evaluation.

Patient and physician surveys

Two cross-sectional patient surveys were conducted between November 2022 and June 2023 (patient survey) and between January and February 2024 (physician survey), following an adapted version of the Consensus-Based Checklist for Reporting Of Survey Studies (CROSS) guideline [14].

The two surveys were developed by three members of the French Society of Digestive Endoscopy (SFED) capsule study group. The patient survey was reviewed by three independent physicians from the capsule study subgroup and two nurses at the involved centers, was pilot tested on five patients, and was approved by all participating sites.

All consecutive adult patients referred for oral ingestion of a capsule endoscope in six high volume French centers (> 200 capsules/year) were invited to complete the anonymous survey following their SBCE examination. Participating centers were those from the SFED capsule group. Physicians involved in the analysis were blinded to the patient identity.

The physician survey was sent to the mailing list of the SFED and through the Society’s Facebook page. Only physicians working in France and actively involved in reading capsule endoscopies were included in the analysis.

Survey domains

Patient survey The survey domains included patient demographics, patients’ concerns regarding climate change, the mode of travel and distance to the hospital for their SBCE, and the generation of waste on the day of the procedure. The survey also asked patients whether they attended an outpatient clinic before the capsule procedure and, if so, what mode of transportation and travel distance was required for this consultation. Patients were also asked if they were aware that disposal of the capsule via wastewater is illegal and whether they would have been willing to recover the capsule from their stool.

Physicians The survey included physician demographics, their mode of travel and distance to the hospital, and the time, resources, and waste involved in capsule reading.

Statistical analysis

Eco-audit

Our study adapted life cycle assessment (LCA) methodology to the hospital setting [15] ([Fig. 1]). An LCA estimates the potential environmental impacts of a product, process, or service over its entire life cycle, from raw material extraction, to use, and end-of-life.

The various constituent materials of each product (including packaging, overwrapping, and cardboard clamping device) necessary for an SBCE procedure were analyzed taking into account its life cycle (i. e. the impact of its production, transport, and disposal). The materials were weighed using an electronic precision balance (Precision Balance XPR204S; Mettler Toledo, Greifensee, Switzerland). Information regarding the primary materials, manufacturing location, design process, transportation method, usage cycle, and disposal process were determined either via the product’s labelling or by accessing the technical information included in the CE marking, when available. When no information was available, an external team of scientists and engineers from the LGEF at the National Institute of Science and Technology of Lyon (INSA Lyon) conducted a material composition analysis with differential scanning calorimetry, X-ray, and microscopic analysis. Manufacturers could be contacted to confirm or clarify the material composition or origin. The LCA was then carried out to estimate the carbon footprint and water resource depletion attributable to each component using Granta Design software (Ansys, San Diego, California, USA) and following the ISO 14040 and 14044 standards [16].

The CES EduPack 2022 database was used to specify emissions by material type [17] and the evaluation was done by independent engineers specialized in material analysis and environmental impact. The quantification of GHGs was calculated using the Global Warming Potential over a 100-year period (GWP-100), and expressed in kgCO₂. For patient transport, the mean travel distance was determined by the survey responses, but we did not ascertain which type of car was used. Therefore, we used a mean emission factor of 0.2 kgCO₂/km according to the mean impact of a fossil fuel car in France evaluated by the French national agency of the ecologic transition (ADEME) [18]. The GHG emissions attributable to the use of public transportation was considered negligible in this study compared with individual fossil fuel car transport.

To estimate data storage requirements, we determined the average file size of 10 consecutive capsule videos performed with the Medtronic PillCam device, which we considered a representative sample. We then calculated the GHG emissions generated by two simulated scenarios: data storage on a computer and on the cloud. For 1-year storage on the cloud, we used an average GHG emission of 0.001–0.03 kgCO₂/GB [19].

The findings from published LCAs were used to estimate the potential emission benefit to be expected from the retrieval and recycling of different components of the capsule, magnets, and packaging [20] [21]. The potential for capsule recycling was assessed as part of the National Campaign for Magnet and Capsule Box Collection; a campaign initiated during the French national congress and promoted through an endoscopy Facebook training page (HEH endoscopie). We examined the number of boxes and magnets collected and evaluated the potential benefits of a simulated recycling process on the components that could be recycled with a dedicated process. A sensitivity analysis was performed applying a range around the base case estimates to understand the effect of assumptions.

Patient survey

For the purposes of this evaluation, we considered a sample size of 100 consecutive patients to provide representative information and sufficient precision for patient travel data. Previous data to create a precise hypothesis for sample size calculation were not available on this topic (mean distance to the center, type of transport for such examination, ecologic concern and waste knowledge of the patients) and therefore a precise sample calculation was not possible. The survey document was given to patients by the nurse in charge of capsule delivery, who also explained what information was required, and then retrieved the completed survey when patients returned the capsule recorder. Data on the clinical management of the patient following capsule examination were not collected.

Statistical analysis was conducted to assess the associations between selected demographic variables (age, sex), size of the city in which the reporting institution is based, and other variables from the survey results. Descriptive statistics are described as absolute number and relative frequencies (%) for categorical variables. Continuous variables are summarized as mean (SD) or median with interquartile range (IQR). Ecologic-related outcomes were tested using the chi-squared, Fisher, or Cochran–Armitage tests. Data analysis was performed by an independent statistician (F.S.) using R software version 4.0.2 (R Foundation for Statistical Computing, Vienna, Austria; www.r-project.org).

Results

Overall GHG emission

The carbon footprint of an SBCE examination was similar across all three devices; PillCam 19.4 kgCO₂, CapsoCam 20.6 kgCO₂, and NaviCam 19.5 kgCO₂. An additional pre-procedural medical consultation, performed in 42 % of cases, added 3.9 kgCO₂ to the carbon footprint (per patient). Assuming a similar proportion of consultations are conducted after the procedure, the overall carbon footprints including consultations surrounding the procedure were 27.2 kgCO₂ for PillCam, 28.4 kgCO₂ for CapsoCam, and 27.3 kgCO₂ for NaviCam. The main results of the study are summarized in [Fig. 2] and [Fig. 3].

Fig. 2 Main results of the patient survey. kgCO₂, kg of carbon dioxide equivalents.

Fig. 3 Main results of the study. kgCO₂, kg of carbon dioxide equivalents.

Weight and GHG emissions of capsule components and packaging

The capsule itself generated 0.04 kgCO₂ for all three brands and accounted for only 0.2 % of the entire impact of the capsule endoscopy procedure ([Table 1]). When packaging was considered, GHG emissions were to 0.25 kgCO₂ (PillCam), 0.35 kgCO₂ (CapsoCam), and 0.15 kgCO₂ (NaviCam). All three brands include a 5-g neodymium magnet in the box to keep the capsule inactive, which is associated with GHG emissions of 0.14 kgCO₂. CapsoCam requires that patients retrieve the capsule using the CapsoRetriever device in order to then download the video; this retrieval device carries an additional impact of 0.98 kgCO₂.

Table 1 Weight and carbon footprint of the different components of the three capsule devices plus bowel preparation with PEG-ASC.

	PillCam		CapsoCam		NaviCam		Average capsule
	Weight, g	Carbon emissions, kgCO2	Weight, g	Carbon emissions, kgCO2	Weight, g	Carbon emissions, kgCO2	Weight, g	Carbon emissions, kgCO2
Capsule components
Packaging	74	0.25	119	0.35	43	0.15	78	0.25
Cardboard	0		28		16
Polymer	46		33		11
Aluminum	0		3		0
Instruction leaflet	23*		50		11
Deactivation magnet	5	0.14	5	0.14	5	0.14
Capsule	4	0.04	4	0.04	4	0.04	4	0.04
Plastic cap	0.7		0.7		0.8
Electronics (PCB)	1.3		1.3		1.3
Button cell battery (SR927)	2.1		2.1		2.1
Retrieval device	NA		255	0.98	NA
Plastic (PETG)			250	0.84
Magnet			5	0.14
Recycling		−0.16		−0.20		−0.13	NA	−0.16
Magnet		−0.06		−0.06		−0.06
Packaging		−0.09		−0.13		−0.06
Capsule		−0.01		−0.01		−0.01
Device transport**	NA	0.36	NA	0.50	NA	0.58	NA	0.48
Bowel preparation (PEG-ASC)	123	0.28	123	0.28	123	0.28	123	0.28
Total
One capsule procedure	78	0.93	125	1.14	47	1.05	83	1.04
If retrieval device used	NA		378	2.12	NA
If capsule is recycled							NA	0.88
Patient transport
To receive capsule		18.4		18.4		18.4		18.4
For pre-procedure consultation		3.9		3.9		3.9		3.9
For post-procedure consultation***		3.9		3.9		3.9		3.9
Physician transport		0.1		0.1		0.1		0.1
Data recording and storage		0.0		0.0		0.0		0.0
Total per capsule journey
Without recycling		27.2		28.5		27.3		27.9
With recycling		27.0		28.3		19.3		27.7

GHG, greenhouse gas; PEG-ASC, polyethylene glycol, acid ascorbic; PCB, polychlorobiphenyls; PETG, polyethylene terephthalate glycol.

* One instruction leaflet for 10 capsule boxes in a larger box.

** From manufacturing to the endoscopy unit.

*** The survey evaluated the pre-procedure consultations, but we hypothesized a similar rate of post-procedure consultations.

Device transportation

GHG emissions generated from the shipping of a capsule from the site of manufacture to the endoscopy unit ranged from 0.36 kgCO₂ (PillCam) to 0.58 kgCO₂ (NaviCam), and depended on the distance and mode of shipping.

Bowel preparation

The bowel preparation using a 1-L PEG-ASC (123 g of powder in water) generated 0.28 kgCO₂.

Video storage impact

The average storage size of a capsule recording was 514 MB (SD 253; range 190–1096 MB). Storage of recordings on a web cloud platform would result in a GHG emission ranging from 0.006 to 0.030 kgCO₂ per year. If the recordings were stored on a computer used for other purposes, the GHG emission for storing one capsule movie would be similarly low.

Recycling assessment

An analysis was carried out to assess the potential carbon emissions savings from capsule recycling. No recycling process currently exists for these capsules and therefore this evaluation was necessarily simulated, based on the potential recycling of the capsule’s main components. To do so, the three subcomponents making up the devices were analyzed: batteries, electronic board, and plastic polymer casing. The emissions associated with each scenario were extrapolated from data available in the literature concerning the recycling of each identified subcomponent [22].

If the magnet was recycled [20], a reduction of 0.06 kgCO₂ (45 %) could be achieved, although the recycling process of the packaging could reduce its impact by 37 % on average [21]. If all the packaging components were recycled, it would lead to emissions reductions of 0.09 kgCO₂ (PillCam), 0.13 kgCO₂ (CapsoCam), and 0.06 kgCO₂ (NaviCam). For the 24 000 capsule endoscopies performed every year in France, and assuming the three brands were to be used in the same proportions, magnet and capsule recycling would lead, respectively, to emissions reductions of 1854 kgCO₂ (corresponding to 8427 km driven on a fossil fuel-powered car) and 2251 kgCO₂ (corresponding to 10 232 km driven on a fossil fuel-powered car).

Patient survey on the capsule journey

A total of 120 patients (mean [SD] age, 58.6 [16.3] years; 54.2 % women) from six different centers, including five university hospitals in Paris (n = 19), Lyon (n = 66), Limoges (n = 10), Rennes (n = 2), and Nancy (n = 5), and one private hospital in Nimes (n = 18) participated in the survey during the study period. In 94.8 % of cases, the patients expressed high (31.0 %) or very high (63.8 %) levels of environmental concern. There was no significant association between environmental concern and age or sex.

Most patients travelled to the hospital by car, with 50.4 % using their private vehicle and 23.5 % using a taxi ([Fig. 2]). The proportions using fossil fuel-powered cars were significantly higher in small cities (< 1 million inhabitants) than in large cities (> 1 million) at 94 % and 65 %, respectively (P = 0.002, adjusted on age).

During the day, 50.8 % of patients returned home and made a second round-trip to the hospital to return the equipment. On average, each patient travelled 92.3 km by car during the entire capsule endoscopy procedure, generating average GHG emissions of 18.4 kgCO₂. On the day of the capsule examination, 26.3 % of patients reported producing additional waste, primarily when staying at the hospital or taking a trip to the city center while waiting for the procedure to be completed. The level of waste generation had no significant association with age, sex, or the type of city.

Regarding waste management, 75.6 % of patients stated that they were not aware that flushing the capsule down the toilet was considered improper waste disposal, and 62.7 % expressed their willingness to retrieve the capsule from their stool, if requested. There was no significant association between willingness to retrieve the capsule and age, sex, or type of city (large vs. small).

Outpatient clinic consultations

In total, 42 % of the patients had an outpatient clinic appointment at the hospital before the capsule examination, corresponding to a global additional impact of 3.9 kgCO₂ per patient in the study. If a similar proportion of patients attend a second outpatient clinic to receive the results of the examination (and use the same mode of transportation), the carbon footprint of associated medical consultations would increase to 7.8 kgCO₂.

Physician survey

A total of 87 physicians who were regularly reading capsule movies completed the survey. They travelled a mean of 22.3 km to work (round trip from home), but with no GHG emissions for 39 % of respondents (bike/walk), although 56 % travelled by car (fossil fuel 36 %; hybrid 13 %; electric 8 %) and 5 % by public transport. The mean number of kilometers in fossil fuel or hybrid cars was 14 km/physician. The mean reading time was 27.5 minutes (range 10–60), representing 3.3 % (0.1 %–100 %) of the working day. Therefore, per capsule, 0.1 kgCO₂ was generated from physician travel to the center for capsule reading.

Capsule reading was performed on a dedicated computer in a dedicated room (median size 15 m² [range 5–45]) in 29 % of cases, on a dedicated computer in a multi-use room (34 %), or on the physician’s usual computer (36 %). During each capsule reading session, the physician read an average of 1.8 capsules (range 1–4) and only 10 % of physicians also received capsule movies to review from other centers. Physicians reported producing waste during capsule reading in only 4 % of cases (drinking a coffee or tea in a disposable cup, with 15 % drinking a coffee or tea in a reusable cup).

At present, the capsule boxes and magnets are retrieved via an organized process in only 29 % of cases.

Magnet collection campaign

We successfully collected a total of 459 capsule boxes containing magnets, and 464 individual magnets were retrieved from their boxes ([Fig. 3]). These boxes will be returned to the manufacturer to be submitted into a recycling process.

Discussion

This study is the first LCA of SBCE supported by a patient survey to assess overall periprocedural impact.

When one considers the whole capsule procedure, patient travel contributes most significantly to GHG emissions, accounting for almost 95 % of the total. This contribution is even greater if we also include consultations surrounding the procedure, to which half of the patients travelled by fossil fuel-powered cars. This French picture should be analyzed with caution as GHG contributions from travel could be different in other countries where public transportation is more developed, with less use of fossil fuel cars, or in centers with a higher proportion of local patients. Nevertheless, if we want to significantly reduce the impact of this procedure, we need to look at reducing the impact of patient travel, either by encouraging more environmentally friendly means of transport to reach the hospital, or by developing alternative solutions such as relocating the procedure to the patient's home. The latter could be achieved by selecting digitally savvy patients, sending the device and recorder to the patient's home via a "green" shipping service, and providing them with virtual assistance from healthcare staff to carry out the examination. This “at-home” capsule endoscopy service was recently evaluated in a preliminary study in which patients could send the recorder back to the hospital or to a download platform, so that the physician could access the video [23].

The size of the video stored in the cloud does not increase the overall impact of the procedure compared with its storage on a dedicated computer in the unit. The physician travel to the hospital does not increase the impact because almost all capsule readers dedicated only 3 % of their workday to reading a single capsule study.

The eco-audit revealed that the capsule procedure itself (device and bowel preparation) has a relatively low GHG emission (~1 kgCO₂; 5 % of the total) and is comparable among the three evaluated brands. With regard to the device, waste mainly comes from packaging, particularly the instruction leaflet. A larger box with multiple devices and a single instruction leaflet might help to overcome this burden and reduce overall paper and cardboard waste. Recycling the packaging in the endoscopy unit could reduce GHG emissions by a third and should therefore be more widely adopted.

While only representing a small contribution in terms of weight and GHG emissions, the magnet used to deactivate the capsule is made of pure neodymium; a rare earth mineral that is difficult to extract, but easy to recycle. This magnet is enclosed in a plastic box, meaning that it avoids contact with either the patient or the nurse, making recycling possible without the need for reprocessing. Although French law does not allow such reprocessing of medical devices, the clean magnet could be placed into another box; this would reduce the carbon footprint of the magnet by 45 %. Recently, one capsule provider (Omom capsule, Asept-In-Med, Quint Fonsagrives, France) has organized a reprocessing cycle: the boxes are collected by the company and sent to Asia for reprocessing in countries in which it is permitted.

The other troublesome element is the capsule itself, which contains electronic circuits, light-emitting diodes, and silver oxide batteries. Even though their carbon impact is small in the context of the overall procedure, it is strictly forbidden to dispose of these batteries into the environment [24]. CapsoCam devices require capsule retrieval in order to download the images from the examination; however, the device proposed by the company is made of 250 g of additional plastic and a 5-g neodymium magnet, which doubles the carbon impact of the procedure itself and the retrieval rate is not 100 % [25] [26] [27]. Simpler and less carbon intensive (possibly reusable) recovery devices are therefore necessary to prevent the electronic device from being flushed down the toilet. The decision to use a retrieval device, which carries an increased carbon impact, in order to reduce the burial of illegal waste should be debated within the sustainability commissions of our scientific societies.

Manufacturers should also innovate to increase the biodegradability of capsule components, because capsules are flushed and subsequently buried with wastewater sludge.

The French Collect scheme was successful, with more than 800 magnets collected (including one half in their original box), and it does not appear to represent a cumbersome task for staff to undertake. We have tried to initiate a partnership with Medtronic to start recycling the recovered magnets but, in the long run, a discussion with manufacturers should be initiated to establish a sustainable virtuous recycling process.

The limitations of our study include the fact that it was a limited sample size survey, which was mainly conducted in large cities with university hospitals. We also did not precisely measure the actual distance of patient travel undertaken during the whole procedural journey. In fact, the inclusion in the study of hospitals in large cities with high rates of public transport use may have underestimated the national picture with regard to car use. Waste production was not formally quantified by weight, nor was it compared with normal daily waste production. Another limitation is the respective market share of the three brands commercially available in France; PillCam has a > 90 % share, which allows this manufacturer to provide larger shipments with only one user instruction leaflet for 10 small capsule boxes, reducing the weight of packaging per procedure.

In conclusion, the GHG emissions of capsule endoscopy are largely determined by patient travel; the capsule device itself contributes far less than expected. Given that disposal of capsule components via wastewater is illegal, recovery of the capsule seems crucial, but current retrieval devices generate three times more kgCO₂ than the capsule itself. Further discussion involving manufacturers is required in order to implement proper waste management and recycling of capsule endoscopy components.

Conflict of Interest

M. Pioche is a consultant for Olympus and a trainer for Olympus, Pentax, Norgine, Boston, and Cook. X. Dray is co-founder and a shareholder of Augmented Endoscopy; he provides consultancy for Norgine and Provepharma, and lectures and demonstrations for Alfasigma, Bouchara Recordati, Fujifilm, Medtronic, Norgine, and Sandoz. E. Rodriguez de Santiago has had educational and advisory roles for Olympus, educational roles at Apollo Endosurgery and Norgine, and has received conference fees from Norgine and Casen.

J.A. Cunha Neves, H. Pohl, M.-Q. Lê, R.Grau, C. Yzet, M. Mochet, J. Jacques, T. Wallenhorst, J. Rivory, N. Siret, A.-L. Peillet, J.-B. Chevaux, F. Mion, U. Chaput, P. Jacob, D. Grinberg, J.-C. Saurin, R. Baddeley, and P.-J. Cottinet declare that they have no conflict of interest.

• References

• 1 Pioche M, Lambin T, Rivory J. Let’s urgently engage ourselves in “greening” endoscopy to address ecological issues!. Endosc Int Open 2021; 9: E1752-E1753
• 2 Leddin D, Omary MB, Veitch A. et al. Uniting the global gastroenterology community to meet the challenge of climate change and non-recyclable waste. Gastroenterology 2021; 161: 1354-1360
• 3 Siau K, Hayee B, Gayam S. Endoscopy’s current carbon footprint. Tech Innov Gastrointest Endosc 2021; 23: 344-352
• 4 Maurice JB, Siau K, Sebastian S. et al. Green endoscopy: a call for sustainability in the midst of COVID-19. Lancet Gastroenterol Hepatol 2020; 5: 636-638
• 5 Vaccari M, Tudor T, Perteghella A. Costs associated with the management of waste from healthcare facilities: An analysis at national and site level. Waste Manag Res 2018; 36: 39-47
• 6 Rodríguez de Santiago E, Dinis-Ribeiro M, Pohl H. et al. Reducing the environmental footprint of gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement. Endoscopy 2022; 54: 797-826
• 7 Lacroute J, Marcantoni J, Petitot S. et al. The carbon footprint of ambulatory gastrointestinal endoscopy. Endoscopy 2023; 55: 918-926
• 8 Yzet C, Figueiredo M, Michoud C. et al. Ecological impact of endoscopic dilatation using the bougie cap device: a low-tech innovation to reduce waste by 99. Endoscopy 2022; 54: E824-E825
• 9 Namburar S, von Renteln D, Damianos J. et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut 2022; 71: 1326-1331
• 10 Dray X, Buzzi J, Quentin V. et al. Small bowel capsule endoscopy and deep enteroscopy procedure load in France: a nationwide population-based study over 7 years. Endosc Int Open 2023; 11: E1013-E1019
• 11 Ashby M. Materials and the Environment: Eco-informed Material Choice. 2nd edn. Oxford: Elsevier; 2012
• 12 Ashby M. The energy-fingerprints of products. Cambridge: Granta Design Ltd; 2012
• 13 Ashby M, Miller A, Rutter F. et al. CES EduPack for Eco Design – A White Paper. Cambridge: Granta Design Ltd; 2012
• 14 Sharma A, Minh Duc NT, Luu Lam Thang T. et al. A consensus-based checklist for reporting of survey studies (CROSS). J Gen Intern Med 2021; 36: 3179-3187
• 15 Ditac G, Cottinet P-J, Quyen LeM. et al. Carbon footprint of atrial fibrillation catheter ablation. EP Europace 2023; 25: 331-340
• 16 Grinberg D, Buzzi R, Pozzi M. et al. Eco-audit of conventional heart surgery procedures. Eur J Cardiothorac Surg 2021; 60: 1325-1331
• 17 Materials Database Highlighted Workshop. ASM International Medical Materials Database highlighted at FDA Biodegradable Metals Workshop. 2012 Available from (Accessed 9 May 2024): https://www.todaysmedicaldevelopments.com/news/asm-materials-database-031612/
• 18 Accueil | Impact CO₂ . Available from (Accessed 9 May 2024): https://impactco2.fr
• 19 Charret G, Arnaud A, Berthoud F. et al. Estimation de l’empreinte carbone du stockage de données. French National Center for Scientific Research [CNRS] –GRICAD. 2020 Available from (Accessed 9 May 2024): https://cnrs.hal.science/hal-03573790
• 20 Jin H, Afiuny P, McIntyre T. et al. Comparative life cycle assessment of NDFEB magnets: virgin production versus magnet-to-magnet recycling. Procedia CIRP 2016; 48: 45-50
• 21 Hillman K, Damgaard A, Eriksson O. et al. Climate benefits of material recycling : inventory of average greenhouse gas emissions for Denmark, Norway and Sweden. Copenhagen: Nordisk Ministerråd; 2015
• 22 Deubzer O. Reduction of hazardous materials in electrical and electronic equipment. Goodship V, Stevels A, Huisman J. Waste Electrical and Electronic Equipment (WEEE) Handbook. 2nd edn. Woodhead Publishing; 2019: 207-230
• 23 Parisi I, Badat S, El-Husseiny MH. et al. P149 Evaluation of the at-home capsule endoscopy (ACE) service at UCLH: preliminary findings. Gut 2022; 71: A113-A113
• 24 EUR-Lex: EU Law and Publications. Disposal of spent batteries. Available from (Accessed 9 May 2024): https://eur-lex.europa.eu/FR/legal-content/summary/disposal-of-spent-batteries.html
• 25 Enns C, Galorport C, Ou G. et al. Assessment of capsule endoscopy utilizing Capsocam Plus in patients with suspected small bowel disease including pilot study with remote access patients during pandemic. J Can Assoc Gastroenterol 2021; 4: 269-273
• 26 Zwinger LL, Siegmund B, Stroux A. et al. CapsoCam SV-1 versus PillCam SB 3 in the detection of obscure gastrointestinal bleeding: results of a prospective randomized comparative multicenter study. J Clin Gastroenterol 2019; 53: e101-e106
• 27 Pioche M, Vanbervliet G, Jacob P. et al. Prospective randomized comparison between axial- and lateral-viewing capsule endoscopy systems in patients with obscure digestive bleeding. Endoscopy 2014; 46: 479-484

Publikationsverlauf

Eingereicht: 14. November 2023

Angenommen nach Revision: 24. April 2024

Accepted Manuscript online:
24. April 2024

Artikel online veröffentlicht:
18. Juni 2024