Endoscopes are an indispensable instrument for modern medicine that gives an edge to doctors by providing them with a very clear picture of the inner mechanisms of the human body, in detail. This article covers the world of endoscopes with various aspects from types of endoscopes and usage cases to important issues in maintenance, cleaning methods, and disinfection.
Looking at the world of endoscopes, one is likely to find that it is very diverse as it has many different but unique medical diagnoses and treatment areas. Taking this into account, here goes a list of different types of endoscopes and their indications:
- Encephaloscope: This is specially devised to use in the brain for locating cavities and defects in this most important organ.
- Laryngoscope: An instrument for specifically studying the larynx, where the vocal cords are located in the neck.
- Esophagoscope: A paramount device to view the mucous membrane of the esophagus which detects abnormalities and problems.
- Thoracoscope: This is an excellent diagnostic equipment used in the pleural cavity with an intercostal space which aids in detecting chest and lung conditions.
- Angioscope: It has a narrow fiber scope for literally viewing the blood vessels as it really requires. Vascular diseases are diagnosed through this.
- Nephroscope: It is used mainly to evaluate the kidneys, allowing diagnosis of kidney problems.
- Colonoscope: A very important instrument for examining the lower part of the bowel, used to determine colorectal problems.
- Proctoscope: Rectal troubles are supposed through this developed instrument, and it is necessary sometimes for making quick diagnoses and proper treatment.
- Arthroscope: This type of endoscope enables the visualization of the internal structures of joints, which has been indispensable in orthopedic surgeries, especially for the treatment of knee issues.
- Rhinoscope: Precisely designed for nasal examination, which is essential in the treatment of sinus and nasal diseases.
- Bronchoscope: Applied for the inside visualization of the bronchi, which is important in the treatment of respiratory diseases.
- Mediastinoscope: Used for visualization of the mediastinum, which comprises internal organs and tissues that separate the lungs in the chest cavity.
- Gastroscope: Essential for the visualization of the stomach, this is very important in gastroenterology.
- Laparoscope: Generally used by surgeons to look into the peritoneal cavity during minimally invasive surgeries.
- Amnioscope: It is very important during the cervical canal examination to avoid injury to the fetal membrane during childbirth.
- Cystoscope: It is somewhat similar to the design of the arthroscopies. It is used to examine the urinary tract, and it is much longer for a deep examination.
- Hysteroscope: It is designed especially for examining the canal of the cervical uterine cervix and uterine cavity for gynecological diagnosis.
Every one of the 17 different types of endoscopes is uniquely suited for one specific task and therefore, a medical practitioner will always have the correct tool for the situation. Of course, there may be more specialized endoscopes appropriate for a certain medical procedure or condition, the sky is the limit.
Endoscope equipment needs maintenance because it is in direct contact with the human body. Major maintenance procedures are
Before the next patient procedure, the endoscope equipment needs to be cleaned and sterilized including proper handling, cleaning, and sterilizing.
Semi-annual preventive maintenance is done by a service engineer or application specialist which includes:
- Proper Handling: Use gloves when handling endoscope equipment; avoid contamination contact with eyepiece lens or objective lens.
- Light source and monitor maintenance:
- Monitor light source hours of operation and bulb replacement after 500 hours.
- Use Alcohol wipes in order to clean the exterior part of the equipment.
- Use Screen Prep in order to improve image display.
- Check light source intensity and measure and clean it.
- Endoscope or Camera System Maintenance:
- Connect the endoscope to the light source so that the displayed image will be checked.
- Clean camera lens and endoscope body.
- Check image quality and white balance test.
- Insufflator Maintenance:
- Surface portion of insufflator, check cables, and tubing.
- Clean and inspect circuit boards.
- Test the insufflator for proper operation.
Note: Swabs and wipes from Chemtronics cannot be reused because they are made of one-time-use disposable material.
Manual cleaning is of great importance, being the most important step toward cleaning and disinfecting an endoscope. Good following of the steps during this manual cleaning ensures maximum removal of up to 99.99% of all the bacteria, which protects the patient as well as the medical practitioner. This is why manual cleaning is important. Here’s why manual cleaning is indispensable:
Biofilm protection: Bacteria protect themselves with the formation of a biofilm that acts as a protective layer. During the cleaning and disinfecting process, the bacteria are protected from all the chemical agents in the process that are designed to kill it. This allows them to remain in the endoscope, thus transferring of the endoscope bacteria to other patients.
Rapid Bacterial Replication: Bacteria like E. coli can reproduce rapidly, and each bacterial cell may take about 20 minutes to produce. For instance, 1000 E. coli can duplicate eight times to 8000 E. coli after just an hour. Hence, the initiation of manual cleaning should be fast to avoid bacterial proliferation.
Very Critical to Patient Safety: Re-processing of flexible endoscopes is critical to patient safety from infection.
No Margin of Error: Re-processing of endoscopes is such a complicated process involving above 50 to 100 steps and there is no margin for error if the purpose of infection prevention in patients is to be achieved.
Biofilm Removal: One of the major challenges in the reprocessing of endoscopes is biofilm, which is difficult to remove once formed. Biofilm can protect bacteria from chemical disinfectants, making bedside cleaning and manual cleaning an immediate requirement.
Automated Reprocessors: Studies indicate that high-level disinfection in the use of automated endoscope reprocessors (AERs) alone is not efficient enough in removing contaminants without the proper bedside and manual cleaning.
Technique for Manual Cleaning: Manual cleaning of a flexible endoscope is normally done in the immersing of the cleaner. Immersing all brushing done in the channel in the endoscope and its components is a must.
AERs and Manual Cleaning: Some of the AERs have a manual cleaning option, but the FDA strongly discourages reprocessing technicians from referring to the AER for manual cleaning because the AER is for high-level disinfection of duodenoscopes only.
Challenges of Manual Cleaning: Due to the intricate channels as well as the elevator mechanism, duodenoscopes are very difficult to clean. Manual reprocessing steps put reprocessing technicians at an increased risk of respiratory complications and physical discomfort.
Effective Bio burden Destruction: Manual washing of flexible endoscopes is essential since it can destroy up to 99 percent of bio burden from flexible endoscopes, providing a guarantee for the next patient’s safety and cleanliness.
In a nutshell, manual cleaning of flexible endoscopes is an essential step in reprocessing for the sake of patient safety by effectively destroying contaminants, including biofilm, and preventing cross-contamination. The step is time-consuming but necessary for the whole reprocessing.
Endoscope reprocessing is a major concern in patient safety and infection control. Due to the risk of bio burden drying and even the possibility of forming biofilms on the surface of the items, the maximum time an endoscope can sit before cleaning is an important consideration. The highlights of the maximum time allowed to sit for an endoscope before cleaning are as follows:
We require a maximum dwell time between the precleaning of the endoscope at the bedside after a procedure and the start of leak testing and manual cleaning. This maximum time limit is set at 60 minutes.
If the endoscope sits waiting for manual cleaning for more than 60 minutes, a delayed reprocessing or presoaking protocol to guarantee the effectiveness of the reprocessing protocol must be done.
This 60-minute time limit does not only depend on the inputs from the FDA but also on the process of reprocessing instruction validation and scientific knowledge regarding biofilm formation are some of the factors that affect the 60-minute time limit.
As per the guidance from the FDA, medical device manufacturers are mandated to validate their device cleaning processes using worst-case scenario testing. This involves simulating the longest estimated time that a device would realistically actually be left uncleaned from completion of one procedure up to start when it is unclean after another 60-minute limit.
The aim then becomes preventing bioburden on an endoscope dry and cures as this can make for less effective cleaning while maybe also helping in forming biofilm.
In cases where an endoscope is used during a procedure and then set aside for possible reuse later in the same procedure, the 60-minute timer for cleaning should start as soon as the endoscope insertion tube is removed from the patient, exposing it to external air.
Precleaning should always take place immediately after the endoscope is removed from the patient, using fresh potable water or sterile water to prevent drying.
Periodic regular wiping with a clean, lint-free cloth or sponge that is dampened as well as flushing of each channel individually should be done using water.
In short, the guideline times recommended by the manufacturer in reprocessing must be followed lest bioburden dries out and cleaning and disinfection will not be effective in inhibiting possible transmission of infection to patients.
Manual cleaning of endoscopes is very meticulous because this ensures its safe use for medical procedures. And so, here are the steps on how you can do manual cleaning from start until finish:
- Squeeze and wipe the insertion tube with a water-soaked cloth.
- Aspirate water, and then air through the suction channel.
- Fitting a cleaning adapter for the AW channel, flush water, then air, through air/water channels.
- Flush water, then air, into the elevator-wire channel/auxiliary-water channel. Alternatively, the auxiliary water channel may be flushed using the OFP pump. The auxiliary water tube should remain attached during transport to the reprocessing room.
- Disconnect all detachable parts.
- Attach a water-resistant cap (except for 190 endoscopes).
- Transport the endoscope to the reprocessing room in a covered container.
- Check for water drops in the ETO valve and the MB-155.
- Loosen the auxiliary water tube and connect the leakage tester.
- Turn on the air source and watch for bending section expansion.
- Completely rinse the entire endoscope in a distilled clean water bath.
- Do a leakage test and angulate the tip during the test.
- Remove the endoscope from the water bath.
- Turn off the air source and detach the leakage tester from the air source.
- Allow the bending section covering to shrink to its pre-expansion size.
- Detach the leakage tester from the endoscope.
- Completely immerse the endoscope in a detergent solution.
- Clean all exterior surfaces especially the air/water nozzle opening and the objective lens at the distal end.
- Raise and lower the forceps elevator while brushing.
- Brush the elevator recess and also the back of the forceps elevator in detergent.
- Lower and raise the forceps elevator in the detergent solution.
- Insert the brush into the suction cylinder and instrument channel port, rotating the brush.
- Aspirate the detergent solution while lifting and lowering the elevator.
- Brush a single-use soft brush across the front face of the forceps elevator and elevator recess.
- Flush with the detergent solution the forceps elevator recess.
- Repeat until no debris is seen.
- Connect channel plug to injection tube.
- Flush with detergent solution the channel.
- Wipe tubular fluid parts on outer surfaces with a cloth wet with detergent solution.
- Rinse the endoscope and all parts; lift and lower the forceps elevator.
- Brush the auxiliary water channel with a soft brush.
- Flush the auxiliary water channel with clean water.
- Disconnect all parts and rinse them with clean water.
- Thoroughly flush air/water nozzle.
- Remove the water-resistant cover and rinse the air/water channel with water.
- Dry all components after ascertaining that they are dry.
- Hang the endoscope vertically such that both the channels face downwards.
- Let it dry using natural means for a minimum of 30 minutes or per the manufacturer’s recommendations.
- Place the endoscope in a designated place or place inside a cabinet to avoid contamination.
The above-detailed manual cleaning mechanism ensures that the endoscope is cleaned of contaminants, debris, and biofilm, thus protecting the lives of the patients during medical procedures.
An endoscope should be thoroughly disinfected. A detailed procedure must be used. Pressure and leak tests must follow every use of the endoscope. Each component and yet fully dismantled part of an endoscope may require complete immersion in an enzymatic detergent after each use.
All parts including valves, channels, connectors as well as detachable components or equipment must be adequately cleaned with a compatible detergent. Properly clean or discard disposable brushes. Discard enzymes once each is used.
FDA-approved high-level disinfectant should be used adhering to FDA-approved label claims for exposure time together with temperature requirements. The endoscope has to be immersed in full along with its compatible liquid medium. Perform manual cleaning otherwise, if other methods are found to be ineffective before the use of an Automated Endoscope Reprocessor (AER), and when it is needed to follow the manufacturer’s directions. Rinse the endoscope with sterile or filtered water; flush channels with a similar fluid. Flush with alcohol; dry using forced air. Store as per manufacturers’ directions. Sterilize the water bottle and its connecting tube daily by utilizing sterile water. Regularly test disinfectant Minimum Effective Concentration (MEC) for keeping it at MEC level. Avoid top-off solution and disinfectant disposal
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Endoscopes are indispensable nowadays in medicine in general, enabling physicians to diagnose and treat many types of pathologies with high accuracy and low invasiveness. The care and maintenance of these scopes besides the cleaning and disinfection of them are very important factors for endoscope safety and efficacy. Following cleaning protocols in terms of cleaning time as well as manual material cleaning properly is very important to avoid infections and cross-contamination.