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World Gastroenterology Organisation

Global Guardian of Digestive Health. Serving the World.

 

Endoscopy Accessory Reuse: Balancing Cost-Effectiveness with Patient Safety

Vol. 30, Issue 4 (December 2025)

Nazish Butt, MBBS, FCPSNazish Butt, MBBS, FCPS
Associate Professor of Gastroenterology
Head of Gastroenterology Department
Jinnah Postgraduate Medical Centre
Karachi, Pakistan
 

Mathew Philip, MD, DMMathew Philip, MD, DM
Senior Consultant, Department of Gastroenterology
Lisie Hospital
Kochi, India

 

Muhammad Ali Khan, MBBS, FCPSMuhammad Ali Khan, MBBS, FCPS
Consultant Gastroenterologist
Sindh Government Hospital, Liaquatabad
Karachi, Pakistan


 

Introduction

Early endoscopy, with its practical implications of diagnosis and therapeutic intervention, was first introduced in the 1950s, parallel to advances in fiber-optic technology. Since then, its use has become a shared practice in healthcare setups all over the world. Modern-day endoscopes, with further refinements in technology, can achieve a multitude of tasks, including but not limited to taking biopsies, stopping bleeding, visually identifying dysplasia and metaplasia, dilatation and stenting, and endoscopic ultrasound (EUS)- guided removal of foreign bodies.1-3

In the procedures mentioned above, the endoscope itself is a facilitator to the said intervention, and most of the work must be carried out by other instruments, termed accessories, which are introduced through the endoscope via different modes and channels. Some of the most used accessories are biopsy forceps, snare forceps, grasping forceps, clipping devices, retrieval baskets, hemostatic clips, sprays and injector needles, dilatation balloons, catheters, bite blocks, EUS needles, and guidewires. The complete list of these accessories is vast, representing the various procedures that are now performed via the endoscope.4

Endoscopy accessories are state-of-the-art, high-precision, and procedure-specific tools that require great cost and care to maintain and manufacture. As such, the question of their single-use (disposable) versus reusable is inevitable. Factors such as cost, effectiveness, contamination risk, reprocessing challenges, and environmental impact and sustainability, along with local national healthcare policies, influence the eventual decision to utilize a reusable variant or otherwise.5 Here, we explore the major issues that affect this choice.

Cost-Effectiveness

The single most important issue that determines the decision between single-use versus reusable accessories is cost. Socialized healthcare setups have limited funding, which correlates directly to the availability and dissemination of endoscopic services. The unavoidable use of endoscopic accessories only adds to the burden; therefore, the impact on non-socialized healthcare systems is greater. A change to a more costly approach can result in denied access to therapeutic/diagnostic procedure(s).

Intuitively, one would assume that reusable accessories cost less in the long run, but one must also consider the cost of disinfection and maintenance with reusable tools that are all but insignificant with single-use accessories. In a comprehensive systematic review done by Zanganah M et al., most of the economic analyses favored the use of reusable endoscopic accessories over single-use ones.5 All studies were conducted using data from the US, Europe, and South Korea, considering maintenance and disinfection costs. Results published by Deprez PH et al. and Rizzo J et al. also found that reusable tools cost only a fraction of the disposable accessories.6, 7 The variety of reusable tools analyzed was limited, with forceps being the primary focus.

Similar observations were reported by Yang R et al.; however, they found reusable forceps more cost-effective after only twenty procedures.8 A threshold of a certain number of methods for reusable(s) to be more cost-effective than disposable(s) was also reported by Muscarella, LF, and Fireman, Z.9, 10 Cartwright JA et al. found that reusable biopsy forceps were more cost-effective after ten uses.11 In general, it appears that reusable accessories are as cost-effective as disposable ones, and after a certain number of uses, they become the more ergonomic option.

Developing nations, including Pakistan, face uphill economic challenges. While most healthcare institutions are socialized and run by the government, they are not necessarily well-funded. Endoscopic facilities are usually limited to endoscopic examinations only; diagnostic or therapeutic interventions, such as biopsy or banding, require arrangement by the patient or their family. The financial onus, therefore, is on the patient and may not always be fulfilled. The choice, in this matter, therefore, is a simple one. Reusing accessories not only redistributes the cost to multiple patients, rather than just one, but the overall expenditure on the endoscopy suite can be substantially reduced.6, 7 On the other hand, single-use accessories are more expensive. Still, they would require a greater expenditure on the part of every patient per procedure, essentially limiting or denying access to most of the patients in such places.

Currently, most, if not all, reliable data comparing the cost-effectiveness of single-use versus reusable endoscopic accessories is from first-world countries and represents a significant area of future research for the developing world.

Environmental Impact and Sustainability

Carbon footprint is defined as the total amount of greenhouse gases emitted directly and indirectly by the actions of humans. The field of upper GI endoscopy is associated with a significantly higher carbon footprint comparatively; the high carbon footprint is attributed to a large amount of non-renewable waste (mostly organic) produced per procedure, coupled with a high number of interventions
requiring the use of accessories and extensive reprocessing and decontamination processes.12 Therefore, it is pivotal for third-world countries to balance environmental concerns with the cost to the patient and the endoscopy suite, all while enabling patients to make an informed choice between reusable and single-use articles. This could be facilitated by implementing recycling policies that start at the endoscopy suites and extends to the entire healthcare setup. Furthermore, region-specific research could be conducted to minimize the carbon footprint of endoscopy suites; this will require tailor-made amendments, as individual nations are impacted differently. Industry-led initiatives to develop environmentally friendly devices and accessories that are easier to dispose of, while maintaining safety packaging standards, should be encouraged. However, as most endoscopic equipment is made in a few specific locations, this entails a global effort rather than a regional one.

Reusable and reprocessed medical or surgical instruments generally provide better environmental outcomes compared to single-use instruments; life cycle assessments have demonstrated that reusable accessories reduce waste production and overall carbon footprint compared to single-use tools.13-17 There is no reason to believe that endoscopic accessories wouldn’t follow the same pattern. Multiple studies have demonstrated that while single-use accessories may provide incremental health benefits to the public, this comes at a grave environmental cost.18 Pioche M et al. reported that using single-use accessories would increase the carbon foot print by 2.5 times compared to reusable accessories; Namburar S et al. reported that using single-use accessories cause a quadruple increase in net waste production.19, 20 Similarly, a detailed review by Nabi Z et al. found that reusable instruments are more cost-effective and universally have a less detrimental effect on the environment across different facets of GI endoscopy21; the main cons of reusable tools was cross-infection, while for single-use tools it was a greater carbon foot print.

Moreover, changes in endoscopic practices can reduce waste production. Strict protocols for selection of patients undergoing upper GI endoscopy will eliminate a large number of unnecessary procedures;
adherence to surveillance guidelines, e.g. avoiding endoscopy in young patients with dyspepsia and without alarm features, cirrhotics with low risk of varices, screening colonoscopies in low risk or high risk debilitated cases, and identifying conditions not requiring surveillance endoscopies all encompass this endeavor. Minimizing sampling and combining procedures where possible will also help. In this respect, using single-use instruments for patients suffering from immune-compromise or multidrug resistant organisms is more viable economically and environmentally.

Regions more negatively affected by climate change include parts of Southeast Asia, South Asia, Sub-Saharan States, the Middle East, and Latin America; as of 2022 Pakistan was the nation most adversely affected by climate change along with Belize and Italy.22 The areas mentioned above lack adaptive capacity with a high population density that is economically dependent on climate sensitive sectors mostly due to their geographical location. In such places, opting for environmentally friendly reusable instruments over single-use tools is not only the smart choice, but perhaps the only realistic way forward.

Risk of Cross-Infection

The data on cross-contamination in single-versus multiple-use accessories is limited, and a definitive choice cannot yet be made alone on this parameter; the shift to either is not yet evidence-based. Concerns have been previously raised about ineffective reprocessing and decontamination of reusable accessories, but no definitive correlation has been proved and the point remains debatable; position statements by the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) did not find evidence of higher cross-infection rates with reusable accessories.23 Heeg et al. reported that single-use devices were not adequately disinfected compared to reusable ones; reusable devices were disinfected effectively, but the challenge of microorganisms’ cross-infection could not be overcome entirely in either of the two types of accessories.24 Similarly, Hambrick D 3rd and Favero MS. reported that reusable devices did not carry excessive rates of cross-contamination.25, 26

The guidelines for the reprocessing and disinfection of reusable endoscopic accessories are relatively precise and immaculate. Following these can be arduous for resource-scarce countries and therein lies the biggest problem with respect to reusing accessories. Disinfection protocols are costly and time-consuming, if even relatively less than that for single-use accessories. These, therefore, can be overlooked, be it because of the large demand of endoscopies necessitating reduced sterilization times, ineffectual disinfection practices of washing and cleaning, substandard sterilization fluids,
etc. As with previous factors discussed here, data we have is largely from developed nations, ergo it is hard to draw conclusions in this matter. Anecdotal knowledge would suggest that cross-contamination due to reusable upper GI endoscopic accessories is rare, and its clinical impact trifling.

Procedural Efficacy and Functionality

The available literature on efficacy and functionality of reusable endoscopic accessories is quite decisive. Analyzing over 1,500 endoscopic procedures, Kozarek RA et al. found reusable biopsy forceps to be 94-99% efficacious, with only 0.6% suffering from non-functionality/being broken; it was reported that the biopsy forceps can be effectively used for a mean of 91 procedures.27 The mechanical
problems reported in this study were minor and had no significant implications.27 Separately, again Kozarek RA et al. and Cohen J et al. showed akin results for papillotomes and retrieval baskets used in ERCP; there were no complications or shortcomings reported with reuse of papillotomes and retrieval baskets, the median combined use of these two accessories was 11 & 9 uses, respectively, in each analysis.28, 29 Prat F et al. encountered similar outcomes during ERCPs, with a much larger sample size.30 All records mentioned in this paragraph also reported effective sterilization and decontamination of reusable accessories.

As reusable accessories do not suffer from malfunction even after multiple uses, they represent an excellent pathway for burdened healthcare systems to reduce and redistribute costs, all while maintaining international standards of diagnosis and therapy. The fact that reusable accessories have optimal effectiveness up to ten or more procedures, whereby patient care will not be compromised, effectively reserves judgment in their favor over other shortcomings, if any.

The Balancing Act and the Future

As a gastroenterologist and physician in a developing nation, the top priority must be for patients to have easy access to endoscopic facilities. In this era of climate change and economic hardships, a delicate balancing act needs to occur. This will require careful evaluation of all factors above. Realistically, what an endoscopist can and cannot offer will be limited to their specific situation and local policies. Patient education can further help patients understand their role in improving the overall situation without compromising their safety. After reviewing options, a case-by-case discussion can be held between the physician and the patient. On a personal level, as mentioned before, the endoscopist can be more selective about their cases, increase procedure yields when using accessories, follow guidelines, and carry out research in this respect, as data from third-world countries is grossly lacking.

As we advance, the criteria for reuse of endoscopic GI accessories need to be objectively defined, considering the cost, environmental impact, burden to the patient and the healthcare system, rates of infection and cross-contamination, long-term functionality and efficacy of each accessory, and the ability of the patients to make an informed choice. This task at hand seems formidable and must be taken by all parties concerned together, but its benefits will be far-reaching and beneficial to all.

References

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