Green Endoscopy in Resource-Limited Settings: Lessons from a Tertiary Care Center in Pakistan

Vol. 31, Issue 3 (September 2026)

Asma Asghar, FCPS (Med), FCPS (Gastro), FRCP (Edin), FRCPI, ESEGH (UK)
Consultant, Medicine and Gastroenterology
Combined Military Hospital, Peshawar
Peshawar, Pakistan

 

Introduction

The environmental impact of medical practice is rapidly being appreciated by health care systems around the world. Endoscopy units face the burden of procedures that require numerous accessories and equipment in addition to specialized skills. As a result, a significant amount of waste, including disposable accessories, disinfectants, containers, and packaging materials, is generated.

High-income countries where the principle of single use has long been practiced vigorously are now considering the importance of green endoscopy and turning to look for measures to reduce waste output. Meanwhile, low and middle-income countries that face significant financial constraints are already re-using many accessories due to non-affordability. Though their efforts are unintentional, they align with principles of environmental sustainability.

Our endoscopy unit in a tertiary care hospital in Pakistan is an example of how we can contribute to environmentally sound endoscopy by meticulous resource utilization, safe reuse of accessories, and efficient workflow.

The Environmental Impact of Endoscopy

Endoscopic accessories are utilized in procedures in high-income countries on a single use basis. These include biopsy forceps, snares, injection needles, sphincterotomes, guide wire, biliary stone extraction balloons, and CRE balloons. This is meant to prevent cross-infection and contamination. Studies from developed countries suggest that almost 0.5 to 2kg of waste is produced as a result of each procedure.^{1, 2} On the other hand, countries and set ups with resource limitation have adopted strategies to reuse certain accessories after sterilization in view of financial issues and high cost of accessories. In our setup, we are reusing biopsy forceps, snares, sphincterotomes, needle knives, guide wires, and biliary stone extraction balloons. This cuts down overall cost incurred on procurement and allows us to accommodate more procedures while also reducing the waste generated.³

Endoscopic Practice in Resource-Limited Settings

Our endoscopy unit is an example of a resource-limited setup with moderate to high volume of procedures. Our unit performs diagnostic as well as therapeutic procedures, including upper gastrointestinal endoscopies, colonoscopies, and endoscopic retrograde cholangiopancreatography. Due to financial constraints, practices are tailored to maintain essential services while curtailing the cost of accessories use. This ultimately leads to a decline in waste generation, which has both an economic and environmental benefit.

Reprocessing and Safe Use of Accessories

Selected accessories are reused after proper processing and disinfection. All accessories intended to be reused are subjected to manual brushing, flushing followed by high level sterilization, and disinfection according to institution guidelines. All accessories intended to be used again are visually inspected prior to procedure for possible damage and fitness for reuse.

Strict adherence to infection control measures ensures patient safety, readmission with infection, and limits unnecessary disposal of accessories and waste generation. In our practical experience, reuse of accessories after proper disinfection can cut down the cost of procurement by one-third.

Efficient Use of Endoscopic Supplies

It is critically important to plan a procedure ahead and exactly assess what accessories and instruments are likely to be used. Accessories should only be opened just prior to their use. Use of multipurpose devices is preferred. For example, instead of using fixed-diameter biliary stone extraction balloon during ERCP, use of variable-diameter balloon can cut down the cost and environmental impact significantly. Similarly, during endoscopy for haemostasis in upper GI bleeding, using an injector-snare combo is preferable to using the snare and injector separately.

Staff Awareness and Training

All members of an endoscopy unit should be well-aware of the importance of sustainable endoscopic practice. They must be trained in disinfection and sterilization of equipment and accessories. In our endoscopy unit, training sessions are regularly conducted for team members in reprocessing techniques, responsible use of accessories, and waste disposal.^{4, 5}

Waste Segregation

Volume of medical waste is also affected by efficient segregation of waste according to its nature. Clear labelling of waste as general, infectious, or recyclable not only facilitates efficient waste management but also reduces environmental impact.⁵

Conclusion

Endoscopy is an extremely important procedure not only for the diagnosis and evaluation of many gastrointestinal issues but also for the treatment of a wide array of gastrointestinal, hepatobiliary, and pancreatic disorders. At the same time, it leads to the generation of huge amounts of waste with significant environmental impact. These accessories are quite costly and put financial burden on healthcare system as well. Making strategies for efficient and safe reuse of accessories can lead to economic benefit.

Experience from resource-limited settings demonstrate that economic and environmental benefit can be achieved through practical measures like controlled reuse of accessories, efficient workflow, staff training, and proper waste segregation. Such endoscopy units may be unintentionally practicing the most sustainable form of healthcare and offering valuable lessons for global movement toward environmentally responsible endoscopy.

References

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2. Singh N, Ogunseitan OA, Tang Y. Medical waste: Current challenges andfuture opportunities for sustainable management. Crit Rev Environ Sci Technol 2022;52:2000–22.
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5. de Latour R, Crockett SD, Palchaudhuri S, Skole KS, Agrawal D, Hernandez LV, von Renteln D, Shimpi RA, Collins J, Pohl H. Practical steps to green your endoscopy unit: appropriate management of endoscopic waste. Gastrointestinal endoscopy. 2025 Apr;101(4):745-50.