Efficacy of spray flushing in the reprocessing of flexible endoscopes

Abstract

This article comments on the article by Du et al, who conducted a randomized controlled trial aiming at evaluating the effectiveness of a novel spray flushing system in cleaning flexible endoscopes while minimizing damage to the working channels. We share our perspective on the importance of improving endoscope reprocessing methods. The findings highlight the spray flushing system's capacity to improve cleaning efficacy while minimizing damage, suggesting that it might be important in enhancing endoscope reprocessing procedures.

Key Words: Spray flushing; Endoscope; Flexible endoscope; Endoscopy; Endoscope cleaning; Endoscope reprocessing

Core Tip: We comment on a randomized controlled trial by Du et al, which evaluates the efficacy of a novel spray flushing system in the reprocessing of flexible endoscopes, demonstrating its potential to reduce damage to the working channels while maintaining cleaning quality. This editorial discusses the implications of these findings for endoscopic safety, the challenges involved with traditional cleaning approaches, and the potential cost benefits of employing spray flushing devices. Furthermore, we evaluate prospective future research fields and assess the broader impact of these developments on endoscope cleaning processes and patient well-being.

TO THE EDITOR

Endoscopic therapies are foundational approaches in modern gastroenterology, enabling precise, minimally invasive diagnosis and treatment for a wide range of gastrointestinal illnesses[1]. The success and safety of these procedures depend on thorough endoscope reprocessing to remove infection and prepare them for reuse. Historically, bristle brushes have been the preferred device for cleaning endoscopic working channels[2]. While effective, these brushes have certain drawbacks: They often cause scratches within the channels, which may serve as breeding grounds for germs and biofilms, endangering patient safety and endoscope longevity[3].

In their innovative study, Du et al[3] address this critical issue by developing a new spray flushing approach for reprocessing flexible endoscopes. Their randomized controlled research provides persuasive evidence that this unique technique not only matches the cleaning efficacy of traditional brushes but also significantly reduces mechanical damage to the endoscope's operational channels. This development holds promise not just for better cleaning outcomes but also for increasing endoscopic safety, lowering reprocessing costs, and extending the life of these critical instruments[3].

In this article, we look at Du et al's findings and place them within a larger framework of current difficulties in endoscope reprocessing[3]. We investigate the spray flushing system's potential to change present practices, the cost consequences of using such technology, and the critical need for ongoing research to improve endoscope reprocessing. By studying these obstacles, we want to demonstrate the greater impact that improved reprocessing may have on patient outcomes and overall treatment quality in gastroenterology.

Spray flushing in flexible endoscope reprocessing

We read with great interest an article entitled “Efficacy of spray flushing in the reprocessing of flexible endoscopes: A randomized controlled trial” by Du et al[3]. Reprocessing flexible endoscopes is an essential part of infection control in gastrointestinal surgeries. Traditional cleaning methods, particularly the use of bristle brushes, have long been the standard[4]. However, these brushes have been linked to issues such as channel deterioration and biofilm formation, which may jeopardize patient safety and the endoscopic equipment's lifespan[4,5]. The study by Du et al[3] presents a novel approach to addressing these difficulties by developing a spray flushing system.

Study findings and their significance

Du et al's study provides strong evidence that the spray flushing approach is more effective than ordinary cleaning brushes[3]. The randomized controlled trial included 60 endoscopes and Teflon tubes that were divided into control and experimental groups. The spray flushing method significantly reduced debris in working channels (46.7% vs 73.3% in the control group; P < 0.05) and produced less damage to Teflon tubes (median damage score of 4 in the experimental group vs. 4-5.25 in the control group; P < 0.01)[3].

These findings are significant because they show that the spray flushing approach may improve the cleaning performance of flexible endoscopes while minimizing damage to their operating channels[4,6]. This twofold benefit may result in longer-lasting endoscopes and a decreased risk of infection transmission, thereby improving patient safety and reducing healthcare costs[4].

The study also shows that the spray flushing technique is cost-effective[4]. Traditional bristle brushes, especially when used in accordance with guidelines that promote single-use to reduce cross-contamination, significantly increase reprocessing costs[6,7]. In contrast, the spray flushing system, which eliminates the need for bristle replacement, offers a more environmentally friendly and cost-effective option[4].

Potential improvements and further research

While the study of Du et al[3] shows a significant improvement in endoscope reprocessing, there are several areas where the spray flushing approach should be improved further. For example, the study found no significant difference in ATP levels between the control and experimental groups (32.5 relative light units vs 26 relative light units; P > 0.05), suggesting that, although the spray system is effective, it may not yet outperform traditional brushes in all areas of cleaning[4]. A real-world study found that even after automated endoscope reprocessor alcohol flush and air purge cycles and 10-minute forced-air drying cycles, fluid retention was still detected in endoscope channels, suggesting room for improvement in drying effectiveness[5]. A study by Benowitz et al[6] showed that flushing alone is inadequate to remove organisms attached to the interior of endoscopes, emphasizing the need for more effective cleaning methods that could be integrated with spray flushing technology. Moreover, a study on foam spray as an alternative for delayed reprocessing showed that foam spray could serve as a useful interim measure, suggesting that combining spraying flushing with foam applications may enhance overall reprocessing effectiveness[7]. Additionally, the Centers for Disease Control has recommended improving facility-level training and competency for reprocessing flexible endoscopes, which could be crucial in ensuring that new technologies like spray flushing are used effectively[6].

Further improvements to the spray system to increase its cleaning power may be proposed. Furthermore, the study's sample size was rather small, with 30 endoscopes in each group. Larger studies are necessary to confirm these findings over a wider range of endoscope models and clinical situations. It would also be beneficial to assess the long-term effect of using spray cleaning technology on endoscope durability and maintenance costs.

However, like with any new technology, transitioning to a spray flushing system requires careful consideration. Healthcare organizations will need to balance the initial costs of implementing this system against the long-term benefits. Furthermore, training and improvements in reprocessing processes will be required to ensure optimal use of the new technology.

Clinical implications and future directions

In practical practice, the spray flushing approach may affect endoscope reprocessing schedules. This technique may reduce the frequency of endoscope repairs and replacements by decreasing the risk of channel deterioration and biofilm formation, resulting in cost savings[4,7]. Furthermore, its ability to remove debris effectively without jeopardizing microbiological safety demonstrates its potential as a superior alternative to typical cleaning brushes[8].

To maximize the impact of this finding, additional research into its use in a variety of therapeutic settings is required. This includes evaluating its effectiveness in high-volume endoscopic facilities and ensuring compatibility with different types of endoscopes and cleaning agents. In flexible endoscope reprocessing, Table 1 compares the spray flushing approach to regular bristle brushes.

Table 1 Comparison of spray flushing system and traditional bristle brushes in flexible endoscope reprocessing.

Parameter	Spray flushing system	Traditional bristle brushes	P value
Number of endoscopes	30	30	NA
Reduction in debris	46.7%	73.3%	P < 0.05
Channel damage (median score)	4	4-5.25	P < 0.01
ATP levels (relative light units)	26	32.5	P > 0.05
Compatibility with Teflon tubes	Less damage observed	More damage observed	P < 0.01
Cleaning efficacy	Effective, with room for improvement	Effective, standard method	NA
Long-term durability	Potentially longer-lasting channels	Standard durability	Further research needed

NA: Not available.

CONCLUSION

The study by Du et al[3] is a good step forward in the effort to improve endoscope reprocessing. The spray flushing system they developed offers a viable solution to some of the core problems associated with traditional cleaning methods. With further research and development, this technology has the potential to set a new standard for endoscope cleaning, resulting in safer treatments and improved outcomes for patients worldwide.