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

Abstract

Climate change and the destruction of ecosystems by human activities are among the greatest challenges of the 21st century and require urgent action. Health care activities significantly contribute to the emission of greenhouse gases and waste production, with gastrointestinal (GI) endoscopy being one of the largest contributors. This Position Statement aims to raise awareness of the ecological footprint of GI endoscopy and provides guidance to reduce its environmental impact. The European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) outline suggestions and recommendations for health care providers, patients, governments, and industry. Main statements 1 GI endoscopy is a resource-intensive activity with a significant yet poorly assessed environmental impact. 2 ESGE-ESGENA recommend adopting immediate actions to reduce the environmental impact of GI endoscopy. 3 ESGE-ESGENA recommend adherence to guidelines and implementation of audit strategies on the appropriateness of GI endoscopy to avoid the environmental impact of unnecessary procedures. 4 ESGE-ESGENA recommend the embedding of reduce, reuse, and recycle programs in the GI endoscopy unit. 5 ESGE-ESGENA suggest that there is an urgent need to reassess and reduce the environmental and economic impact of single-use GI endoscopic devices. 6 ESGE-ESGENA suggest against routine use of single-use GI endoscopes. However, their use could be considered in highly selected patients on a case-by-case basis. 7 ESGE-ESGENA recommend inclusion of sustainability in the training curricula of GI endoscopy and as a quality domain. 8 ESGE-ESGENA recommend conducting high quality research to quantify and minimize the environmental impact of GI endoscopy. 9 ESGE-ESGENA recommend that GI endoscopy companies assess, disclose, and audit the environmental impact of their value chain. 10 ESGE-ESGENA recommend that GI endoscopy should become a net-zero greenhouse gas emissions practice by 2050.

^* Joint first authors

Publication History

Article published online:
08 July 2022

• References

• 1 National Aeronautics and Space Administration. Global Climate Change. Vital signs of the planet. https://climate.nasa.gov/
• 2 Masson-Delmotte V, Zhai P, Pirani A. IPCC. et al. Climate change 2021: The physical science basis. Working Group I contribution to the Sixth Assessment Report of the Intergovernmental Panel on Climate Change. Intergovernmental Panel on Climate Change 2021. https://www.ipcc.ch/sr15/chapter/spm/
• 3 Centers for Disease Control and Prevention (CDC). Preparing for the regional health impacts of climate change in the United States 2020. https://www.cdc.gov/climateandhealth/docs/Health_Impacts_Climate_Change-508_final.pdf
• 4 van Daalen K, Füssel HM, Kazmierczak A. et al. Responding to the health risks of climate change in Europe. March 2021. Lancet Countdown on Health and Climate Change and the European Environment Agency. https://www.dropbox.com/s/2dib9sjaz9xxszb/Responding%20to%20the%20health%20risks%20of%20climate%20change%20in%20Europe.pdf?dl=0
• 5 Lenzen M, Malik A, Li M. et al. The environmental footprint of health care: a global assessment. Lancet Planet Health 2020; 4: e271-e279 . DOI: 10.1016/S2542-5196(20)30121-2.
• 6 Siau K, Hayee B, Gayam S. Endoscopy’s current carbon footprint. Techn Innov Gastrointest Endosc 2021; 23: 344-352 . DOI: 10.1016/j.tige.2021.06.005.
• 7 Hassan C, Ponchon T, Bisschops R. et al. European Society of Gastrointestinal Endoscopy (ESGE) Publications Policy – Update 2020. Endoscopy 2020; 52: 123-126 . DOI: 10.1055/a-1067-4657.
• 8 Bahraini A. Waste4Change Supports 3R (Reduce-Reuse-Recycle) Green Concept! Waste4Change 2019.. Accessed: 24 Jan 2022 at: https://waste4change.com/blog/waste4change-supports-3r-reduce-reuse-recycle-green-concept
• 9 Carbon Trust. Carbon footprinting guide. Accessed: 26 Jan 2022 at: https://www.carbontrust.com/resources/carbon-footprinting-guide
• 10 European Parliament. News. 2 Dec 2015. Circular economy: definition, importance and benefits. Accessed: 24 Jan 2022 at: https://www.europarl.europa.eu/news/en/headlines/economy/20151201STO05603/circular-economy-definition-importance-and-benefits
• 11 Intergovernmental Panel on Climate Change (IPCC). Global warming of 1.5 °C. Glossary. Accessed: 24 Jan 2022 at: https://www.ipcc.ch/sr15/chapter/glossary
• 12 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 . DOI: 10.1016/S2468-1253(20)30157-6.
• 13 Centre for Sustainable Healthcare (CSH) Networks. Green Endoscopy. Accessed: 25 Jan 2022 at: https://networks.sustainablehealthcare.org.uk/network/green-endoscopy
• 14 Greenhouse Gas Protocol. About us. Accessed: 12 Mar 2022 at: https://ghgprotocol.org/about-us
• 15 Arup and Health Care Without Harm. Healthcare’s climate footprint. Accessed: 26 Jan 2022 at: https://www.arup.com/en/perspectives/publications/research/section/healthcares-climate-footprint
• 16 Mortimer F, Isherwood J, Wilkinson A. et al. Sustainability in quality improvement: redefining value. Future Healthc J 2018; 5: 88-93 . DOI: 10.7861/futurehosp.5-2-88.
• 17 Rasheed FN, Baddley J, Prabhakaran P. et al. Decarbonising healthcare in low and middle income countries: potential pathways to net zero emissions. BMJ 2021; 375: n1284 . DOI: 10.1136/bmj.n1284.
• 18 Eckelman MJ, Huang K, Lagasse R. et al. Health care pollution and public health damage in the United States: An update. Health Aff (Millwood) 2020; 39: 2071-2079
• 19 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 . DOI: 10.1177/0734242X17739968.
• 20 European Commission. Environment. Integrated Product Policy. European Platform on Life Cycle Assessment. Accessed: 26 Jan 2022 at: https://ec.europa.eu/environment/ipp/lca.htm
• 21 Gayam S. Environmental impact of endoscopy: “Scope” of the problem. Am J Gastroenterol 2020; 115: 1931-1932 . DOI: 10.14309/ajg.0000000000001005.
• 22 Namburar S, von Renteln D, Damianos J. et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut 2021; DOI: 10.1136/gutjnl-2021-324729.
• 23 Gordon IO, Sherman JD, Leapman M. et al. Life cycle greenhouse gas emissions of gastrointestinal biopsies in a surgical pathology laboratory. Am J Clin Pathol 2021; 156: 540-549 . DOI: 10.1093/ajcp/aqab021.
• 24 Hernandez LV, Le NNT, Patnode C. et al. Comparing the impact of reusable and single-use duodenoscopes using life cycle assessment. Gastrointest Endosc 2021; 93: AB29 . DOI: 10.1016/j.gie.2021.03.123.
• 25 Olympus Medical Systems. Accessed: 22 Jan 2022 at: https://www.olympus-europa.com/medical/en/Home/
• 26 Fujifilm Endoscopy. Accessed: 22 Jan 2022 at: https://www.fujifilm-endoscopy.com/products
• 27 Williams D. Essential biomaterials science. Cambridge: Cambridge University Press; 2014
• 28 Goldis A, Goldis R, Chirila TV. Biomaterials in gastroenterology: A critical overview. Medicina (Kaunas) 2019; 55: E734 . DOI: 10.3390/medicina55110734.
• 29 Ministry of Environment of Denmark Environmental Protection Agency. Fact sheet: PVC and phthalates. Accessed: 02 Mar 2022 at: https://eng.mst.dk/chemicals/chemicals-in-products/legal-framework-for-managing-chemicals/fact-sheets/fact-sheet-pvc-and-phthalates/
• 30 Regulation (EU) 2017/745 of the European Parliament and of the Council on medical devices, amending Directive 2001/83/EC, Regulation (EC) No 178/2002 and Regulation (EC) No 1223/2009 and repealing Council Directives 90/385/EEC and 93/42/EEC. Regulations 2017. Official Journal of the European Union. https://eur-lex.europa.eu/legal-content/EN/TXT/PDF/?uri=CELEX:32017R0745
• 31 Early DS, Ben-Menachem T. et al. ASGE Standards of Practice Committee. Appropriate use of GI endoscopy. Gastrointest Endosc 2012; 75: 1127-1131 . DOI: 10.1016/j.gie.2012.01.011.
• 32 Rodríguez-de-Santiago E, Frazzoni L, Fuccio L. et al. Digestive findings that do not require endoscopic surveillance – Reducing the burden of care: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2020; 52: 491-497 . DOI: 10.1055/a-1137-4721.
• 33 Elli L, Tontini GE, Filippi E. et al. Efficacy of endoscopic triage during the Covid-19 outbreak and infective risk. Eur J Gastroenterol Hepatol 2020; 32: 1301-1304 . DOI: 10.1097/MEG.0000000000001856.
• 34 Edwards R, Foulser P, Gould S. et al. PTH-23 Consultant triage of endoscopy waiting lists during the Covid-19 pandemic saves money and reduces workload. Gut 2021; 70: A182-A182 . DOI: 10.1136/gutjnl-2021-BSG.338.
• 35 Marín-Gabriel JC, de Santiago ER. en representación de la Asociación Española de Gastroenterología y la Sociedad Española de Endoscopia Digestiva. AEG-SEED position paper for the resumption of endoscopic activity after the peak phase of the COVID-19 pandemic. Gastroenterol Hepatol 2020; 43: 389-407 . DOI: 10.1016/j.gastrohep.2020.05.004.
• 36 Frazzoni L, La Marca M, Radaelli F. et al. Systematic review with meta-analysis: the appropriateness of colonoscopy increases the probability of relevant findings and cancer while reducing unnecessary exams. Aliment Pharmacol Ther 2021; 53: 22-32 . DOI: 10.1111/apt.16144.
• 37 Zullo A, Manta R, De Francesco V. et al. Diagnostic yield of upper endoscopy according to appropriateness: A systematic review. Dig Liver Dis 2019; 51: 335-339 . DOI: 10.1016/j.dld.2018.11.029.
• 38 Tavakkoli A, Appelman HD, Beer DG. et al. Use of appropriate surveillance for patients with nondysplastic Barrett’s esophagus. Clin Gastroenterol Hepatol 2018; 16: 862-869.e3 . DOI: 10.1016/j.cgh.2018.01.052.
• 39 Djinbachian R, Dubé A-J, Durand M. et al. Adherence to post-polypectomy surveillance guidelines: a systematic review and meta-analysis. Endoscopy 2019; 51: 673-683 . DOI: 10.1055/a-0865-2082.
• 40 Shandro B, Chang V, Mathur J. et al. Real-life cost savings and capacity improvements on implementation of the new BSG post-polypectomy surveillance guideline. Clin Med (Lond) 2020; 20: 116-117 . DOI: 10.7861/clinmed.2019-0401.
• 41 Valori R, Cortas G, de Lange T. et al. Performance measures for endoscopy services: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2018; 50: 1186-1204 . DOI: 10.1055/a-0755-7515.
• 42 Pasha SF, Acosta R. ASGE Standards of Practice Committee. et al. Routine laboratory testing before endoscopic procedures. Gastrointest Endosc 2014; 80: 28-33 . DOI: 10.1016/j.gie.2014.01.019.
• 43 Richie C. Environmental sustainability and the carbon emissions of pharmaceuticals. J Med Ethics 2021; DOI: 10.1136/medethics-2020-106842.
• 44 Weisz U, Pichler P, Jaccard I. et al. Ergebnisse der Studie HealthFootprint CO₂-Fussabdruck des österreichischen Gesundheitssektors [in German]. Accessed: 02 Feb 2022 at: https://www.klimafonds.gv.at/wp-content/uploads/sites/16/HealthFootprint_Einleitung-und-Kernausssagen-lektoriert.pdf
• 45 Sulbaek Andersen MP, Nielsen OJ, Wallington TJ. et al. Medical intelligence article: assessing the impact on global climate from general anesthetic gases. Anesth Analg 2012; 114: 1081-1085 . DOI: 10.1213/ANE.0b013e31824d6150.
• 46 NHS England. Delivering a “net zero” National Health Service. Accessed: 12 Dec 2022 at: https://www.england.nhs.uk/greenernhs/wp-content/uploads/sites/51/2020/10/delivering-a-net-zero-national-health-service.pdf
• 47 Baddeley R, de Santiago ER, Maurice J. et al. Sustainability in gastrointestinal endoscopy. Lancet Gastroenterol Hepatol 2021; DOI: 10.1016/S2468-1253(21)00389-7.
• 48 Pin-Vieito N, Puga M, et al. Fernández-de-Castro D. Faecal immunochemical test outside colorectal cancer screening?. World J Gastroenterol 2021; 27: 6415-6429 . DOI: 10.3748/wjg.v27.i38.6415.
• 49 Jukic A, Bakiri L, Wagner EF. et al. Calprotectin: from biomarker to biological function. Gut 2021; 70: 1978-1988 . DOI: 10.1136/gutjnl-2021-324855.
• 50 Rodríguez de Santiago E, Téllez L, Garrido-Lestache Rodríguez-Monte E. et al. Fontan protein-losing enteropathy is associated with advanced liver disease and a proinflammatory intestinal and systemic state. Liver Int 2020; 40: 638-645 . DOI: 10.1111/liv.14375.
• 51 Gisbert JP, Alcedo J, Amador J. et al. V Spanish Consensus Conference on Helicobacter pylori infection treatment. Gastroenterol Hepatol 2021; DOI: 10.1016/j.gastrohep.2021.07.011.
• 52 Januszewicz W, Tan WK, Lehovsky K. et al. Safety and acceptability of esophageal cytosponge cell collection device in a pooled analysis of data from individual patients. Clin Gastroenterol Hepatol 2019; 17: 647-656.e1 . DOI: 10.1016/j.cgh.2018.07.043.
• 53 de Franchis R. Baveno VI Faculty. Expanding consensus in portal hypertension: Report of the Baveno VI Consensus Workshop: Stratifying risk and individualizing care for portal hypertension. J Hepatol 2015; 63: 743-752
• 54 Pennazio M, Spada C, Eliakim R. et al. Small-bowel capsule endoscopy and device-assisted enteroscopy for diagnosis and treatment of small-bowel disorders: European Society of Gastrointestinal Endoscopy (ESGE) Clinical Guideline. Endoscopy 2015; 47: 352-376 . DOI: 10.1055/s-0034-1391855.
• 55 Cave D, Saltzman JR, Travis AC. Wireless video capsule endoscopy. UpToDate. Accessed: 10 Nov 2021 at: https://www.uptodate.com/contents/wireless-video-capsule-endoscopy?search=Cave%20D,%20Saltzman%20JR,%20Travis%20AC.%20Wireless%20video%20capsule%20endoscopy.&source=search_result&selectedTitle=1~150&usage_type=default&display_rank=1
• 56 Grant RK, Brindle WM, Robertson AR. et al. Unsedated transnasal endoscopy: a safe, well-tolerated and accurate alternative to standard diagnostic peroral endoscopy. Dig Dis Sci 2022; 1-11 . DOI: 10.1007/s10620-022-07432-9.
• 57 Dobrusin A, Hawa F, Gladshteyn M. et al. Gastroenterologists and patients report high satisfaction rates with telehealth services during the novel coronavirus 2019 pandemic. Clin Gastroenterol Hepatol 2020; 18: 2393-2397.e2 . DOI: 10.1016/j.cgh.2020.07.014.
• 58 Keihanian T, Sharma P, Goyal J. et al. Telehealth utilization in gastroenterology clinics amid the COVID-19 pandemic: impact on clinical practice and gastroenterology training. Gastroenterology 2020; 159: 1598-1601 . DOI: 10.1053/j.gastro.2020.06.040.
• 59 Purohit A, Smith J, Hibble A. Does telemedicine reduce the carbon footprint of healthcare? A systematic review. Future Healthc J 2021; 8: e85-e91 . DOI: 10.7861/fhj.2020-0080.
• 60 Pouw RE, Barret M, Biermann K. et al. Endoscopic tissue sampling – Part 1: Upper gastrointestinal and hepatopancreatobiliary tracts. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 53: 1174-1188 . DOI: 10.1055/a-1611-5091.
• 61 Pouw RE, Bisschops R, Gecse KB. et al. Endoscopic tissue sampling – Part 2: Lower gastrointestinal tract. European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2021; 1261-1273 . DOI: 10.1055/a-1671-6336.
• 62 Thosani N, Abu Dayyeh BK. ASGE Technology Committee. et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE Preservation and Incorporation of Valuable Endoscopic Innovations thresholds for adopting real-time imaging-assisted endoscopic targeted biopsy during endoscopic surveillance of Barrett’s esophagus. Gastrointest Endosc 2016; 83: 684-698.e7 . DOI: 10.1016/j.gie.2016.01.007.
• 63 Bisschops R, East JE, Hassan C. et al. Advanced imaging for detection and differentiation of colorectal neoplasia: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – Update 2019. Endoscopy 2019; 51: 1155-1179 . DOI: 10.1055/a-1031-7657.
• 64 Dekker E, Houwen BBSL, Puig I. et al. Curriculum for optical diagnosis training in Europe: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2020; 52: 899-923 . DOI: 10.1055/a-1231-5123.
• 65 Rutter MD, East J, Rees CJ. et al. British Society of Gastroenterology/Association of Coloproctology of Great Britain and Ireland/Public Health England post-polypectomy and post-colorectal cancer resection surveillance guidelines. Gut 2020; 69: 201-223 . DOI: 10.1136/gutjnl-2019-319858.
• 66 Abu Dayyeh BK, Thosani N. ASGE Technology Committee. et al. ASGE Technology Committee systematic review and meta-analysis assessing the ASGE PIVI thresholds for adopting real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2015; 81: 502.e1-502.e16 . DOI: 10.1016/j.gie.2014.12.022.
• 67 Rex DK, Kahi C, O’Brien M. et al. The American Society for Gastrointestinal Endoscopy PIVI (Preservation and Incorporation of Valuable Endoscopic Innovations) on real-time endoscopic assessment of the histology of diminutive colorectal polyps. Gastrointest Endosc 2011; 73: 419-422 . DOI: 10.1016/j.gie.2011.01.023.
• 68 Gulati S, Emmanuel A, Ong M. et al. Near-focus narrow-band imaging classification of villous atrophy in suspected celiac disease: development and international validation. Gastrointest Endosc 2021; 1071-1081 . DOI: 10.1016/j.gie.2021.06.031.
• 69 Turan AS, Didden P, Peters Y. et al. Factors involved in endoscopists’ choice for prophylactic clipping after colorectal endoscopic mucosal resection: a discrete choice experiment. Scand J Gastroenterol 2020; 55: 737-744 . DOI: 10.1080/00365521.2020.1770851.
• 70 Day LW, Muthusamy VR, Collins J. et al. Multisociety guideline on reprocessing flexible GI endoscopes and accessories. Gastrointest Endosc 2021; 93: 11-33.e6 . DOI: 10.1016/j.gie.2020.09.048.
• 71 Beilenhoff U, Biering H, Blum R. et al. Reprocessing of flexible endoscopes and endoscopic accessories used in gastrointestinal endoscopy: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA) – Update 2018. Endoscopy 2018; 50: 1205-1234 . DOI: 10.1055/a-0759-1629.
• 72 Agrawal D, Rockey DC. Sterile water in endoscopy: habit, opinion, or evidence. Gastrointest Endosc 2013; 78: 150-152 . DOI: 10.1016/j.gie.2013.02.031.
• 73 Huang C, Choong M. Comparison of wounds’ infection rate between tap water and normal saline cleansing: A meta-analysis of randomised control trials. Int Wound J 2018; 16: 300-301 . DOI: 10.1111/iwj.12980.
• 74 Puterbaugh M, Barde C, Van Enk R. Endoscopy water source: tap or sterile water?. Gastroenterol Nurs 1997; 20: 203-206 . DOI: 10.1097/00001610-199711000-00003.
• 75 Wilcox CM, Waites K, Brookings ES. Use of sterile compared with tap water in gastrointestinal endoscopic procedures. Am J Infect Control 1996; 24: 407-410 . DOI: 10.1016/s0196-6553(96)90031-0.
• 76 Kawamura T, Sakai H, Ogawa T. et al. Feasibility of underwater endoscopic mucosal resection for colorectal lesions: a single center study in Japan. Gastroenterology Res 2018; 11: 274-279 . DOI: 10.14740/gr1021w.
• 77 Fischer LS, Lumsden A, Leung FW. Water exchange method for colonoscopy: learning curve of an experienced colonoscopist in a U.S. community practice setting. J Interv Gastroenterol 2012; 2: 128-132 . DOI: 10.4161/jig.23734.
• 78 Cadoni S, Ishaq S, Hassan C. et al. Water-assisted colonoscopy: an international modified Delphi review on definitions and practice recommendations. Gastrointest Endosc 2021; 93: 1411-1420.e18 . DOI: 10.1016/j.gie.2020.10.011.
• 79 Tennison I, Roschnik S, Ashby B. et al. Health care’s response to climate change: a carbon footprint assessment of the NHS in England. Lancet Planet Health 2021; 5: e84-e92 . DOI: 10.1016/S2542-5196(20)30271-0.
• 80 Baldaque-Silva F, Marques M, Andrade AP. et al. Endoscopic submucosal dissection of gastrointestinal lesions on an outpatient basis. United European Gastroenterol J 2019; 7: 326-334 . DOI: 10.1177/2050640618823874.
• 81 Zhang LY, Bejjani M, Ghandour B. et al. Rethinking the need for overnight admission after peroral endoscopic myotomy (POEM): a pandemic-driven approach to the future. Endosc Int Open 2021; 9: E1381-E1385 . DOI: 10.1055/a-1490-9385.
• 82 Coté GA, Lynch S, Easler JJ. et al. Development and validation of a prediction model for admission after endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol 2015; 13: 2323-2332.e1-9 . DOI: 10.1016/j.cgh.2015.06.023.
• 83 Rizan C, Steinbach I, Nicholson R. et al. The carbon footprint of surgical operations: a systematic review. Ann Surg 2020; 272: 986-995 . DOI: 10.1097/SLA.0000000000003951.
• 84 Grinberg D, Buzzi R, Pozzi M. et al. Eco-audit of conventional heart surgery procedures. Eur J Cardiothorac Surg 2021; 60: 1325-1331 . DOI: 10.1093/ejcts/ezab320.
• 85 Thiel CL, Woods NC, Bilec MM. Strategies to reduce greenhouse gas emissions from laparoscopic surgery. Am J Public Health 2018; 108: S158-S164 . DOI: 10.2105/AJPH.2018.304397.
• 86 Mulder CJJ, Jacobs MAJM, Leicester RJ. et al. Guidelines for designing a digestive disease endoscopy unit: report of the World Endoscopy Organization. Dig Endosc 2013; 25: 365-375 . DOI: 10.1111/den.12126.
• 87 Part B – Health Facility Briefing & Design. International Health Facility Guidelines Version 4 May 2014. Accessed: 01 Nov 2021 at: https://healthfacilityguidelines.com/ViewPDF/ViewIndexPDF/iHFG_part_b_complete
• 88 Özkan S, Gökdag B. Reflections of sustainable design principles into hospital interiors; investigation of Boulder Community Foothills Hospital and VKV American Hospital in the green hospital context. IAI Academic Conference Proceedings, September 2019; Rome, Italy. Accessed: 4 Dec 2021 at: https://www.academia.edu/es/43106340/reflections_of_sustainable_design_principles_into_hospital_interiors_investigation_of_Boulder_Community_Foothills_Hospital_and_VKV_American_Hospital_in_the_green_hospital_context
• 89 Büyüksa S, Aydin D, Yaldiz E. Sustainable hospital design for sustainable development. Accessed: 04 Dec 2021 at: https://www.academia.edu/44406203/Sustainable_Hospital_Design_for_Sustainable_Development
• 90 Tomson C. Reducing the carbon footprint of hospital-based care. Future Hosp J 2015; 2: 57-62 . DOI: 10.7861/futurehosp.2-1-57.
• 91 Borges de Oliveira K, dos Santos EF, Neto AF. et al. Guidelines for efficient and sustainable energy management in hospital buildings. J Clean Prod 2021; 329: 129644 . DOI: 10.1016/j.jclepro.2021.129644.
• 92 Gutierrez-Aliaga L, Williams E. Co-alignment of comfort and energy saving objectives for U.S. office buildings and restaurants. . Sustain Cities Soc 2016; 27: 32-41 . DOI: 10.1016/j.scs.2016.08.010.
• 93 Calderwood AH, Chapman FJ. ASGE Ensuring Safety in the Gastrointestinal Endoscopy Unit Task Force. et al. Guidelines for safety in the gastrointestinal endoscopy unit. Gastrointest Endosc 2014; 79: 363-372 . DOI: 10.1016/j.gie.2013.12.015.
• 94 Thiel CL, Eckelman M, Guido R. et al. Environmental impacts of surgical procedures: life cycle assessment of hysterectomy in the United States. Environ Sci Technol 2015; 49: 1779-1786 . DOI: 10.1021/es504719g.
• 95 Day LW, Belson D. Studying and incorporating efficiency into gastrointestinal endoscopy centers. Gastroenterol Res Pract 2015; 2015: 764153 . DOI: 10.1155/2015/764153.
• 96 Martínez J, Aparicio JR, Peña A. et al. The current situation of digestive endoscopy units in the Valencian community. Rev Esp Enferm Dig 2019; 111: 556-562 . DOI: 10.17235/reed.2019.5676/2018.
• 97 Wu J, Zhao S-B, Wang S-L. et al. Comparison of efficacy of colonoscopy between the morning and afternoon: A systematic review and meta-analysis. Dig Liver Dis 2018; 50: 661-667 . DOI: 10.1016/j.dld.2018.03.035.
• 98 Dri M, Canfora P, Antonopoulos I. European Commission, Joint Research Centre. et al. Best environmental management practice for the waste management sector: learning from frontrunners. Publications Office 2018. Accessed: 13 Jan 2022 at: https://data.europa.eu/doi/10.2760/50247
• 99 European Circular Economy Stakeholder Platform. Sustainable healthcare waste management in the EU Circular Economy model. Accessed: 3 Mar 2022 at: https://circulareconomy.europa.eu/platform/en/toolkits-guidelines/sustainable-healthcare-waste-management-eu-circular-economy-model
• 100 Babanyara YY, Ibrahim BD, Garba T. et al. Poor medical waste management (MWM) practices and its risks to human health and the environment: a literature review. Int J Health Med Eng 2013; 7: 780-787
• 101 Agrawal D, Shoup V, Montgomery A. et al. Disposal of endoscopic accessories after use: do we know and do we care?. Gastroenterol Nurs 2017; 40: 13-18 . DOI: 10.1097/SGA.0000000000000280.
• 102 Turley M, Porter C, Garrido T. et al. Use of electronic health records can improve the health care industry’s environmental footprint. Health Aff (Millwood) 2011; 30: 938-946 . DOI: 10.1377/hlthaff.2010.1215.
• 103 Rutgers University. The supply chain/Green purchasing overview. Accessed: 21 Dec 2021 at: http://greenpurchasing.rutgers.edu/supply_chain.html
• 104 Energy Star. Top 10 computer power management myths...and realities. Accessed: 4 Dec 2021 at: https://www.energystar.gov/products/low_carbon_it_campaign/put_your_computers_sleep/myths_realities
• 105 Roisin B, Bodart M, Deneyer A. et al. Lighting energy savings in offices using different control systems and their real consumption. Energ Buildings 2008; 40: 514-523 . DOI: 10.1016/j.enbuild.2007.04.006.
• 106 Ponchon T, Pioche M. Reprocessing single-use devices: A new season in a long-running show? A European perspective. Endoscopy 2017; 49: 1195-1197 . DOI: 10.1055/s-0043-121988.
• 107 Wang F, Zhang D, Zeng J. et al. Comparison of endoscopic radial incision and Savary–Gilliard’s bougie dilation in efficacy on refractory esophagogastric anastomosis strictures. Ann Palliat Med 2021; 10: 10963-10970 . DOI: 10.21037/apm-21-2648.
• 108 Piotet E, Escher A, Monnier P. Esophageal and pharyngeal strictures: report on 1,862 endoscopic dilatations using the Savary–Gilliard technique. Eur Arch Otorhinolaryngol 2008; 265: 357-364 . DOI: 10.1007/s00405-007-0456-0.
• 109 Robles-Medranda C, Oleas R, Alvarado-Escobar H. et al. Treating simple benign esophageal strictures with Savary–Gilliard dilators: is the rule of three still necessary?. Arq Gastroenterol 2019; 56: 95-98 . DOI: 10.1590/S0004-2803.201900000-21.
• 110 Jung M, Beilenhoff U, Pietsch M. et al. Standardized reprocessing of reusable colonoscopy biopsy forceps is effective: results of a German multicenter study. Endoscopy 2003; 35: 197-202 . DOI: 10.1055/s-2003-37270.
• 111 Rizzo J, Bernstein D, Gress F. A performance, safety and cost comparison of reusable and disposable endoscopic biopsy forceps: a prospective, randomized trial. Gastrointest Endosc 2000; 51: 257-261 . DOI: 10.1016/s0016-5107(00)70351-8.
• 112 Yoon JH, Yoon BC, Lee HL. et al. Comparison of sterilization of reusable endoscopic biopsy forceps by autoclaving and ethylene oxide gas. Dig Dis Sci 2012; 57: 405-412 . DOI: 10.1007/s10620-011-1884-7.
• 113 Visrodia K, Haseeb A, Hanada Y. et al. Reprocessing of single-use endoscopic variceal band ligation devices: a pilot study. Endoscopy 2017; 49: 1202-1208 . DOI: 10.1055/s-0043-115004.
• 114 Kozarek RA, Raltz SL, Ball TJ. et al. Reuse of disposable sphincterotomes for diagnostic and therapeutic ERCP: a one-year prospective study. Gastrointest Endosc 1999; 49: 39-42 . DOI: 10.1016/s0016-5107(99)70443-8.
• 115 Wilcox CM, Geels W, Baron TH. How many times can you reuse a “single-use“ sphincterotome? A prospective evaluation. Gastrointest Endosc 1998; 48: 58-60 . DOI: 10.1016/s0016-5107(98)70130-0.
• 116 Lee RM, Vida F, Kozarek RA. et al. In vitro and in vivo evaluation of a reusable double-channel sphincterotome. Gastrointest Endosc 1999; 49: 477-482 . DOI: 10.1016/s0016-5107(99)70046-5.
• 117 Kozarek RA, Raltz SL, Brandabur JJ. et al. In vitro study and in vivo application of a reusable double-channel sphincterotome. Endoscopy 2001; 33: 401-404 . DOI: 10.1055/s-2001-14262.
• 118 Prat F, Spieler J-F, Paci S. et al. Reliability, cost-effectiveness, and safety of reuse of ancillary devices for ERCP. Gastrointest Endosc 2004; 60: 246-252 . DOI: 10.1016/s0016-5107(04)01685-2.
• 119 Cohen J, Haber GB, Kortan P. et al. A prospective study of the repeated use of sterilized papillotomes and retrieval baskets for ERCP: quality and cost analysis. Gastrointest Endosc 1997; 45: 122-127 . DOI: 10.1016/s0016-5107(97)70233-5.
• 120 Ende A, Zopf Y, Heide R. et al. Hemodynamic efficacy of sequential hemoclip application using the Olympus HX-110/610 reloadable clipping device in spurting bleedings. Med Sci Monit 2011; 17: MT1-MT6 . DOI: 10.12659/msm.881313.
• 121 Cheung DY, Jang BI, Kim SW. et al. Multidisciplinary and multisociety practice guideline on reprocessing flexible gastrointestinal endoscopes and endoscopic accessories. Clin Endosc 2020; 53: 276-285 . DOI: 10.5946/ce.2020.106.
• 122 Limani F, Garley D, Cocker D. et al. Lessons learnt from the rapid implementation of reusable personal protective equipment for COVID-19 in Malawi. BMJ Glob Health 2021; 6: e006498 . DOI: 10.1136/bmjgh-2021-006498.
• 123 Reynier T, Berahou M, Albaladejo P. et al. Moving towards green anaesthesia: Are patient safety and environmentally friendly practices compatible? A focus on single-use devices. Anaesth Crit Care Pain Med 2021; 40: 100907 . DOI: 10.1016/j.accpm.2021.100907.
• 124 Kethu SR, Adler DG. ASGE Technology Committee. et al. ERCP cannulation and sphincterotomy devices. Gastrointest Endosc 2010; 71: 435-445 . DOI: 10.1016/j.gie.2009.07.038.
• 125 Muscarella LF. Inconsistencies in endoscope-reprocessing and infection-control guidelines: the importance of endoscope drying. Am J Gastroenterol 2006; 101: 2147-2154 . DOI: 10.1111/j.1572-0241.2006.00712.x.
• 126 Beilenhoff U, Biering H, Blum R. et al. Prevention of multidrug-resistant infections from contaminated duodenoscopes: Position Statement of the European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA). Endoscopy 2017; 49: 1098-1106 . DOI: 10.1055/s-0043-120523.
• 127 Fraser TG, Reiner S, Malczynski M. et al. Multidrug-resistant Pseudomonas aeruginosa cholangitis after endoscopic retrograde cholangiopancreatography: failure of routine endoscope cultures to prevent an outbreak. Infect Control Hosp Epidemiol 2004; 25: 856-859 . DOI: 10.1086/502309.
• 128 Saleem N, Ismail MK, Tombazzi CR. et al. Endoscopic transmission of carbapenem-resistant Enterobacteriaceae: implications for U.S. Food and Drug Administration approval and postmarket surveillance of endoscopic devices. Gastrointest Endosc 2021; 93: 231-238 . DOI: 10.1016/j.gie.2020.07.061.
• 129 Thiel CL, Woods NC, Bilec MM. Strategies to reduce greenhouse gas emissions from laparoscopic surgery. Am J Public Health 2018; 108: S158-S164 . DOI: 10.2105/AJPH.2018.304397.
• 130 Kinney TP, Kozarek RA, Raltz S. et al. Contamination of single-use biopsy forceps: a prospective in vitro analysis. Gastrointest Endosc 2002; 56: 209-212 . DOI: 10.1016/s0016-5107(02)70179-x.
• 131 European Commission. Public Health. National rules on reprocessing of single-use devices. Accessed: 1 Mar 2022 at: https://ec.europa.eu/health/medical-devices-new-regulations/getting-ready-new-regulations/national-rules-reprocessing-single-use-devices_en
• 132 Casini B, Pan A, Guarini A. et al. Multisocieties position paper: Microbiological surveillance on flexible endoscopes. Dig Liver Dis 2021; 53: 1105-1111 . DOI: 10.1016/j.dld.2021.06.016.
• 133 Ng FH, Wong SY, Lai ST. et al. Reloading a variceal rubber band ligator with hemorrhoidal bands: an inexpensive and effective method. Endoscopy 1997; 29: 233 . DOI: 10.1055/s-2007-1004181.
• 134 Calderwood AH, Day LW. ASGE Quality Assurance in Endoscopy Committee. et al. ASGE guideline for infection control during GI endoscopy. Gastrointest Endosc 2018; 87: 1167-1179 . DOI: 10.1016/j.gie.2017.12.009.
• 135 Kovaleva J, Peters FTM, van der Mei HC. et al. Transmission of infection by flexible gastrointestinal endoscopy and bronchoscopy. Clin Microbiol Rev 2013; 26: 231-254 . DOI: 10.1128/CMR.00085-12.
• 136 American Gastroenterological Association. FDA transition to disposable component duodenoscopes – talking points for your patients. September 18, 2019. Accessed: 18 January 2022 at: https://gastro.org/news/fda-transition-to-disposable-component-duodenoscopes-talking-points-for-your-patients
• 137 Barakat MT, Ghosh S, Banerjee S. Cost utility analysis of strategies for minimizing risk of duodenoscope related infections. Gastrointest Endosc 2022; 95: 929-938 . DOI: 10.1016/j.gie.2022.01.002.
• 138 Travis HS, Ehlers LH, Thornton J. The total cost of reusable duodenoscopes – are single-use duodenoscopes the future of ERCP?. Pharmacoeconomics 2020; 5: 1-3 . DOI: 10.37421/pe.2020.5.125.
• 139 Das A, Cangelosi MJ, Muthusamy VR. . A cost-effectiveness analysis of EXALT model-D single-use duodenoscope versus current duodenoscope reprocessing methods. Techn Innov Gastrointest Endosc 2021; DOI: 10.1016/j.tige.2021.09.007.
• 140 Lockhart PB, Brennan MT, Sasser HC. et al. Bacteremia associated with toothbrushing and dental extraction. Circulation 2008; 117: 3118-3125 . DOI: 10.1161/CIRCULATIONAHA.107.758524.
• 141 Balan GG, Sfarti CV, Chiriac SA. et al. Duodenoscope-associated infections: a review. Eur J Clin Microbiol Infect Dis 2019; 38: 2205-2213 . DOI: 10.1007/s10096-019-03671-3.
• 142 Kwakman JA, Erler NS, Vos MC. et al. Risk evaluation of duodenoscope-associated infections in the Netherlands calls for a heightened awareness of device-related infections: a systematic review. Endoscopy 2022; 54: 148-155 . DOI: 10.1055/a-1467-6294.
• 143 Ofstead CL, Heymann OL, Quick MR. et al. Residual moisture and waterborne pathogens inside flexible endoscopes: Evidence from a multisite study of endoscope drying effectiveness. Am J Infect Control 2018; 46: 689-696 . DOI: 10.1016/j.ajic.2018.03.002.
• 144 Agrawal D, Tang Z. Sustainability of single-use endoscopes. Techn Innov Gastrointest Endosc 2021; 23: 353-362 . DOI: 10.1016/j.tige.2021.06.001.
• 145 Kenters N, Tartari E, Hopman J. et al. Worldwide practices on flexible endoscope reprocessing. Antimicrob Resist Infect Control 2018; 7: 153 . DOI: 10.1186/s13756-018-0446-6.
• 146 Musu M, Lai A, Mereu NM. et al. Assessing hand hygiene compliance among healthcare workers in six intensive care units. J Prev Med Hyg 2017; 58: E231-E237
• 147 Holzwanger EA, Bilal M, Saperia J. et al. Duodenoscope-related infections and potential role of single-use duodenoscopes. VideoGIE 2020; 5: 628-629 . DOI: 10.1016/j.vgie.2020.08.011.
• 148 Trindade AJ, Copland A, Bhatt A. et al. Single-use duodenoscopes and duodenoscopes with disposable end caps. Gastrointest Endosc 2021; 93: 997-1005 . DOI: 10.1016/j.gie.2020.12.033.
• 149 Sahakian AB, Siddiqui UD. Single-use duodenoscopes: The next disruptor or passing fad?. Gastrointest Endosc 2021; 94: 1056-1058 . DOI: 10.1016/j.gie.2021.08.010.
• 150 Sahu DK, Basadonna G. Health economic savings of single use flexible endoscopes vs current re-usable endoscopes and disposable sheath systems. SAGES Abstract Archives. Accessed: 30 Jan 2022 at: https://www.sages.org/meetings/annual-meeting/abstracts-archive/health-economic-savings-of-single-use-flexible-endoscopes-vs-current-re-usable-endoscopes-and-disposable-sheath-systems
• 151 Napoléon B, Gonzalez J-M, Grandval P. et al. Evaluation of the performances of a single-use duodenoscope: Prospective multi-center national study. Dig Endosc 2022; 34: 215-221 . DOI: 10.1111/den.13965.
• 152 Lisotti A, Zagari RM, Fusaroli P. et al. Optimal safety and pooled technical success rate for ERCP performed with single-use duodenoscopes. Dig Liver Dis 2021; DOI: 10.1016/j.dld.2021.11.003.
• 153 Muthusamy VR, Bruno MJ, Kozarek RA. et al. Clinical evaluation of a single-use duodenoscope for endoscopic retrograde cholangiopancreatography. Clin Gastroenterol Hepatol 2020; 18: 2108-2117.e3 . DOI: 10.1016/j.cgh.2019.10.052.
• 154 Ross AS, Bruno MJ, Kozarek RA. et al. Novel single-use duodenoscope compared with 3 models of reusable duodenoscopes for ERCP: a randomized bench-model comparison. Gastrointest Endosc 2020; 91: 396-403 . DOI: 10.1016/j.gie.2019.08.032.
• 155 Bang JY, Hawes R, Varadarajulu S. Equivalent performance of single-use and reusable duodenoscopes in a randomised trial. Gut 2021; 70: 838-844 . DOI: 10.1136/gutjnl-2020-321836.
• 156 Slivka A, Ross AS, Sejpal DV. et al. Single-use duodenoscope for ERCP performed by endoscopists with a range of experience in procedures of variable complexity. Gastrointest Endosc 2021; 94: 1046-1055 . DOI: 10.1016/j.gie.2021.06.017.
• 157 Martínez-Ortega A, Albillos A, Vázquez-Sequeiros E. A new single-use disposable duodenoscope (EXALTTMModel D) for the treatment of an anastomotic biliary stenosis in a liver transplant patient. Rev Esp Enferm Dig 2021; DOI: 10.17235/reed.2021.8201/2021.
• 158 Foo C-C, Leung W-K, Lui TK-L. et al. Feasibility study of a single-use balloon-assisted robotic colonoscope in healthy volunteers. Endosc Int Open 2021; 9: E537-E542 . DOI: 10.1055/a-1352-3688.
• 159 Rösch T, Adler A, Pohl H. et al. A motor-driven single-use colonoscope controlled with a hand-held device: a feasibility study in volunteers. Gastrointest Endosc 2008; 67: 1139-1146 . DOI: 10.1016/j.gie.2007.10.065.
• 160 Ciocîrlan M. Low-cost disposable endoscope: pros and cons. Endosc Int Open 2019; 7: E1184-E1186 . DOI: 10.1055/a-0959-6003.
• 161 Li D-F, Shi R-Y, Tian Y-H. et al. The feasibility and safety of disposable endoscope vs. conventional endoscope for upper gastrointestinal tract examination: a multicenter, randomized, parallel, non-inferiority trial. Z Gastroenterol 2021; DOI: 10.1055/a-1555-0568.
• 162 Shoup T. As low as reasonably practicable: An approach to managing device risk. Biomed Instrum Technol 2018; 52: 248 . DOI: 10.2345/0899-8205-52.3.248.
• 163 Gandhi V, Al-Hadithy N, Göpfert A. et al. Integrating sustainability into postgraduate medical education. Future Healthc J 2020; 7: 102-104 . DOI: 10.7861/fhj.2020-0042.
• 164 Shaw E, Walpole S, McLean M. et al. AMEE Consensus Statement: Planetary health and education for sustainable healthcare. Med Teach 2021; 43: 272-286 . DOI: 10.1080/0142159X.2020.1860207.
• 165 Park KY, Russell JI, Wilke NP. et al. Reducing cost and waste in pediatric laparoscopic procedures. J Pediatr Surg 2021; 56: 66-70 . DOI: 10.1016/j.jpedsurg.2020.09.052.
• 166 Depew WT, Hookey LC, Vanner SJ. et al. Opportunity costs of gastrointestinal endoscopic training in Canada. Can J Gastroenterol 2010; 24: 733-738 . DOI: 10.1155/2010/304689.
• 167 McCashland T, Brand R, Lyden E. et al. The time and financial impact of training fellows in endoscopy. CORI Research Project. Clinical Outcomes Research Initiative. Am J Gastroenterol 2000; 95: 3129-3132 . DOI: 10.1111/j.1572-0241.2000.03280.x.
• 168 Blackburn SC, Griffin SJ. Role of simulation in training the next generation of endoscopists. World J Gastrointest Endosc 2014; 6: 234-239 . DOI: 10.4253/wjge.v6.i6.234.
• 169 Goodman AJ, Melson J. ASGE Technology Committee. et al. Endoscopic simulators. Gastrointest Endosc 2019; 90: 1-12 . DOI: 10.1016/j.gie.2018.10.037.
• 170 Valenti A, Fortuna G, Barillari C. et al. The future of scientific conferences in the era of the COVID-19 pandemic: Critical analysis and future perspectives. Ind Health 2021; 59: 334-339 . DOI: 10.2486/indhealth.2021-0102.
• 171 Duane B, Lyne A, Faulkner T. et al. Webinars reduce the environmental footprint of pediatric cardiology conferences. Cardiol Young 2021; 31: 1625-1632 . DOI: 10.1017/S1047951121000718.
• 172 Webster GJ, El Menabawey T, Arvanitakis M. et al. Live endoscopy events (LEEs): European Society of Gastrointestinal Endoscopy Position Statement – Update 2021. Endoscopy 2021; 53: 842-849 . DOI: 10.1055/a-1511-1657.
• 173 Bisschops R, Rutter MD, Areia M. et al. Overcoming the barriers to dissemination and implementation of quality measures for gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) and United European Gastroenterology (UEG) position statement. Endoscopy 2021; 53: 196-202 . DOI: 10.1055/a-1312-6389.
• 174 Kaminski MF, Thomas-Gibson S, Bugajski M. et al. Performance measures for lower gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2017; 49: 378-397 . DOI: 10.1055/s-0043-103411.
• 175 Bisschops R, Areia M, Coron E. et al. Performance measures for upper gastrointestinal endoscopy: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2016; 48: 843-864 . DOI: 10.1055/s-0042-113128.
• 176 Domagk D, Oppong KW, Aabakken L. et al. Performance measures for ERCP and endoscopic ultrasound: a European Society of Gastrointestinal Endoscopy (ESGE) Quality Improvement Initiative. Endoscopy 2018; 50: 1116-1127 . DOI: 10.1055/a-0749-8767.
• 177 Sinonquel P, Eelbode T, Bossuyt P. et al. Artificial intelligence and its impact on quality improvement in upper and lower gastrointestinal endoscopy. Dig Endosc 2021; 33: 242-253 . DOI: 10.1111/den.13888.
• 178 Wu L, Zhang J, Zhou W. et al. Randomised controlled trial of WISENSE, a real-time quality improving system for monitoring blind spots during esophagogastroduodenoscopy. Gut 2019; 68: 2161-2169 . DOI: 10.1136/gutjnl-2018-317366.
• 179 Bretthauer M, Aabakken L, Dekker E. et al. Requirements and standards facilitating quality improvement for reporting systems in gastrointestinal endoscopy: European Society of Gastrointestinal Endoscopy (ESGE) Position Statement. Endoscopy 2016; 48: 291-294 . DOI: 10.1055/s-0042-100186.
• 180 Lyle K, Dent L, Bailey S. et al. Carbon cost of pragmatic randomised controlled trials: retrospective analysis of sample of trials. BMJ 2009; 339: b4187 . DOI: 10.1136/bmj.b4187.
• 181 Adshead F, Al-Shahi Salman R, Aumonier S. et al. A strategy to reduce the carbon footprint of clinical trials. Lancet 2021; 398: 281-282 . DOI: 10.1016/S0140-6736(21)01384-2.
• 182 Tiseo I. Switzerland: carbon dioxide emissions 1970-2020. Statista. Accessed: 20 Jan 2022 at: https://www.statista.com/statistics/449824/co2-emissions-switzerland/
• 183 Ligozat A-L, Névéol A, Daly B. et al. Ten simple rules to make your research more sustainable. PLoS Comput Biol 2020; 16: e1008148 . DOI: 10.1371/journal.pcbi.1008148.
• 184 Sustainable Trials Study Group. Towards sustainable clinical trials. BMJ 2007; 334: 671-673 . DOI: 10.1136/bmj.39140.623137.BE.
• 185 National Institute for Health and Care Research (NIHR) Carbon reduction guidelines. 30 Jul 2019. Accessed: 03 Dec 2021 at: https://www.nihr.ac.uk/documents/the-nihr-carbon-reduction-guidelines/21685
• 186 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 . DOI: 10.1055/a-1546-8975.
• 187 Wu S, Cerceo E. Sustainability initiatives in the operating room. Jt Comm J Qual Patient Saf 2021; 47: 663-672 . DOI: 10.1016/j.jcjq.2021.06.010.
• 188 Agache I, Sampath V, Aguilera J. et al. Climate change and global health: a call to more research and more action. Allergy 2022; 1389-1407 . DOI: 10.1111/all.15229.
• 189 Thiel CL, Schehlein E, Ravilla T. et al. Cataract surgery and environmental sustainability: Waste and lifecycle assessment of phacoemulsification at a private healthcare facility. J Cataract Refract Surg 2017; 43: 1391-1398 . DOI: 10.1016/j.jcrs.2017.08.017.
• 190 Tauber J, Chinwuba I, Kleyn D. et al. Quantification of the cost and potential environmental effects of unused pharmaceutical products in cataract surgery. JAMA Ophthalmol 2019; 1156-1163 . DOI: 10.1001/jamaophthalmol.2019.2901.
• 191 Johansson M, Bero L, Bonfill X. et al. Cochrane Sustainable Healthcare: evidence for action on too much medicine. Cochrane Database Syst Rev 2019; 12: ED000143 . DOI: 10.1002/14651858.ED000143.
• 192 Andrews JC, Schünemann HJ, Oxman AD. et al. GRADE guidelines: 15. Going from evidence to recommendation – determinants of a recommendation’s direction and strength. J Clin Epidemiol 2013; 66: 726-735 . DOI: 10.1016/j.jclinepi.2013.02.003.
• 193 European Commission. Climate Action. European Green Deal. Accessed: 13 Dec 2021 at: https://ec.europa.eu/clima/eu-action/european-green-deal_en
• 194 United Nations Global Compact. The power of principles. The Ten Principles of the UN Global Compact. Accessed: 13 Dec 2021 at: https://www.unglobalcompact.org/what-is-gc/mission/principles
• 195 United Nations Global Compact. The world’s largest corporate sustainability initiative. Accessed: 13 Dec 2021 at: https://www.unglobalcompact.org/what-is-gc
• 196 Zeng T, Deschênes J, Durif F. Eco-design packaging: An epistemological analysis and transformative research agenda. J Clean Prod 2020; 276: 123361 . DOI: 10.1016/j.jclepro.2020.123361.
• 197 United Nations Carbon Offset Platform. What is offsetting?. Accessed: 14 Dec 2021 at: https://offset.climateneutralnow.org/aboutoffsetting
• 198 Joshi NP, Stahnisch FW, Noseworthy TW. Reassessment of health technologies: Obsolescence and waste. Ottawa: Canadian Agency for Drugs and Technologies in Health; 2009. http://dx.doi.org/10.11575/PRISM/33622
• 199 Biomedical Engineering Advisory Group. Life span of biomedical devices. Accessed: 03 Dec 2021 at: http://cedglobal.org/download/Life%20Span%20of%20Biomedical%20Devices%20-%20Guidance%20Paper%20Final.pdf
• 200 The Health Foundation. Public perceptions of climate change and health (September 2021). Accessed: 5 March 2022 at: https://www.health.org.uk/publications/public-perceptions-of-climate-change-and-health-september-2021
• 201 European Commission. Climate Action. Transport emissions. Accessed: 26 Feb 2022 at: https://ec.europa.eu/clima/eu-action/transport-emissions_en
• 202 World Health Organization. Patient empowerment and health care. 2009. https://www.ncbi.nlm.nih.gov/books/NBK144022/
• 203 Pekonen A, Eloranta S, Stolt M. et al. Measuring patient empowerment – A systematic review. Patient Educ Couns 2020; 103: 777-787 . DOI: 10.1016/j.pec.2019.10.019.
• 204 Kambhampati S, Ashvetiya T, Stone NJ. et al. Shared decision-making and patient empowerment in preventive cardiology. Curr Cardiol Rep 2016; 18: 49 . DOI: 10.1007/s11886-016-0729-6.
• 205 European Commission. Climate Action. 2050 long-term strategy. Accessed: 26 Feb 2022 at: https://ec.europa.eu/clima/eu-action/climate-strategies-targets/2050-long-term-strategy_en
• 206 Hassan C, Ponchon T, Bisschops R. et al. European Society of Gastrointestinal Endoscopy (ESGE) Publications Policy – Update 2020. Endoscopy 2020; 52: 123-126 . DOI: 10.1055/a-1067-4657.