Endoscopic Sustainability PrimAry Reporting Essentials (E-SPARE): European Society of Gastrointestinal Endoscopy (ESGE) Position Statement

Abstract

A growing number of studies aim to evaluate gastrointestinal (GI) endoscopy services from the perspective of their environmental impact. However, there are currently no guidelines or frameworks which provide specifically for the reporting of endoscopy sustainability studies, and a variety of metrics and assessment tools have been employed in the literature. To improve the clarity, transparency, and quality of reporting, the European Society of Gastrointestinal Endoscopy (ESGE) has developed a reporting framework for the community of researchers interested in conducting studies on sustainable GI endoscopy.

Abbreviations

CO₂e: carbon dioxide equivalent

ESGE: European Society of Gastrointestinal Endoscopy

GHG: greenhouse gas

GI: gastrointestinal

GWP: global warming potential

ISO: International Organization for Standardization

LCA: life cycle assessment

LCI: life cycle inventory (analysis phase)

LCIA: life cycle impact assessment

1 Introduction

Healthcare provision is estimated to account for 4 %–5 % of global greenhouse gas emissions [1]. It is now a focus for endoscopic societies worldwide to mitigate environmental pollution attributable to gastrointestinal (GI) endoscopy services and to identify strategies to align with national decarbonization commitments [2] [3] [4]. However, there is currently no standardized approach to the measurement of environmental impacts in this context. Methodological heterogeneity in the studies conducted to date limits the extent to which research findings can be generalized beyond an individual setting. The lack of a consistent approach to measurement and reporting also complicates attempts to compare the environmental impacts of various products or strategies. The complex relationships between clinical process, resource utilization, waste management, and environmental impacts hamper reproducibility even further.

The need for methodological consistency in this evolving field has compelled the European Society of Gastrointestinal Endoscopy (ESGE) to develop a methodological and reporting framework for the community of researchers interested in conducting studies on sustainable GI endoscopy. This document also underlines the commitment of the ESGE Green Endoscopy Working Group to develop an international research network around the issue of environmental awareness.

The aim of E-SPARE (Endoscopic Sustainability PrimAry Reporting Essentials) is to outline the core dimensions for the conduct and reporting of GI endoscopy sustainability studies, and to develop a checklist which helps standardize this approach. This document, developed by and addressed to endoscopists, is designed to create recommendations and serve as a minimum reporting standards guide for authors, readers, editors, and reviewers involved in GI endoscopy sustainability studies. To enhance the understanding of some core terminology and improve its standardized implementation in the clinical literature, a glossary of technical terminology is provided in [Table 1].

Table 1 Glossary of technical terminology for a better understanding of sustainable gastrointestinal endoscopy studies.

Term	Definition/description
5 R principles	Reduce–Reuse–Recycle–Rethink–Research. Circular model to improve sustainable practices, often applied in waste management and resource conservation [5]
carbon dioxide equivalent, CO2e	Standardized metric to quantify the emissions of various greenhouse gases (GHGs) based up on their global warming potential relative to CO2 [6]
carbon footprint	Total set of greenhouse gas emissions generated directly and indirectly by an individual, event, organization, or product [7]
carbon neutrality	GHG offsetting objective achieved when human-related CO2 emissions are counterbalanced by human-induced CO2 removals within a designated timeframe. In contrast to net zero CO2 emissions, it may involve the purchase of carbon certificates as a carbon emission offsetting strategy [6]
circular economy	Economic model characterized by activities intentionally designed to restore or regenerate resources. The aim is to eliminate waste through innovative material, product, and system design in order to ultimately decouple growth from the consumption of finite resources [8]
climate change	Long-term weather and temperature changes mostly driven by human-related activities [6]
decarbonization	Endeavor pursued by nations, individuals, or organizations to reach zero fossil carbon presence. Mostly refers to measures aimed at reducing carbon emissions associated with electricity generation, industrial activities, and transportation [6]
ecosystem	An ecosystem comprises living organisms, their abiotic environment, and the interactions occurring within and among them, forming a functional unit [6]
energy efficiency	The measure of useful energy, service, or physical outputs a system, conversion process, transmission, or storage activity provides compared to the energy it takes in [6]
fossil fuel	Fuel derived from fossilized hydrocarbon deposits, primarily composed of carbon. Examples include coal, petroleum, and natural gas [6]
functional unit	The measure of a product or system determined by the performance it delivers in its intended use (i. e., item or process that is being measured) [9]
global warming	Prolonged rise in global temperatures, primarily driven by an increase in atmospheric GHGs [6]
global warming potential (GWP)	Measure developed to quantify the warming effects of various gases relative to CO2 emissions. A GWP greater than 1 indicates that the particular gas has a greater warming effect on Earth compared to CO2 during that specific timeframe (usually 100 years) [10]
green endoscopy	GI endoscopy practice aimed at raising awareness of the environmental impact of endoscopy and assessing, and developing measures to reduce it. May also represent an international group of healthcare professionals that advocate for sustainable practices within endoscopic practice [11] [12]
green public procurement/green purchasing	A procurement strategy which prioritizes the purchase of products which have been created and supplied with minimal environmental impact, when compared with competing products that serve the same purpose [13]
greenhouse gases (GHGs)	Atmospheric elements that absorb and release radiation at particular wavelengths within the range of terrestrial radiation emitted by the Earth's surface, the atmosphere, and clouds. This characteristic leads to the greenhouse effect. Key GHGs include water vapor, carbon dioxide, nitrous oxide, methane, and ozone [6]
ISO 14040/14044 standards	International Organization for Standardization (ISO) refers to a worldwide federation of national standards bodies. In this particular case, ISO 14040/14044 refers to international standards that cover life cycle assessment (LCA) studies [9] [13]
landfill waste	Landfill waste refers to solid waste materials such as nonrecyclable items (plastic bags, food waste, paper products, and other household waste) that are disposed of in specially designed areas called landfills. Also, in the present context, non-recyclable endoscopy supplies not contaminated with body fluids [14] [15]
LCA	Life cycle assessment. Methodology that systematically evaluates the environmental factors and potential consequences of product systems through a “cradle-to-grave” or “cradle-to-cradle” analysis, spanning from obtaining raw materials to their ultimate disposal, according to specified objectives and boundaries [9] [13]
LCA goal and scope	First phase of an LCA: Includes the specifying principles (functional unit and system boundaries), requirements and guidelines to assess the environmental impacts of products, processes, and organizations [9] [13]
life cycle inventory (LCI) analysis phase	Second phase of an LCA: Compilation and quantification of data inputs and outputs for a product or service throughout its life cycle, necessary to meet the goals of the defined study [9] [13]
life cycle impact assessment (LCIA) phase	Third phase of an LCA: Evaluation of the scale and importance of potential environmental impacts associated with a product system over its entire lifecycle. In this phase, LCI results are assigned to impact categories, with specific emissions and resource usages linked to broader environmental and human health impacts. These results provide insights into the environmental concerns linked with both the inputs and outputs of the product system [9] [13]
life cycle interpretation	Final phase of an LCA: Summary and discussion of LCI and/or LCIA results in relation to the defined goal and scope, in order to reach conclusions and recommendations [9] [13]
net zero (CO2) emissions	The state when human-related GHG emissions are counterbalanced by human-induced GHG removals from the atmosphere within a designated timeframe. Frequently referred as a synonym of carbon neutrality. However, net zero CO2 emissions do not allow carbon offsetting strategies of any other kind, such as the purchase of carbon certificates [6]
planetary health (study of)	Interdisciplinary domain and societal initiative dedicated to examining and tackling the consequences of human activities on Earth's natural systems, impacting both human health and global biodiversity [16] [17]
regulated medical waste	Nonrecyclable items saturated with body fluids or containing infectious agents [14] [15]
Scopes 1, 2, and 3	Scope 1: Direct emissions (e. g. fuel combustion for boilers or vehicles, CO2 insufflation) Scope 2: Indirect emissions associated with the purchase of electricity (e. g., for heating, ventilation, or cooling) Scope 3: Indirect emissions generated within the supply chain of endoscopic supplies (manufacturing, transportation, and disposal) [18] [19]
sustainability	Dynamic process composed of three domains: environmental, economic, and social. Sustainability foresees the fulfillment of present needs without jeopardizing the capacity of future generations to fulfill their own [6]
sustainable health care	Equally distributed high quality health care based on patient empowerment, prevention, lean services, and low carbon alternatives [20] [21]
sustainable value in healthcare	A framework which aims to maximize health care outcomes for patients and populations, while considering the environmental, social, and economic costs [20]
system boundary	A defined set of criteria for selecting the unit processes that form a product system [9]
temperature overshoot	Temporary surpassing of a predetermined threshold for global warming [6]
triple bottom line	Accounting framework that assesses performance across three dimensions: social, environmental, and financial [22]

2 Methods

2.1 Methods approach

This document focuses on reporting strategies in GI endoscopy sustainability studies and has been developed according to the current ESGE Publications Policy [23]. Considering the current lack of robust evidence and the significance of the topic, a position statement was deemed the most suitable approach. The E-SPARE was developed based on available evidence, complemented by expert consensus where evidence was lacking. The checklist ([Table 2]) was developed to provide authors, readers, editors, and reviewers with a practical tool to aid study design, reporting, and interpretation of GI endoscopy-related sustainability studies. The comprehensive reporting of environmental impact assessment methods, including life cycle assessment (LCA) or engineering domains, fall outside the scope of this document.

Table 2 Endoscopic Sustainability PrimAry Reporting Essentials (E-SPARE) checklist.

		Item	Recommendation	Reported on manuscript page
Title and Abstract: Topic and Overview	Title	1	Title should include the environmental impact and intervention, as appropriate.
	Abstract	2	The abstract should include a description of the rationale, the intervention, if applicable, and the method used for environmental impact assessment.
Introduction: Background and Aims	Background/Motivation	3	Describe the scientific background and the rationale for the reported study.
	Aims/Objectives	4	State the study hypothesis and objectives.
		5	Describe the potential impact of the study on GI endoscopy practice.
Methods: Data Acquisition and Description	Study design	6	State and justify the goal and scope of the environmental impact assessment, defining:
			a: The functional unit of analysis, i. e. a clearly quantified definition of the item or process that is being measured[1].
			b: The boundary of analysis, including the clinical care pathway and the temporospatial boundaries (an illustrative schematic is recommended).
		7	Describe key study parameters, including, where applicable:
			a: Clinical setting (e. g., home, ambulatory, inpatient).
			b: Departmental characteristics[2].
			c: Time period and location of data collection and any recruitment/exposure.
			d: A description of the multidisciplinary expertise involved in the study team[3].
		8	The methodological approach used to assess environmental impacts should be explicitly stated and justified[4].
		9	An evaluation of the patient perspective should be included if relevant to the study outcome measure(s).
	Interventions	10	Describe any interventions performed, in sufficient detail to permit replication.
	Variables and outcomes	11	Define and justify the environmental impacts chosen for assessment[5] using standard terminology and units of measurement (e. g. kgCO2e).
		12	Clearly state and justify any assumptions or exclusions.
	Data sources/management	13	Data sources are reported based on the type of analysis applied[6].
		14	Where resources are shared across activities, provide details on how these resources have been assigned to each activity and justify the rationale for the allocation method used[7].
	Bias	15	Clearly describe any attempts to address potential sources of bias[8].
	Sample size	16	Provide an explanation as to how the sample size was calculated.
	Quantitative and qualitative variables	17	Describe how quantitative and qualitative variables were handled in the analyses.
	Statistical methods	18	Describe all statistical methods, including those to control confounders.
		19	Describe methods used to examine subgroups and interactions.
		20	Explain how missing data were addressed.
		21	Data sources used for the impact assessment are described and justified[9].
Results: Outcome reporting and Results presentation	Outcome data	22	Endoscopic procedures included in the analysis should be characterized, including (as applicable): type and number, setting (outpatient/inpatient), length of stay, type of sedation, anesthesia, or other medication used.
		23	Details of the endoscopic devices used in the study should be disclosed, when applicable[10].
		24	The reporting of GHG emissions should include a breakdown according to the “scope” classification included in the GHG Protocol, when applicable[11].
		25	Outcome data should be separated into the following domains: preprocedure; periprocedure; post-procedure, when applicable.
		26	Disclose unadjusted estimates and potential confounder-adjusted estimates with respective precision (e. g., 95 % confidence interval). Clearly state which confounders were adjusted for and the reason to do so, when applicable. The sensitivity of the results to key assumptions or parameters should be explored with an uncertainty assessment.
Discussion: Interpretation	Main results	27	Describe the main results of the study according to the study objectives.
	Interpretation	28	Discuss relevant social and financial implications of the findings, in addition to environmental impacts (the “triple bottom line” framework). Particular attention should be paid to any implications for clinical service provision.
	Generalizability	29	Discuss the generalizability and applicability of the results.
	Limitations	30	Include a paragraph with the limitations of the study, including potential sources of bias. Discuss potential ways to overcome these limitations. If this has already been included in the interpretation section, may discuss additional limitations.
	Conclusion	31	If study findings have clear implications for a potential change in process, practice or policy, discuss the necessary next steps for researchers and key stakeholders (e. g., clinicians, suppliers, regulators).
		32	Draw the main conclusions from the study and recommendations for future study.

GI, gastrointestinal; GHG, greenhouse gas; CO2e, carbon dioxide equivalent.
Examples:

¹ “The functional unit of the study was chosen as ‘the use of endoscopic forceps to obtain a colonic biopsy,’ or ‘one diagnostic gastroscopy.’”

² Setting, floor area, heating, ventilation, air conditioning (HVAC) system, energy source, procedure mix and volume, decontamination protocol, staffing model, patient and staff travel patterns.

³ For example, if study authors include those with expertise in environmental or materials science.

⁴ Carbon footprinting, life cycle assessment (LCA).

⁵ Global warming, fine particulate matter formation, water consumption.

⁶ Whether activity data is process-based (e. g., production data or operational metrics) or financial (e. g., cost or expenditure records), and whether these are derived from primary or secondary sources.

⁷ “Utility use (water, electricity) was allocated to the endoscopy department by its share of floor surface area.”

⁸ Selection bias (e. g., limiting analysis to procedures with clear environmental benefits), measurement bias (e. g., variability in calculating carbon footprints or waste), or confirmation bias (e. g., focusing solely on positive outcomes of green initiatives).

⁹ Emission-related impact studies should specify the emission factors used and their origin, ensuring transparency regarding the reliability of the emissions factors, their relevance to endoscopy, their geographic and temporal applicability, and their scope and boundaries (e. g., cradle-to-grave or operational phases only). Disclose any related assumptions or uncertainties, and if a life cycle inventory database was used (e. g. Ecoinvent, Base Carbone).

¹⁰ Type, brand, major components, single-use vs. reusable, recyclable vs. non-recyclable.

¹¹ Scope 1, emissions directly produced from healthcare facilities, e. g. anesthetic gases or fossil fuels. Scope 2, indirect emissions, e. g. electricity or heating/cooling. Scope 3, emissions occurring in the health care supply chain, both upstream and downstream, e. g. transportation.

In the absence of guidelines or frameworks which provide specifically for the reporting of GI endoscopy sustainability studies, a variety of metrics and assessment tools have been employed in the literature. This methodological heterogeneity hinders a systematic comparison of reporting and data presentation. Acknowledging the challenges posed by the heterogeneity of reporting in GI endoscopy sustainability studies, in April 2024 the project leaders (J.A.C.N., R.B., E.R.D.S., and M.D.R.) carried out a relevance assessment phase, based on a systematic search of all studies on sustainable GI endoscopy, proposing an initial list of core domains and a preliminary checklist.

In June 2024, an email invitation to participate in the Position Statement was sent to a group of experts in sustainable GI endoscopy. The selection of panelists was conducted by the project leaders, according to their expertise in sustainable GI endoscopy, research background, and position statement development. The ESGE Executive Committee subsequently approved a final list encompassing 24 panelists, all of whom are practising gastrointestinal endoscopists.

A virtual online meeting was held in July 2024, during which panelists provided feedback on the Position Statement’s structure, preliminary list of domains, checklist, and glossary. A final list of 6 core domains: topic and overview (2 statements), background and aims (3 statements); data acquisition (4 statements) and data description (12 statements); outcome reporting and results presentation (5 statements); and interpretation (6 statements) ([Fig. 1]) was shared with the group, alongside a literature review text supporting the recommendations and a revised version of the checklist.

Fig. 1 The six core domains of gastrointestinal endoscopy sustainability studies.

The consensus among panelists for the checklist statements was reached using a modified anonymous Delphi process. A brief summary of the Delphi process is presented in [Fig. 2]. In November 2024 panelists voted and provided feedback for each statement in a free-text box. To reach consensus, a maximum of two voting rounds was established beforehand. Statements were graded with a 5-point Likert scale (1, Strongly disagree; 2, Disagree; 3, Neither agree nor disagree; 4, Agree; 5, Strongly agree) via SurveyMonkey (SurveyMonkey, San Mateo, California, USA; www.surveymonkey.com). Consensus was defined as ≥ 80 % agreement (the sum of Agree and Strongly agree) on each statement. Prior to the second voting round (December 2024), checklist statements and text modifications were reviewed and refined based on panelists’ suggestions. Response changes from one round to the next were considered relevant if ≥ 20 %. The results of each voting round are detailed in the Supplementary Material (available online-only). Once the voting rounds were complete, the project leaders shared a final draft of the manuscript for approval by all members. During this final assessment of the manuscript, no modifications of the checklist content were allowed.

Fig. 2 Delphi process for developing checklist statements.

The peer review process for ESGE policy documents was followed. Members from the ESGE board, along with project leaders and external experts reviewed the manuscript. The final position statement was approved by all authors and submitted to the journal Endoscopy for publication.

2.2 Search strategy

A systematic search for relevant articles in English from January 2014 until January 2024 was performed in the following databases: PubMed, Web of Science, and CENTRAL. The included search terms and strategy, combining keywords (e. g. MeSH) and natural language, are described in the Supplementary Material. Two authors (J.A.C.N. and R.B.) independently performed the literature search and reviewed the obtained results. This search included articles on sustainable GI endoscopy, focusing on methodology and reporting of environmental impacts.

2.3 Inclusion and exclusion criteria

The inclusion criteria for article selection encompassed original articles that aimed to quantify the environmental impacts of GI endoscopy. Systematic reviews, reviews, abstracts, posters, editorials, brief communications, letters to the editor, and non-English records were excluded. Following the elimination of duplicates, and screening based on titles and abstracts, the remaining articles underwent eligibility review by J.A.C.N. and R.B. When an overlap was identified, it was resolved by the corresponding authors (E.R.D.S. and M.D.R.).

2.4 Data extraction and outcomes

To facilitate systematic data extraction and methodological assessment of included studies, project leaders collectively agreed upon evaluating specific domains within each study. Variables of interest such as the first author of the study, year of publication, study setting and design, aims, and outcomes of the study were identified ([Table 3]). All relevant information was extracted by J.A.C.N. and R.B. independently.

Table 3 Published original articles on sustainable gastrointestinal endoscopy.

Author	Year	Setting	Study design	Aims	Outcomes
Gordon IO, et al. [24]	2021	USA	Cross-sectional study	Assessment of the environmental footprint of processing a GI biopsy sample	Primary outcome: carbon dioxide emissions (kgCO2e)
Namburar S, et al. [25]	2022	USA	Cross-sectional study	Assessment of endoscopic waste generation at a low- and high-volume hospitals and comparative impact assessment of single-use and reusable endoscopes	Primary outcome: average amount of waste produced per endoscopic procedure at each and both hospitals Secondary outcome: single-use endoscope waste estimation
Le NNT, et al. [26]	2022	USA	Cross-sectional study	Comparison of “cradle-to-grave” environmental and human health burdens of single-use and reusable duodenoscopes	Primary outcome: carbon dioxide emissions (kgCO2e) plus 22 other environmental indicators Secondary outcome: impact on human health
Cunha Neves JA, et al. [15]	2023	Portugal	Single-center prospective interventional study	Implementation of sustainable endoscopy practice and audit on waste carbon footprint and processing expenses in a low/medium volume endoscopy unit. Assessment of waste carbon footprint from diagnostic upper GI endoscopy and colonoscopy.	Primary outcomes: (i) waste carbon footprint (kgCO2e); (ii) waste-processing expenses – disposal of landfill and regulated medical waste in € per kg; (iii) presentation of retrieved data and educational seminars for endoscopy staff; (iv) reorganization and implementation of recycling streams within endoscopy rooms Secondary outcomes: (i) anonymous survey of the study's impact on daily work routine; (ii) waste carbon footprint of diagnostic GI upper endoscopy (kgCO2e) prior to and after intervention; (iii) waste carbon footprint of diagnostic colonoscopy (kgCO2e) prior to and after intervention
Yong KK, et al. [27]	2023	UK	Multicenter retrospective study	Assessment of the environmental and clinical impact of combining several small colorectal polyps within a single specimen pot	Primary outcome: carbon dioxide emissions associated with histology sampling (kgCO2e)
Lacroute J, et al. [28]	2023	France	Single-center retrospective observational study	Analysis of the annual carbon footprint of GI procedures performed in an ambulatory endoscopic digestive center	Primary outcome: carbon footprint of GI endoscopy (tCO2e) Secondary outcome: contribution (%) of each emission class to the total carbon footprint
López-Muñoz P, et al. [29]	2023	Spain	Single-center prospective interventional study	Determination of endoscopic instruments’ composition and LCA. Establishment of a recycling mark (“green mark”) on endoscopic instruments and assessment of its potential to reduce environmental impact related to GI endoscopy practice	Primary outcome: endoscopic instrument (biopsy forceps, polypectomy snares and hemostatic clips) composition analysis and LCA (carbon footprint) Secondary outcome: prospective intervention to assess carbon footprint differences based on the establishment of the “green mark”
Zullo A, et al. [30]	2023	Italy	Cross-sectional study	Ability of real time Endofaster-guided biopsies to reduce the environmental impact of upper GI endoscopy compared to conventional biopsy sampling	Primary outcome: comparison of CO2 emissions (kgCO2e) between Endofaster-guided biopsies and conventional biopsy sampling
Henniger D, et al. [31]	2023	Germany	Single-center prospective interventional study	Assessment of the yearly carbon emissions of a GI endoscopy unit	Primary outcome: annual Scope 3 emissions (tCO2e)
Shiha MG, et al. [32]	2024	UK	Cross-sectional study	Estimation of potential cost-benefits and environmental impact of noninvasive strategies for diagnosing celiac disease during adulthood	Primary outcome: overall cost savings (in pounds, £) Secondary outcomes: (i) GHG emissions from endoscopic procedures and biopsy samples (tCO2e); (ii) productivity savings (in pounds, £)
Desai M, et al. [33]	2024	USA	Single-center prospective observational study	Assessment of solid and liquid waste and energy use practices in a tertiary endoscopy unit. Assessment of staff-guided recyclable waste audit, encompassing examination of used and discarded materials, with identification of areas of potential improvement.	Primary outcome: total and per day waste generation and energy consumption during routine GI endoscopy Secondary outcomes: (i) average total waste per 100 procedures and annually; (ii) identification of potentially recyclable waste based on an audit
Elli L, et al. [34]	2024	Italy	Cross-sectional study	Environmental impact of inappropriate endoscopic procedures	Primary outcome: global carbon footprint (tCO2e) per endoscopic procedure
Ribeiro T, et al. [35]	2024	Portugal	Single-center prospective observational study	Estimation of endoscopic waste produced at a tertiary gastroenterology center	Primary outcomes: (i) amount of endoscopic waste produced in pre- and postprocedural areas, endoscopy rooms, and reprocessing area; (ii) waste-processing expenses as a result of waste disposal Secondary outcome: water consumption (liters) during reprocessing after a single endoscopy
Cho JH, et al. [36]	2024	South Korea	Single-center prospective observational study	Assessment of the environmental impact and cost reduction of using EGGIM score versus OLGIM staging through biopsy sampling	Primary outcome: environmental impact (kgCO2e) and cost reduction (dollars, $) of performing and processing biopsies according to OLGIM criteria versus optical diagnosis using EGGIM score
Pioche M, et al. [37]	2024	France	Single-center prospective observational study	Quantification of the GHG emissions related to a small-bowel capsule endoscopy (SBCE) examination	Primary outcome: GHG emissions (kgCO2e) of an SBCE procedure
Pioche M, et al. [38]	2024	France	Single-center prospective observational study	LCA comparison of carbon emissions of single-use versus reusable gastroscopes. Examination of environmental impact outcomes associated with reprocessing and waste management of single-use and reusable gastroscopes	Primary outcome: carbon footprint of single-use or reusable gastroscopes for upper endoscopy Secondary outcome: assessment of other environmental impacts

CO₂e carbon dioxide equivalent (kgCO₂e, kilograms; tCO₂e, tonnes); EGGIM, endoscopic grading of gastric intestinal metaplasia; GHG, greenhouse gas; GI, gastrointestinal; LCA, life cycle assessment; OLGIM, operative link on gastric intestinal metaplasia; UK, United Kingdom; USA, United States of America.

3 The 6 core domains of GI sustainability studies

3.1 Topic and overview (Title and abstract)

3.2 Background and aims (Introduction)

3.3 Data acquisition (Methods)

3.4 Data description (Methods)

3.5 Outcome reporting and Results presentation (Results)

3.6 Interpretation (Discussion)

4 Discussion

A review of the literature revealed 16 studies which have sought to quantify environmental impacts relating to GI endoscopy. There is notable heterogeneity across these studies, particularly with regard to the study setting, subject of analysis, and assessment methodology. Four studies are primarily quantifications of waste production in GI endoscopy [15] [25] [33] [35]. Three studies are described as carbon footprint studies, evaluated at the level of an endoscopy department [28] [31] [34]. Five studies report the use of life cycle assessment (LCA) to evaluate emissions generated by: (i) the processing of GI biopsies [24]; (ii) endoscopic accessories [29]; (iii) single-use duodenoscopes [26]; (iv) single-use gastroscopes [38]; and (v) small-bowel video capsule endoscopy [37]. Four studies predominantly use the findings from these previous studies to quantify the GHG emission profile of strategies that reduce the number of procedures performed or biopsies taken [27] [30] [32] [36].

In part, the methodological heterogeneity in the evidence landscape reflects the varied research questions that have been posed. The data, as it currently stands, cannot be aggregated for meta-analysis. However, a review of these studies does reveal inconsistency in the reporting of key environmental impact assessment requirements ([Fig. 3]). Particular parameters that have been inconsistently reported include the functional unit, the system boundary, and any assumptions or exclusions. An uncertainty assessment is also frequently omitted from the analysis. These aspects of environmental impact assessments need to be clearly and comprehensively communicated if readers are to understand the scope of the analysis and assess the generalizability of the study findings. If the evidence base is to inform strategies for mitigating environmental impacts, it is important that findings can be meaningfully compared across studies and that true variation in environmental impacts can be reliably distinguished from that attributable to methodological choices.

Fig. 3 Reporting of key environmental impact assessment requirements. GHG, greenhouse gas; LCA, lifecycle assessment.

Several guidelines do exist for evaluating environmental impacts, although none have been developed specifically for those conducting and reporting research studies in the setting of GI endoscopy. The GHG Protocol (2011) is the most widely used standard globally for measuring, managing, and reporting GHG emissions [39]. However, it is a general framework that can be applied across industries and not specific to the health care context. The GHG Protocol has been further built upon to provide more sector-specific guidance such as the Greenhouse Gas Accounting Sector Guidance for Pharmaceutical Products and Medical Devices (2012) [40] and the Sustainable Healthcare Coalitionʼs guidance on appraising clinical care pathways [41]. LCA is a systematic method used to evaluate a range of environmental impacts associated with all stages of a product’s life cycle, from the extraction of raw materials to its disposal or recycling. The conduct of an LCA is guided by a pair of international standards which specify the principles and framework (ISO 14040) [9] and the requirements and guidelines (ISO 14044) [42].

These guidelines have been variably referenced in the “green endoscopy” studies published to date. There is currently no guideline tailored to the reporting of environmental impact assessments in the field of GI endoscopy. We have drawn on the core reporting principles from existing guidance documents and adapted these to produce a reporting checklist which is accessible to endoscopists. The checklist is not expected to serve as a fully prescriptive nor exhaustive guideline. Instead, the checklist is a set of minimum reporting standards which aims to improve clarity, transparency, and the quality of reporting in the field of “green endoscopy.”

Disclaimer

The legal disclaimer for ESGE Guidelines [23] applies to this Position Statement.

Conflict of Interests

Mário Dinis-Ribeiro has received consultancy fees from Roche and Medtronic. Ian M. Gralnek declares Motus GI, Medtronic, Boston Scientific, CheckCap, Clexio Biosciences, Astra-Zeneca, and Vifor Pharma as competing interests. Heiko Pohl declares work for Olympus and Pentax. Enrique Rodríguez de Santiago declares educational and advisory activities for Olympus, educational activities for Apollo Endosurgery, congress fees from Norgine and Casen Recordati, speaker’s fees from Izasa and 3-D Matrix, research grant from 3-D Matrix, and advisory work for Adacyte Therapeuthics. The remaining authors declare that they have no conflict of interest.

^‡ Joint first authors

^* Joint senior authors

• References

• 1 Lenzen M, Malik A, Li M. et al. The environmental footprint of health care: a global assessment. Lancet Planet Health 2020; 4: e271-279
• 2 Rodríguez de Santiago E, Dinis-Ribeiro M, Pohl H. et al. 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. Endoscopy 2022; 54: 797-826
• 3 Sebastian S, Dhar A, Baddeley R. et al. Green endoscopy: British Society of Gastroenterology (BSG), Joint Accreditation Group (JAG) and Centre for Sustainable Health (CSH) joint consensus on practical measures for environmental sustainability in endoscopy. Gut 2023; 72: 12-26
• 4 Neves JAC, de Santiago ER, Pohl H. et al. Perspectives and awareness of endoscopy healthcare professionals on sustainable practices in gastrointestinal endoscopy: results of the LEAFGREEN survey. Endoscopy 2024; 56: 355-363
• 5 Cunha MF, Pellino G. Environmental effects of surgical procedures and strategies for sustainable surgery. Nat Rev Gastroenterol Hepatol 2023; 20: 399-410
• 6 Intergovernmental Panel on Climate Change. Glossary, annex I 2018. Accessed 23 Mar 2024: https://www.ipcc.ch/sr15/chapter/glossary/
• 7 Carbon Trust. A guide to carbon footprinting for businesses. Accessed 13 Mar 2024: https://www.carbontrust.com/en-eu/our-work-and-impact/guides-reports-and-tools/a-guide-to-carbon-footprinting-for-businesses
• 8 United States Environmental Protection Agency. What is a circular economy?. Accessed 23 Mar 2024: https://www.epa.gov/recyclingstrategy/what-circular-economy
• 9 International Organization for Standardization. ISO 14040:2006(en) Environmental management — Life cycle assessment — Principles and framework. Accessed 16 Mar 2024: https://www.iso.org/obp/ui#iso:std:iso:14040:ed-2:v1:en
• 10 United States Environmental Protection Agency. Understanding global warming potentials. Accessed 16 Mar 2024: https://www.epa.gov/ghgemissions/understanding-global-warming-potentials
• 11 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
• 12 Centre for Sustainable Healthcare (CSH) Networks. Green endoscopy. Accessed 23 Mar 2024: https://networks.sustainablehealthcare.org.uk/network/green-endoscopy
• 13 Finkbeiner M. The international standards as the constitution of life cycle assessment: the ISO 14040 series and its offspring. In: Klöpffer W. (ed.). Background and future prospects in life cycle assessment. Dordrecht: Springer Netherlands; 2014: 85-106
• 14 de Melo Jr. SW, Taylor GL, Kao JY. Packaging and waste in the endoscopy suite. Techniques Innovations Gastrointest Endosc 2021; 23: 371-375
• 15 Neves JAC, Roseira J, Queirós P. et al. Targeted intervention to achieve waste reduction in gastrointestinal endoscopy. Gut 2023; 72: 306-313
• 16 Barna S, Maric F, Simons J. et al. Education for the Anthropocene: planetary health, sustainable health care, and the health workforce. Med Teach 2020; 42: 1091-1096
• 17 Whitmee S, Haines A, Beyrer C. et al. Safeguarding human health in the Anthropocene epoch: report of The Rockefeller Foundation–Lancet Commission on Planetary Health. Lancet 2015; 386: 1973-2028
• 18 Karliner J, Slotterback S, Boyd R. et al. Health care’s climate footprint Health care without harm 2019. Accessed 23 Mar 2024: https://noharm-global.org/sites/default/files/documents-files/5961/HealthCaresClimateFootprint_092319.pdf
• 19 World Resources Institute. Greenhouse gas protocol 2022. Accessed 23 Mar 2024: https://www.wri.org/initiatives/greenhouse-gas-protocol
• 20 Mortimer F, Isherwood J, Wilkinson A. et al. Sustainability in quality improvement: redefining value. Future Healthc J 2018; 5: 88-93
• 21 Ganatra S, Dani SS, Al-Kindi SG. et al. Health care and climate change: challenges and pathways to sustainable health care. Ann Intern Med 2022; 175: 1598-1600
• 22 Elkington J. Enter the triple bottom line. 2013 Accessed 29 Mar 2024: https://johnelkington.com/archive/TBL-elkington-chapter.pdf
• 23 Hassan C, Ponchon T, Bisschops R. et al. European Society of Gastrointestinal Endoscopy (ESGE) publications policy – Update 2020. Endoscopy 2020; 52: 123-126
• 24 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
• 25 Namburar S, von Renteln D, Damianos J. et al. Estimating the environmental impact of disposable endoscopic equipment and endoscopes. Gut 2022; 71: 1326-1331
• 26 Le NNT, Hernandez LV, Vakil N. et al. Environmental and health outcomes of single-use versus reusable duodenoscopes. Gastrointest Endosc 2022; 96: 1002-1008
• 27 Yong KK, He Y, Cheung HCA. et al. Rationalising the use of specimen pots following colorectal polypectomy: a small step towards greener endoscopy. Frontline Gastroenterol 2023; 14: 295-299
• 28 Lacroute J, Marcantoni J, Petitot S. et al. The carbon footprint of ambulatory gastrointestinal endoscopy. Endoscopy 2023; 55: 918-926
• 29 López-Muñoz P, Martín-Cabezuelo R, Lorenzo-Zúñiga V. et al. Life cycle assessment of routinely used endoscopic instruments and simple intervention to reduce our environmental impact. Gut 2023; 72: 1692-1697
• 30 Zullo A, Chiovelli F, Esposito E. et al. Can gastric juice analysis with Endofaster® reduce the environmental impact of upper endoscopy?. Healthc Basel Switz 2023; 11: 3186
• 31 Henniger D, Windsheimer M, Beck H. et al. Assessment of the yearly carbon emission of a gastrointestinal endoscopy unit. Gut 2023; 72: 1816
• 32 Shiha MG, Nandi N, Hutchinson AJ. et al. Cost-benefits and environmental impact of the no-biopsy approach for the diagnosis of coeliac disease in adults. Frontline Gastroenterol 2024; 15: 95-98
• 33 Desai M, Campbell C, Perisetti A. et al. The environmental impact of gastrointestinal procedures: a prospective study of waste generation, energy consumption, and auditing in an endoscopy unit. Gastroenterology 2024; 166: 496-502.e3
• 34 Elli L, Mura SL, Rimondi A. et al. The carbon cost of inappropriate endoscopy. Gastrointest Endosc 2024; 99: 137-145.e3
• 35 Ribeiro T, Morais R, Monteiro C. et al. Estimating the environmental impact of endoscopic activity at a tertiary center: a pilot study. Eur J Gastroenterol Hepatol 2024; 36: 39-44
• 36 Cho JH, Jin SY, Park S. Carbon footprint and cost reduction by endoscopic grading of gastric intestinal metaplasia using narrow-band imaging. J Gastroenterol Hepatol 2024; 39: 942-948
• 37 Pioche M, Neves JAC, Pohl H. et al. The environmental impact of small-bowel capsule endoscopy. Endoscopy 2024; 56: 737-746
• 38 Pioche M, Pohl H, Neves JAC. et al. Environmental impact of single-use versus reusable gastroscopes. Gut 2024; 73: 1816-1822
• 39 World Resources Institute. Greenhouse gas protocol, product life cycle accounting and reporting standard 2011. Accessed 27 Mar 2024: https://www.wri.org/research/greenhouse-gas-protocol-product-life-cycle-accounting-and-reporting-standard
• 40 Environmental Resources Management. Greenhouse gas accounting sector guidance for pharmaceutical products and medical devices 2012. Accessed 27 Mar 2024: https://ghgprotocol.org/sites/default/files/tools/Summary-Document_Pharmaceutical-Product-and-Medical-Device-GHG Accounting_November-2012.pdf
• 41 Sustainable Healthcare Coalition. Care pathways: Guidance on appraising sustainability – Main document (Second edition). Accessed 27 Mar 2024: https://shcoalition.org/wp-content/uploads/2024/01/Sustainable-Care-Pathways-Guidance-Main-Document-December-2023.pdf
• 42 International Organization for Standardization. ISO 14044:2006 – Environmental management — Life cycle assessment — Requirements and guidelines. Accessed 27 Mar 2024: https://www.iso.org/standard/38498.html

Publication History

Article published online:
20 March 2025