title: Use of flexible endoscopes for NOTES: sterilization or high-level disinfection?
abstract: BACKGROUND
  Natural orifice translumenal endoscopic surgery (NOTES) involves the use of flexible endoscopes to perform intra-abdominal or intra-thoracic surgeries. Surgery in the operating room usually involves sterile instrumentation, whereas in the endoscopy suite high-level disinfection seems to be sufficient. Our objective was to assess the necessity for endoscope sterilization for clinical NOTES and to develop an endoscope processing protocol based on a score for the available processing options.
  
  
  METHODS
  Score and processing protocol development for clinical NOTES endoscopes was based on a comprehensive review of the available relevant literature. Options for sterilization for flexible endoscopes in the Good Samaritan Hospital, Legacy Health in Portland, Oregon, were analyzed for patient safety, potential for recontamination, cost, and validation.
  
  
  RESULTS
  Literature survey indicated that there is controversy surrounding the necessity for sterilization of surgical endoscopes. However, standard of practice seems to call for sterile instrumentation for surgery and it is possible to terminally sterilize flexible endoscopes. Within our institution, a score was created to rank the available sterilization options. We successfully introduced a protocol for sterilization of endoscopes for use in clinical NOTES procedures. The protocol involved mechanical cleaning and high-level disinfection per Multi-Society Guidelines, with subsequent terminal sterilization using a validated peracetic acid protocol.
  
  
  CONCLUSIONS
  It remains controversial whether sterile instrumentation is truly needed for surgery. It is difficult but possible to terminally sterilize flexible endoscopes. We recommend sterile instrumentation for clinical NOTES until well-designed, randomized, clinical trials are available and guidelines are published.
authors.affiliation: Legacy Health, Portland, OR, USA. georg.spaun@gmail.com
authors.forename: Georg O
authors.initials: GO
authors.lastname: Spaun
authors.forename: Trudie A
authors.initials: TA
authors.lastname: Goers
authors.forename: Richard A
authors.initials: RA
authors.lastname: Pierce
authors.forename: Maria A
authors.initials: MA
authors.lastname: Cassera
authors.forename: Sandy
authors.initials: S
authors.lastname: Scovil
authors.forename: Lee L
authors.initials: LL
authors.lastname: Swanstrom
mesh_terms: D002985:Clinical Protocols; D004203:Disinfection / Q000379:methods / Q000592:standards; D019723:Endoscopes; D004724:Endoscopy; D004866:Equipment Contamination; D006801:Humans; D019060:Minimally Invasive Surgical Procedures / Q000295:instrumentation*; D013242:Sterilization / Q000379:methods* / Q000592:standards