Continue using simethicone for endoscopy: GESA

GI tract

By Michael Woodhead

4 Jul 2019

The de-foaming agent simethicone can continue to be used to prevent bubbles in the lumen that impair muscosal assessment in GI endoscopy procedures, GESA says.

A new position statement from GESA contradicts warnings from endoscope manufacturers who have recommended that simethicone not be used due to concerns of biofilm formation and a possible increased the risk of microorganism transmission.

But the June 2018 advisory letter from Olympus is not based on evidence derived from decades of use, according to GESA, and there is still a place for the agent if it used appropriately and with adequate cleaning and disinfection protocols.

In its statement, GESA notes there have been concerns about the use of simethicone for many years, leading to contradictory advice from various international gastroenterology bodies. The European Society of Gastrointestinal Endoscopy (ESGE) recommends adding simethicone to standard bowel preparation for colonoscopy, whereas the British Society of Gastroenterology advised that the concentration of simethicone be kept to a minimum and that it be administered orally or via the biopsy port and not via the water bottle or flushing pump.

A working group of GESA’s Infection Control in Endoscopy Guidelines (ICEG) Committee, led by Dr Benedict Devereaux  of Queensland University, therefore conducted an evidence review.

Their literature search found no published reports of adverse events related specifically to the use of simethicone, delivered either orally or via any endoscope. The committee therefore concluded that the benefits of simethicone use in improving mucosal assessment, polyp detection rate, adenoma detection rate and reducing procedure time outweighed any possible risk of adverse events.

They acknowledged published reports documenting residual liquid or crystalline simethicone in endoscope channels after high level disinfection, and a lack of data confirming that simethicone can be cleared from channels by brushing. But they said there was no evidence that simethicone promoted biofilm formation or that the presence of biofilm promoted simethicone residue in endoscope channels.

“After assessing the benefits and risks, we consider it important to continue the use of simethicone during gastrointestinal endoscopic procedures to suppress bubble formation and optimise mucosal inspection,” they wrote.

“Given the evidence of improved quality of endoscopic imaging and polyp detection, without evidence of clinical adverse events over decades of use, we believe that continued use of simethicone is appropriate and it can be administered through any endoscope channel.”

“We also emphasise that strict adherence to instrument reprocessing protocols is essential.”

GESA recommendations on simethicone:

  1. The continued use of simethicone is considered reasonable as it improves mucosal inspection during gastroscopy and colonoscopy and likely facilitates adenoma detection at colonoscopy. Evidence Level: IA, Recommendation Grade: A
  2. The smallest effective quantity of simethicone should be added to lavage fluid. A suggested, yet untested concentration, would be 2-3ml of 120mg/ml (ie 0.24-0.36% (g/L)) simethicone added to 1L of sterile water. Level of Evidence: IV, Recommendation Grade: D
  3. Simethicone may be administered orally or through any endoscope irrigating channel. Evidence Level IV, Recommendation Grade D
  4. Strict adherence to instrument reprocessing protocols is essential. We highlight the importance of immediate bedside pre-clean endoscope decontamination that includes post-procedure flushing and prompt commencement of manual or machine cleaning. Evidence level: IIb, Recommendation grade:B

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