can do, and the safety of ERCP, and kind of building on the same thing, the safety of deodinoscopes themselves. I think Dr. Lee did a great job on showcasing what the procedure, how to make that safe. I'm going to talk about the actual equipment and the device itself. So we're going to go over some deodinoscope-related issues and what we've done to overcome them. So over the years, as Dr. Chahal and Dr. Rain, I thank you for giving this invitation and having me here today with this lineup. And the reason that we're all here is this is an ever-growing field. I don't think ERCP is an old procedure. It's actually gotten more dynamic. It's transitioned from diagnostic modality to a therapeutic modality. And within the therapeutic modality, there are more and more innovations coming down. And our industry partners have been our friends in filling the needs of what we do. And we take the devices and equipment and use them on-label, off-label for the benefit of our patients as we innovate the field. This data is over a decade old, but these numbers keep growing. The current number for the last year was anywhere between 650,000 to 700,000 ERCPs performed annually. And it may be performed for various indications, as we heard, for stones, strictures, malignancies. And whenever there is a blockage of bile, this causes stasis. And this bile stasis causes sludging or thickening of the bile. And that inherently is a very rich medium for infection or bacteria to grow. And if this is left untreated, it's going to affect the patient and cause sepsis. Now when we do an exogenous or endogenous pathogens, it would be introduced by the ERCP because now we are violating the biological barriers. By doing a sphincterotomy, we're connecting this to the enteric environment, which inherently has a lot of bacteria that can now be introduced. So this big thing started about a decade ago, roughly, where there was this outbreak of deodorinoscope-related infections across the country. And people think it's the West Coast, but it's not. It's actually all over the country and closer to home in Pennsylvania. This was at UPMC. This was in centers in Florida and the Midwest, all over. And there was this superbug outbreak. And what happened is when people started looking at various centers at UCLA, Cedars, UPMC, Johnson, as we saw from the map all over, suddenly people started realizing that there were these multidrug-resistant organism infections that the patients were getting. And then when they did a root cause analysis of where this was coming down, they were able to pinpoint this as a deodorinoscope-related infection in all these cases. The biggest issue that they found was adherence to the manufacturer's instructions and guidelines was not following them. And I cannot stress this enough on the training that it is so vital for our endoscopy staff, nurses, techs who process these scopes. They're literally playing with life and death. We think that we are affecting the patient with the procedure, but having the clean equipment, having processes, quality metrics is so vital. And then we realized that it wasn't actually their fault entirely either. It's not that they were not following it, but it's inherently the instrument itself. And we'll go into some of these technical complexities of how complex it is for a deodorinoscope compared to a regular endoscope or a colonoscope. So for endoscopes in general, there are long, narrow lumens that are hard to clean, hard to get into. We need tiny devices to clean these. Especially for a deodorinoscope, there is angles and bends. It's not a straight channel. So with the elevator, it's a side-viewing scope with the lens pointing to the left. And that's because the ampulla is on the side. It's not straight in the lumen. So you need a scope that looks at the side. Now that means the devices have to come out sideways. There are rough and pitted surfaces. The elevator, the lens, everything has valleys and crevices that infections can get harbored and more importantly are harder to clean for reprocessible scopes. There are springs, valves, damaged scope channels with reusable scopes. Over time, these scopes break down and cause these damaged chips. This presence of biofilms inherently for deodorinoscopes especially, we're dealing with cholangitis, we're dealing with obstructions and tumors, all of this comes into the scope. And it's not like a prepped colon where it's clean. This is inherently a dirty area you're trying to get into. So all of these biofilms develop in the scope. Many times, as Dr. Lee showed, we do multiple procedures. We do EGD with EUS and ERCP. So there are multiple scopes laying in the room. As per the instructions, as soon as you're done with the scope, less than an hour, the scope should be reprocessed. Some of these cases go for two to three hours when you have a dirty scope sitting in there with the biofilm that now solidifies. So that actually creates a harder to clean scope. So our rules have been, if you need the scope again, just get a second scope. Get a new scope. But again, do you have the inventory to do that? You know, if you only have one or two deodorant scopes and there is two rooms going, you cannot just send it back in and then expect another scope to be ready. So there are operational challenges to this as well. Heavy contaminants and then the cleaning essentials for safe instrument use. So this is what a deodorant scope looks like sideways, where you have the scope with the camera light channel, the air water nozzle on the side. So the front of the scope is blind. It's literally a blind passage. Because you're looking on the side of the lumen, not on the front of the lumen. Also as you can see, when the equipment comes down in a normal gastroscope or colonoscope, the channel is pointing front. So the devices, biopsy forceps, snares, clips, they come in straight. Here they literally have to make a right angle turn. So they come down the channel, and then through the elevator, they make a hard right. And unlike EOS scopes, which are oblique view, where there is not a hard channel, this is one of the most acute channels in all the endoscopes that we use. So all devices have to be flexible, as well as the scope has to be robust enough to bend it and let it come out on the side. So in the device design, if you can see, normally there is the suction channel that goes through the endoscope channel itself. There is an air water channel that's what cleans the lens. There is the suction channel that then continues down the scope and out. And then there's the CO2 or the insufflation channel. So all of these different channels have to travel through the umbilicus and then down the shaft of the scope. Again, with more complex devices like colonoscopes, now we are delivering thicker, bigger devices that have to fit in these channels with everything else that's crowded in there. So this is a highly complex mechanism. We just see the end product, but all the engineering that goes into it is not easy, and to make it all clean and reusable. So if you think about endoscopy, other than the endoscopes, almost everything is disposable. It's a single-use item. Snares, biopsy forceps, graspers. And not too long ago, these were all reusable. We would reprocess them, clean them, high-level disinfect them, sterilize them. And then because of these inherent issues, do we really have the right resources to clean these things appropriately? And the answer is no, which is why we've gone towards single-use items. The only thing we still reuse is an endoscope. And more importantly, the duodenoscope. So the scope-tip design. Now we're going to focus on this is where the root cause problem lies, is the rest of the scope is similar to a gastroscope or a colonoscope. The problem comes in the tip, and that's how complex a duodenoscope is, or ERCP scope is, is there is the lens channel, there is the insufflation, but there is the elevator where things come out of. And then this is a cut view of the mechanism of the elevator itself. So if you think of a EOS scope, the most complicated things it handles is probably a lumen-opposing stent or a FNF or a FNB needle. But here, there are so many devices a duodenoscope handles, sphinctrotomes, stents, needle knives, cholangioscopes, you know, all sorts of things. And every single item has to function over an elevator. So the scope not only has to function by itself, but also has to make the equipment function that goes through them. So this is an opened-up view compared to open- and closed-channel duodenoscopes. We almost don't have these anymore, and this was as a result of this outbreak that happened about a decade ago. But this is a traditional duodenoscope where it's sealed. So as you can see, the only accessible way to clean them was through the front. So we would put cleaning brushes down from the front, but you could imagine there's no way to get to the back, and that's where things are going to hide, is when you have that elevator, it's going to be very hard to clean behind that. And this is that opened-up view. So once you open the distal covering, you could see getting behind this area is what was important. Also, with the elevator, this elevator is very different than an EOS elevator. This elevator has locking mechanisms in it. It's sharp. As I mentioned, it has to literally deflect the devices at a 90 degree, so it has to be robust to be able to bend that, all the devices to come out sideways. And the conventional wire elevator channel is where the problem was. So when they did analysis, so this is an Olympus TJF Q180V. So the 180 scopes, when this outbreak happened, they looked at where the problems lied in, and they found that over time, there is an o-ring that seals the glass or the lens. And this o-ring breaks down, just like any plumbing issue. You know, we have a o-ring that goes in that seals fluid from going in or out. Over time, this o-ring disintegrates. Imagine putting it through a high-level disinfectant in high-volume endoscopy centers where we're doing multiple cases. Over time, it's either going to stiffen up or crack, and that's where leaks happen. So they found that there was bile and sludge inside the camera. You can see it right there at 6 o'clock. And there's no way to get that out once it gets there, and that's what's going to harbor the mechanism. Now imagine putting this from one patient to another. Or imagine doing this to your family. If this was a family member, that you took out a scope and now you're going to put this dirty scope in somebody else. Without even realizing this was happening, obviously this was not intentional. And then they looked at the various tips, and when these were cultured, there were bacteria that were harboring inside all of these cracks. And this is an electron microscope view, and what looks amazingly smooth on the outside, you could tell that it is a very rough surface. So when they did the electron microscope view of the distal tip, there were cracks in the sheathing or the shielding of the deodorant scope, and the surface is where the bacteria were harboring. So the point of this was that the deodorant scope design over time was a problem. That there had to be a better way to clean it. We cannot make it not dirty. We're literally doing it to fix cholangitis in person. As you've all been part of cases, you literally see just purulent discharge coming out of the bile duct. So all of that harbors on the scope. And no matter how great the techs are or the nurses are in cleaning it, the design of the deodorant scope just does not permit that level of cleaning or the access into it. So FDA did a review of this. This was a big deal where all the companies who makes deodorant scopes, Fuji, Olympus, Pentax, you name it, everybody started looking at their designs on how to make this better. This was a learning opportunity for everyone. And FDA looked at it and said, is it even worth having a deodorant scope? Because if you cannot make it better, you know, the first thing was do no harm, right? You don't want to fix a patient, but then cause these outbreaks and people are dying from a procedure that they needed. And then we found out that the benefits outweigh the risk. There was still a huge societal benefit in saving these patients. These are life saving procedures. Yes, there is the risk of infections, but we could potentially do something about it. But the answer was not, not using deodorant scopes. But it literally got to that point. The time to cleaning was the most important step in the process of reprocessing these scopes. And the time to cleaning was vital to the appropriate cleaning and reprocessing. If you use a scope, it should be cleaned within an hour. There should be an immediate bedside cleaning also. So there's a chemical cleaning that happens immediately at the bedside, and then there is a high level disinfection that happens at the back end in the scope reprocessing room. The other part was standardization of protocols for reprocessing. Should we be doing post-procedure surveillance? Should we be culturing all our deodorant scopes after being used? And we at Geisinger looked at it also, and luckily did not find any clinically significant infections that were still harboring. Now again, these are not sterilized scopes. So there will be some level of contamination, right? Because this is just soap and water and chemicals cleaning it. You're not putting it in a sterilization unit. However, it should be to an acceptable point that it's not going to be risky to the patient. And then those who reprocess scopes should be trained and certified. This is where societies like ASGE, these programs make a difference in partnering and training our endoscopy lab. So there is an ASGE program that actually trains the endoscopy techs and nurses on how to take care of these equipment, because we rely on them. When a tech hands me a scope, I'm not going to go there and culture and swab it. If there is a tag on it that says it's cleaned, I take it for its face value. But it's important that we train our techs on how to do this right, and that there is a standardization, because it shouldn't be the blind leading the blind. If somebody's making a mistake and they're teaching the new trainee the same thing, they're going to keep repeating the same mistake. So some of the QIs we do is we'll have the vendors come in and watch our techs and make sure that they're following all the protocols. Because if they made the high-level disinfectant machines and they can tell us, well, you missed a step here, you could do this better. So having those quality metrics, having taken them ASGE courses to better educate them, this is important in the procedure we do, because they are our partners. At the end of the day, as Dartley mentioned, it's our name. We are finally responsible for that procedure. The team is behind us. But if something bad happens to the patient, that's my patient, my procedure. So I have to make sure I have a good team behind that. The sterilization may be the best way, but is it the most practical way? With sterilizing scopes, there are almost no outbreaks, but not all facilities have sterilization capabilities. And it is costly, time-consuming, and also, do we have the inventory? So if something goes for sterilization, do we have enough scopes to keep going? Also, sterilization is much more caustic to the scope. So will the scope then have the same life as it would versus high-level disinfection? So the point of it was just having protocols for scope surveillance and just doing it right the first time. So where do we go from here? The ultimate solution is a design change, but that's going to take time. And it is happening. You know, we've come a decade since then. This was a 10-year-old story. We have made design changes. Our industry partners have made design changes based on the feedback that we've given them. And the short-term changes are just enhanced cleaning methods. Just follow the protocol strictly. Don't skip a step. Don't rush your staff. I need a scope. The next patient's there. Come on, give it to me quick. Or, you know, get it out of the washer. We've all done that. Let it dry. Let it hang. That drying process is there for a reason. Don't take a wet scope and reuse it just because you're running short on time. Schedule it better or increase the scope inventory. Redundancy, enhanced cleaning methods, quality controls, visual cues. If you see a crack in the scope, we've also started boroscopes where we check the channels now. So especially for these scopes that are heavy use scopes, we'll put a scope through the scope. So there are boroscopes that you can do channel checks and make sure that there is no cracks or dents inside the scope channel. And that, if you see that, then that needs to be sent for repair and taken out of circulation. And there are loaner scopes you can get for that. Measurement of the time required to adequately perform these high-level disinfection. So many units now have smart cabinets that track the time and hang these. And they tell us when the scope is good, when it's not good, when they expire. Don't let them hang. You know, we have a seven-day time. So we have a seven-day hang time. If it's not used in seven days, it goes back to cleaning. You just don't let it hang and keep using it. So Olympus did this very proactively because the initial outbreaks were tracked down to the Olympus scopes. And again, I don't think it's anything to do with Olympus. That's just the most commonly used scope. So that's how most of these were related to that TJQ180 device. So the FDA looked into this, and Olympus recalled the duodenal scopes because of reduced infection risk. And then there was a cost utility study that looked at competing strategies to see not just practicality of it, but what's the most cost-effective strategy. So do we perform ERCP by just a strict FDA-recommended endoscope reprocessing versus ERCP followed by endoscope culture and hold? So after a clean scope comes out, you culture it, you hold it. The culture is clean, then you use it. Versus performing ERCP with sterilization. Do you sterilize every single scope like the OR does, right? Any equipment in the OR, it's not a high-level disinfection. These are sterilized equipments. But at the same time, these are sterile fields. What we do is completely not sterile. As soon as you touch the mouth, there is no sterility left, right? There's bacteria. As soon as you enter the oral cavity and then all the way down. But does sterilization get rid of that cross-contamination? Or just stop performing ERCP altogether and go back in time and do lab cholecystectomy with a common bile duct exploration, just don't use the scopes anymore. And the outcome was assessed in regards to quality-adjusted life years. And what they found was that the ERCP with just following a strict protocol was the most cost-effective strategy. So it wasn't that don't use the scope. It wasn't to sterilize the scopes. That's not practical or cost-effective. But just follow the protocol. And it seems simple enough, right? Just follow the rulebook. But it's interesting until something bad like this happens as we all wake up, it's like, wait, I gotta follow what the rulebook says. Both the ERCP with culture and the hold were unacceptable strategies for significantly cost without improving quality of life. The lab cholecystectomy with a bile duct exploration dominated both more costly and less effective. Again, the success rates of these are not the best. And in sensitivity analysis, the ERCP with culture and hold was the most cost-effective approach. But the pretest is that that only works if your CRE infection risk is greater than 24%. So if you have a high-risk population, and there is some value to this, right? Because this lays the groundwork for the single-use scolangioscopes. If you have a high-risk patient, or if you have a high-risk population, then yes, actually holding it and making sure it's a clean sterile scope does make sense. But if it's less than that probability, it does not. So there is a fine line here that there is value in single-use scopes as well. So the institutions where there is low CRE prevalence, all you gotta do is just wash it, right? That's all, right? It's like hand washing. Who really follows the 10-second rule, right? You're sitting there and scrubbing. Like, yes, we all know we should be washing our hands, but do we really do it? And this says, yes, actually wash the scopes as it's supposed to be. The only settings with extremely high CRE prevalence, greater than 24%, is the culture and hold becomes cost-effective. Now, but do you have the inventory to do that, right? So it's cost-effective, yes, but now do you have 10 deodinoscopes just hanging on the wall to let one sit, waiting for the culture to come back? So after multiple outbreaks of transmissions of MDROs, again, something bad has to happen before we wake up, FDA made recommendations to mediate this of double reprocessing. So you wash it once and then you wash it twice. So you follow the same protocol and then do it twice. Sterilization, again, if you have the means and the facilities to do that. Routine culturing, just randomly culturing the scopes, making sure that the staff is truly following what you're supposed to. Using modified scopes or disposables, and we'll touch on this, of how industry innovated and kind of found us an in-between that wasn't as onerous and made it easier and reduced that risk. And then asking the scope manufacturers to just simplify the process. Has anybody actually read the Olympus rule book on how to clean this? It is so onerous. I have, as the end of director, I sat with the techs and they're like, you're telling us to follow this. Have you actually read it? I'm like, no, I haven't. And if you go through it, it's like, oh, wow, this is crazy. It's how complex it is, teaching it. And again, for our techs, right? If you are a doctor, you go through medical school. If you're a nurse, you go through nursing school. For the techs, for the most part, these are not specially trained people. We train them on the job, right? So our requirement is a high school or a college graduate who has some healthcare experience. But these are not people who've gone through any medical or healthcare related schooling or training. Now you're taking them and telling them to do something that's gonna literally affect people's lives, right? That's how important education is. And asking to simplify it made sense. So again, these IFUs are made for the FDA. They are these thick booklets that companies submit to the FDA to get approval for their device. But they're not the ones following it. It's our endoscopy friends and technicians doing it. So simplifying this process made a big difference as well. But what were some of the changes that did happen as a result of this? One is the disposable scope. So Boston Scientific and Ambu, the A-scope and the Exalt, just use a fresh, clean, sterilized scope every single time, right? You have good mechanisms on them. They're not beaten down. They don't have loose dials. But the trade-off is that you need a new scope every single time. There is cost to it, right? There's an increase. There is an environmental burden. You're literally throwing these out in the garbage every single time you use them. But the in-between was a disposable cap. So this is what most of the companies did. Olympus, Pentax, and Fuji, the three big scope manufacturers, they made cleaning a little bit easier. So what Pentax did is they came out with this disposable tip with the elevator built in. So once we found out the elevator is the problem, they said, why don't we just have a throwaway elevator? Why do you have to clean it? That's where the problem lies. So the entire tip with the elevator is disposable. So the tip comes off, and all of this you don't have to clean. You just clean the clipping mechanism where it attaches to the scope. Olympus has a disposable cap, but the elevator stays on. So the elevator is not disposable, but they made it easier to get around it and clean it. The back was the problem. Again, the staff has to make sure they're following those cleaning instructions. So Olympus can only give you the product. You still are responsible for cleaning it. So getting behind the nooks and crannies and cleaning it well is what they did. And then same thing with Fuji. They removed the ceiling that is now disposable. So different solutions. Some work better than others. For challenging cases, sometimes having a robust elevator is important. So having that metallic elevator may be a little bit more robust than having a plastic elevator. But if you're doing basic cases, then here you don't have to worry about cleaning. So again, whatever fits your practice. But they definitely did make a difference on making this easier to clean. So the clear cap can be removed, making cleaning easier, what I just mentioned. There is no data that these made any difference. So is this truly an optics? Because nobody studied it. However, we've not had a major outbreak. We're not on the news anymore. People are not looking at ERCPs and saying, oh my God, this doctor's gonna kill me. Or the labs are in violation of everything. So they definitely got us out of the news. So that's a good thing. But we don't have objective data to show that this actually made a difference. In my experience, there are some things you have to be careful about. The cap can fall off because it's not welded shut or taped shut. It's not even clipped. It's just a sleeve on. So if the tech does not put it on properly, it can sleeve off. Especially if you're putting devices through it, the device can get caught. So I have had cases where coming out and when the scope comes out, I'm like, where's the cap at? And then you go back down with the gastroscope and it's sitting in the duodenum. Again, so the point is inspect your devices. Don't just take the scope and walk away. Inspect, so we actually have a clause in our endoscopy report that you check all devices and equipment for integrity upon withdrawal. So if you removed something, if you removed a snare, did the snare break? If you removed a stent, is half of it left in the patient? Did the flange fall off the stent? Same thing for the duodenoscopes. Make sure that the cap is there intact out of the patient. Cap can entrap mucosa, so if it's not sleeved in, so if it doesn't fall off, but if it kind of slips off, it creates a gap in the middle. And as you're pulling out, it can catch a loop of bowel and it can cause a mucosal tear and can cause bleeding. So if you come out and there is a piece of tissue hanging in there, something's wrong. Go take a look again. That you don't have to clip it or cauterize it. And then the poor function with cholangioscope. Again, you have to have things that are robust. Again, with this disposable tips, will a cholangioscope go through it? Can it elevate? Now remember, a cholangioscope, just like any other device, has to make that right turn or a left turn out of the scope, so make that 90 degree turn with this disposable caps. Then comes the single use devices. It's a technological marvel. You take all of that complex engineering and put it into something that you're gonna throw away and make it single use. And make it cost effective. So you have to make it cheap enough, but at the same time function just like a deodorant scope and still do all the therapeutic stuff we do. Upsides, downsides. Upsides, obviously, is that we are able to avoid all these infections. You have a clean scope every single time. Downsides, inventory, you have to stock all of these scopes. Do you have the physical space to do that in the lab? The cost of it, it's an incremental cost burden because you don't get paid extra. There is no code for ERCP with a reusable scope versus a disposable scope. Again, the business model, the revenue cycle management, supply chain, are they able to stock this enough? And the unit operations, do you have to come up with Department of Health approvals and so on? So single use, I'm just gonna touch base on the two that are available on the market. The FDA cleared the exalt in December of 2019. There have been five studies published on this device and the AMBU released the disposable ACE scope in 2021. It does need its own processor, so that's the other cost to it. It does not plug into an Olympus or an existing processor. It also doesn't plug into a Spyglass processor, although it looks the same. Currently, if you have cholangioscopy, you need a Spyglass box and you need an exalt box. So you need to have two separate processors. So there is a capital that you need to purchase for it and then the disposable piece to it. And then it has the disposable buttons that go through with it, but it performs turns. It has all the knobs and buttons, the same as a traditional deodorant scope. Things has the same accessory channel that you could pass a wire, sphincter tomes, cholangioscopes. And then this is the view. That's the other part is the optics of it. These are fiber optic optics. They are not the high level 4K or 8K pictures we're used to. So there is slight trade off in the visuals of it, although it's pretty close to what we're using. It's not the same, that's all. It does take some getting used to. And then the view is different, slightly compared to a Olympus deodorant scope. And then same thing for the, so what they found is it's easily adoptable. So they looked at expert endoscopist and less expert endoscopist. And the procedure success rate was not significant. So people were able to obtain the same level of expertise and get the procedure completed without any increase in side effect rate. Initial versions of these were too stiff. So there were reports of perforations. So if you were used to the memory of the scope, when we unlock the dial, they should fall back down to neutral position with a reusable scope. This one, you have to manually readjust and make sure it straightens out. The newer versions of these have been better. They're not as rigid and stiff. But for the original versions, you had to be careful when we're drawing the scope. It was a little rigid. Same thing with the Ambu-A scope, a disposable platform that needs its own processor to plug it into, and then it integrates with the existing EHR. But you need that capital for the integration of this. And then the views again are a little different. It's more rectangular as compared to the vertical square that we're used to. So considerations for incorporating into the practice, it's an alternative to reusable duodenoscopes. Technical and clinical equivalency in the hands of a novice or an expert endoscopist. It does require some staff training and reprocessing consideration. So if you look at the cost analysis, the point is there is a cost to reprocessing a scope. There's chemicals involved, there is electricity involved, there is the staff time involved. If you have a late case, now the staff has to wait 45 minutes after hours or on a weekend. If you have a high risk patient, somebody who's immunocompromised or post-transplant where the stakes are too high to take a risk and given this patient a potential infection, those are some of the unique cases where a single use duodenoscope completely makes sense. Financial considerations, the acquisition cost, does your unit have the capital to purchase the boxes? The supply chain considerations, do you have this physical space to keep this? Do you have the revenue cycle management? And I'll give you a personal example at Geisinger, one thing for the company to say, yes, it's gonna be reimbursed. There was a pass-through code that you got paid for for using these scopes. And having talked to some of my colleagues, they were actually breaking even or actually making money on using a single use scope because the reimbursement for it was slightly higher than the cost of the scope. I'm like, oh, this makes sense. We put it through our financial team, supply chain, everything was great. When I used it, I said, let's do a pilot of five. We lost money on every single case. So this was in the red. So for every scope used, we were not getting the same reimbursement. And the fault was on our side. As you all know, on the finance side of things, there is an up-billing. There is a certain up-charge that you do, and then insurance pays a certain percentage of that. We were not up-charging enough. So the Geisinger's up-charge was standard. So again, getting involved with the finance and the billing team, giving them a heads up, we're bringing new technology, you gotta change the way you're billing these procedures in order to cover this. So all of that needs to be discussed up front so you don't do something wrong for the institution. So having these CMS pass-through codes and so on. More changes at more rapid pace than ever. Infection control is a important piece to what we do. Resistant organisms are increasing because of overuse of antibiotics and poor stewardship. And old reprocessing algorithms are too onerous, too complicated, so those need to be simplified, which they are. And reprocessing team education, training our staff through programs like ASGE. Traditional reprocessing deodinoscopes are no longer even available. So that's a serial thing, that deodinoscope doesn't exist anymore thanks to this self-awareness that we all checked ourselves and fixed. And then the newest deodinoscope include now this replaceable tip or just using a single-use deodinoscope. But time-flow replacement of the old deodinoscopes is in essence, and this is part and parcel of what you are all part of and partners with us today. Thank you.

ERCP

duodenoscopes

MDRO infections

single-use duodenoscopes

cleaning protocols

patient safety

healthcare infrastructure