Gastrointestinal endoscopy is resource-intensive and contributes substantially to healthcare’s environmental footprint. While the ESGE position statement on green endoscopy highlights the need for a more sustainable practice, concrete guidance on implementation remains limited¹. This study explored sustainability efforts in endoscopy departments in the south-west of the Netherlands and examined barriers and facilitators influencing their adoption. 

Semi-structured interviews were conducted with green team members from eight endoscopy departments. Transcripts were thematically analyzed to map sustainability initiatives and implementation factors. A second interview round validated the initiative list, and sustainability coordinators provided additional hospital-wide information. 

Across the eight hospitals, 73 distinct sustainability initiatives were identified, with departments having implemented a mean of 42 initiatives (range: 38–49). Frequently reported measures included reducing suction tubing and canisters (n=8), oxygen catheters (n=8), sterile water bottles (n=7), and absorption pads (n=6). All departments used strict triage protocols to prevent unnecessary procedures and addressed patient and staff travel through telemedicine and cycling incentive programs. In general, three interrelated themes affected implementation:

a. Institutional and organizational factors: barriers included conflicting policies from other disciplines (n=6), limited time (n=5), cost constraints (n=4), and restrictive hospital rules (n=4); enablers included hospital-wide alignment (n=7), supportive leadership (n=6), and structural resources (n=4). 

b. Behavioral and cultural factors: barriers included staff resistance (n=7), lack of evidence (n=6), and low prioritization (n= 5); enablers included active green teams (n=7), visualized before-and-after results (n=6), and protected time (n=5).  

c. System-level factors: barriers included limited influence on industry (n=3) and national and international regulations (n=2); enablers included collaboration across endoscopy departments regionally (n=6), across departments within the hospital (n=5), and the availability of empirical evidence (n=5). 

Endoscopy departments in the south-west of the Netherlands have adopted a wide range of sustainability initiatives, primarily targeting reductions in single-use items, unnecessary procedures, and travel emissions. Despite this progress, substantial institutional, cultural, and system-level barriers persist. Advancing sustainable endoscopy will require coordinated organizational support, engaged leadership, robust evidence, and strong cross-departmental and inter-hospital collaboration.