{"id":282150,"date":"2026-09-21T19:14:52","date_gmt":"2026-09-21T17:14:52","guid":{"rendered":"https:\/\/www.matachana.com\/282136\/"},"modified":"2026-09-21T19:32:45","modified_gmt":"2026-09-21T17:32:45","slug":"ltsf-reaching-sterility-where-others-fail-part-ii","status":"publish","type":"post","link":"https:\/\/www.matachana.com\/en\/ltsf-reaching-sterility-where-others-fail-part-ii\/","title":{"rendered":"LTSF: Reaching Sterility Where Others Fail. Part II | Matachana"},"content":{"rendered":"

LTSF: REACHING STERILITY WHERE OTHERS FAIL. PART II<\/h1>\n

\u00abTerminal sterilization of duodenoscopes by Low Temperature Steam and Formaldehyde (LTSF) under extreme organic contamination conditions\u00bb<\/em><\/p>\n

<\/h4>\n

ABSTRACT<\/h4>\n

The sterilization of complex flexible endoscopes remains one of the most significant challenges in the reprocessing of reusable medical devices [1-3].<\/p>\n

Building on Part I [4] of this series, which evaluated the efficacy of Low Temperature Steam and Formaldehyde (LTSF) sterilization on surfaces contaminated with organic matter and Hollow Process Challenge Devices (HPCDs), this White Paper goes a step further by assessing the microbiological efficacy of the LTSF process in complex endoscopes requiring advanced reprocessing. Specifically, Olympus duodenoscopes (EVIS EXERA III, model TJF-Q190V) were subjected to extreme organic contamination and microbiological challenge conditions.<\/p>\n

Selected internal channels were inoculated with one million spores of Geobacillus stearothermophilus<\/em> ATCC 7953, the reference microorganism used for evaluating LTSF sterilization processes. In addition, the biopsy channel was challenged with a protein load approximately 73 times higher than the action limit established by ISO 15883-5 for assessing cleaning efficacy in reusable medical devices.<\/p>\n

Following three independent LTSF sterilization cycles at 60 \u00b0C in the 130LF\u00ae sterilizer using the three endoscopes, no microbiological growth was detected in any of the evaluated channels<\/strong>. Under the conditions tested, the results demonstrate the high capability of the LTSF process to achieve a Sterility Assurance Level (SAL) of 10\u207b\u2076<\/strong> in a clinically representative device with highly complex internal geometries.<\/p>\n

These findings reinforce the results presented in Part I and suggest that, for compatible complex devices processed using validated cycles, terminal sterilization by LTSF may provide an additional margin of microbiological safety, even under organic contamination conditions that are considerably more challenging than those typically encountered<\/strong>, without replacing the essential steps of cleaning and disinfection.<\/p>\n

 <\/p>\n

1. INTRODUCTION<\/h4>\n

The Challenge of Duodenoscope Sterilization<\/strong><\/p>\n

The difficulty in reprocessing flexible endoscopes stems both from their limited compatibility with high-temperature steam sterilization processes due to the presence of heat-sensitive materials and from the complex configuration of their internal channels, which may hinder the removal of residues following cleaning and microorganisms following disinfection and sterilization.<\/p>\n

Within this group, duodenoscopes represent a particularly critical case due to the presence of movable distal mechanisms (including the elevator or Albarr\u00e1n channel) and their long internal channels, features that may promote the persistence of residual contamination and biofilms following cleaning [1-3].<\/p>\n

Following clinical use, organic and inorganic residues may remain, including proteins, biological fluids, salts, and other materials capable of interfering with subsequent reprocessing stages such as washer-disinfection and low-temperature sterilization. Furthermore, the presence of residual contamination or biofilm formation may compromise the effectiveness of disinfection and sterilization procedures if adequate cleaning is not performed [7,8].<\/p>\n

The complexity of duodenoscope reprocessing has prompted extensive research and numerous safety communications in recent years. Several studies have documented microbiological transmission events associated with duodenoscopes and other highly complex endoscopes, including cases involving multidrug-resistant microorganisms, even after the implementation of reprocessing procedures consistent with current recommendations [7-9].<\/p>\n

As a result, there has been growing interest in approaches capable of enhancing microbiological safety following reprocessing in these devices. These strategies are not intended to replace established cleaning, disinfection, quality control, and traceability procedures but rather to minimize the risks associated with residual contamination and improve the overall robustness of the reprocessing process.<\/p>\n

In this context, LTSF sterilization, as described in ISO 25424<\/strong> [5], represents an alternative for processing heat-sensitive devices such as duodenoscopes. The 130LF\u00ae sterilizer combines the action of low-temperature steam (60-78 \u00b0C) and formaldehyde (2%) for the inactivation of microorganisms and has demonstrated efficacy in devices with complex configurations and long internal channels subjected to particularly demanding microbiological challenge and organic contamination conditions.<\/p>\n

Figure 1<\/strong> shows the Olympus EVIS EXERA III TJF-Q190V duodenoscope used in the study and illustrates the complexity of the channels selected for microbiological evaluation.<\/p>\n

\"Figure<\/div>\n

Figure 1.<\/strong> Olympus EVIS EXERA III TJF-Q190V duodenoscope and characteristics of the channels evaluated. (A)<\/strong> Olympus EVIS EXERA III TJF-Q190V duodenoscope used in the study to evaluate the microbiological efficacy of the LTSF sterilization process. The biopsy channel (A.1) and the air\/water channel (A.2) were evaluated, both of which are representative of complex configurations featuring long channels and demanding internal geometries for reprocessing and sterilization processes. (B)<\/strong> Geometrical characteristics of the channels evaluated microbiologically, including total length, internal diameter, and calculated internal surface area. Internal surface area calculated as \u03c0 \u00d7 internal diameter \u00d7 channel length. \u2020Confidential Olympus data.<\/p>\n

 <\/p>\n

2. STUDY DESIGN<\/h4>\n

The microbiological efficacy of the LTSF sterilization process<\/strong> was initially evaluated to determine its Sterility Assurance Level (SAL)<\/strong> on protein-contaminated metal surfaces, representing the potential persistence of residual organic matter following cleaning. This evaluation was conducted in accordance with ISO 25424<\/strong> [16], which describes the validation procedures for LTSF sterilization<\/strong>. For this study, Geobacillus stearothermophilus<\/em> ATCC 7953 spores were used as the biological indicator.<\/p>\n

The objective of the study was to verify the ability of the 130LF\u00ae LTSF process to achieve a SAL of 10\u207b\u2076, defined as a probability of one in one million of finding a viable microorganism after sterilization, under conditions that greatly exceed the levels of residual contamination considered acceptable following cleaning procedures.<\/p>\n

The microbiological efficacy of the LTSF sterilization process was evaluated using three Olympus EVIS EXERA III TJF-Q190V duodenoscopes as test devices [10]. The internal channels selected for microbiological evaluation were the biopsy channel and the air\/water channel, the characteristics of which are summarized in Figure 1 and Table 1.<\/p>\n

The channels evaluated were inoculated with a biological challenge of 1 \u00d7 10\u2076 spores of Geobacillus stearothermophilus<\/em> ATCC 7953<\/strong>, the reference microorganism specified in ISO 11138-5<\/strong> [11] for the evaluation and monitoring of LTSF sterilization processes.<\/p>\n

In addition, to assess the robustness of the process under particularly demanding conditions, a high protein load was applied to the biopsy channel. The contamination level reached 466 \u00b5g\/cm\u00b2<\/strong>, a value 72.8 times<\/strong> higher than the 6.4 \u00b5g\/cm\u00b2 action limit established in ISO 15883-5<\/strong> [6] for evaluating cleaning efficacy in reusable medical devices.<\/p>\n

Table 1. Characteristics of the test device, applied contamination conditions, and key microbiological parameters used throughout the study.<\/p>\n\n\n\n\n\n\n\n\n\n\n\n\n\n\n
Parameter<\/th>\nValue<\/th>\n<\/tr>\n<\/thead>\n
Device Evaluated<\/td>\nOlympus Evis Exera III TJF-Q190V<\/td>\n<\/tr>\n
Sterilizer<\/td>\n130LF\u00ae<\/td>\n<\/tr>\n
Biopsy Channel<\/td>\n1240 mm \u00d7 4.2 mm<\/td>\n<\/tr>\n
Air\/Water Channel<\/td>\n>1240 mm \u00d7 <4.2 mm*<\/td>\n<\/tr>\n
Challenge Microorganism<\/td>\nGeobacillus stearothermophilus<\/em> ATCC 7953<\/td>\n<\/tr>\n
Sterilization Cycle<\/td>\nLTSF, 60 \u00b0C, 30 min<\/td>\n<\/tr>\n
ISO 15883-5 Action Limit<\/td>\n6.4 \u00b5g\/cm\u00b2<\/td>\n<\/tr>\n
Applied Protein Contamination<\/td>\n466 \u00b5g\/cm\u00b2<\/td>\n<\/tr>\n
Increase Relative to the ISO Limit<\/td>\n72.8-fold<\/td>\n<\/tr>\n
Microbiological Objective<\/td>\nSAL 10\u207b\u2076<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

* Confidential Olympus data.<\/p>\n

Following microbiological inoculation and the application of organic contamination, the duodenoscopes were sterilized using the LTSF process with the 130LF\u00ae sterilizer<\/strong> (Matachana). The study was conducted in three independent sterilization cycles at 60\u00b0C, with an exposure time of 30 minutes. During each cycle, the three duodenoscopes and two channels per device were evaluated, resulting in a total of 18 microbiological assessments of internal channels.<\/p>\n

The load configuration and barrier systems used during the testing are shown in Figure 2<\/strong>.<\/p>\n

Subsequent microbiological evaluation made it possible to determine the presence or absence of growth of the inoculated spores within the channels examined after the sterilization process.<\/p>\n

\"Figure<\/div>\n

Figure 2.<\/strong> Sterile barrier system and load configuration used during duodenoscope sterilization. The figure shows the Aesculap PrimeLine\u00ae sterile container system equipped with a single-use filter and loaded into the 130LF\u00ae sterilizer for the 60 \u00b0C LTSF cycle. The duodenoscopes were placed inside the containers. The location of the chemical indicator, positioned within a Helix Process Challenge Device (PCD) to verify exposure to the sterilization process, is also shown.<\/p>\n

 <\/p>\n

3. RESULTS<\/h4>\n

Following completion of each sterilization cycle, a microbiological evaluation of the channels under study was performed through recovery and incubation of microorganisms (58-60 \u00b0C, 7 days).<\/p>\n

The microbiological results obtained from the biopsy and air\/water channels are summarized in Table 2<\/strong>. In both cases, complete inactivation of the inoculated spores was observed, demonstrating achievement of a SAL 10\u207b\u2076.<\/p>\n

Table 2. Microbiological Efficacy Results<\/p>\n\n\n\n\n\n\n
Evaluated Channel<\/th>\nApplied Protein Load (\u00b5g\/cm\u00b2)<\/th>\nSurviving Spore Population (CFU)<\/th>\nResult<\/th>\n<\/tr>\n<\/thead>\n
Biopsy Channel<\/td>\n466<\/td>\nNot detected<\/td>\nSAL 10\u207b\u2076<\/td>\n<\/tr>\n
Air\/Water Channel<\/td>\nNot applicable<\/td>\nNot detected<\/td>\nSAL 10\u207b\u2076<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

CFU – Colony-Forming Units.<\/p>\n\n\n\n
Despite the extremely challenging level of residual protein contamination in the biopsy channel, no microbiological growth was detected following the sterilization process in any of the three endoscopes.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

4. MICROBIOLOGICAL ROBUSTNESS OF THE LTSF PROCESS<\/h4>\n

The microbiological efficacy of the process was analyzed by considering the resistance of the G. stearothermophilus<\/em> spores used in the study (D-value). The D-value corresponds to the time required to achieve a 90% reduction in a microbial population. In this study, the duodenoscope channels were inoculated with G. stearothermophilus<\/em> spores exhibiting a DFA 60\u00b0C<\/sub> value of 20.2 min.<\/p>\n

For reference, in Part I of this series, the efficacy of the LTSF technology was evaluated using Hollow Process Challenge Devices (HPCDs) inoculated with spores exhibiting a DFA 60\u00b0C<\/sub> value of 17.2 min<\/strong> [4]. Although lower, both values are considerably higher than the DFA 60\u00b0C<\/sub> value of 6 min specified in ISO 25424<\/strong> [5] as guidance for the validation of LTSF sterilization processes.<\/p>\n

Figure 3<\/strong> illustrates the theoretical microbiological reduction associated with these three resistance levels. While the HPCD studies already represented a microbiological challenge exceeding the requirements established by the standard, the duodenoscope trials were conducted using spores with even greater resistance, thereby constituting a particularly demanding evaluation condition for the sterilization process.<\/p>\n

\"Figure<\/div>\n

Figure 3.<\/strong> Theoretical evaluation of the microbiological reduction of Geobacillus stearothermophilus<\/em> spores over time during the LTSF process at 60 \u00b0C. The lines represent the calculated microbiological reduction using different D-values under formaldehyde conditions: DFA 60\u00b0C<\/sub> = 6 min (ISO 25424 reference value), DFA 60\u00b0C<\/sub> = 17.2 min (spores used in the HPCD studies presented in Part I), and DFA 60\u00b0C<\/sub> = 20.2 min (spores used in the Olympus TJF-Q190V duodenoscope studies). The vertical dashed line indicates the exposure time of the LTSF cycle (30 min).<\/p>\n\n\n\n
The extreme conditions evaluated in this study provide a robust assessment of the LTSF process against a combined challenge of high organic contamination, complex device geometry, and a resistant microbiological load.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

 <\/p>\n

5. CLINICAL IMPLICATIONS<\/h4>\n

Cleaning and disinfection remain fundamental and irreplaceable steps in endoscope reprocessing. The effective removal of organic residues and microorganisms is the foundation for reducing the risk of infection transmission associated with reusable medical devices [7,8].<\/p>\n

In addition, the reprocessing of these devices involves multiple manual and automated steps, the outcome of which may be influenced by both the complexity of the device itself and the nature of the biological contamination, as well as by the high clinical workload encountered in healthcare settings [2,3,8]. This aspect is especially relevant for highly complex devices, whose design may complicate reprocessing and promote the persistence of residual contamination [2,3,8].<\/p>\n

The significance of these findings becomes even greater when considering that certain low-temperature sterilization technologies may exhibit limitations in the presence of residual organic matter, proteins, salts, or complex luminal configurations. Such limitations have been reported particularly for H\u2082O\u2082-based technologies, including Vaporized Hydrogen Peroxide (VHP) and Hydrogen Peroxide Gas Plasma (HPGP), when challenged by combinations of organic contamination and restrictive geometries [12-16].<\/p>\n

In this context, the results obtained reinforce the value of terminal sterilization using LTSF as part of a comprehensive infection prevention and control strategy.<\/p>\n

The principal implications of these findings include:<\/p>\n

    \n
  • Enhanced microbiological safety.<\/strong> Despite the presence of organic residues, any remaining pathogens are not protected by the organic matrix, reducing the likelihood of survival and potentially decreasing the risk of microbial persistence and biofilm formation associated with residual organic contamination.<\/li>\n
  • Applicability to devices with complex internal configurations.<\/strong> Effective sterilization of devices with long and difficult-to-access internal channels.<\/li>\n
  • Potential utility as a terminal sterilization strategy<\/strong> for highly complex reusable medical devices, particularly in scenarios where other low-temperature technologies may present limitations.<\/li>\n<\/ul>\n\n\n\n
    It is important to emphasize that no sterilization process can replace adequate prior cleaning and disinfection<\/strong>. Achieving a Sterility Assurance Level (SAL) of 10\u207b\u2076 under particularly demanding challenge conditions provides an additional margin of microbiological safety in the reprocessing of medical devices.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

     <\/p>\n

    6. CONCLUSIONS<\/h4>\n

    The 130LF\u00ae LTSF sterilization process developed by MATACHANA demonstrated high microbiological efficacy in Olympus EVIS EXERA III TJF-Q190V duodenoscopes subjected to organic and microbial contamination conditions considerably more demanding than those typically considered acceptable following cleaning procedures.<\/p>\n

    Consistent with the findings presented in Part I, the results further reinforce the microbicidal potential of the 130LF\u00ae sterilizer, even under conditions of high microbiological complexity. Moreover, these findings open new avenues for research aimed at evaluating the performance of this technology against what remains the greatest challenge in endoscope reprocessing: biofilms<\/strong>. This topic will be specifically addressed in Part III of this series.<\/p>\n\n\n\n
    Collectively, these results support the use of LTSF technology as a robust terminal sterilization strategy for highly complex reusable medical devices, such as flexible endoscopes, provided that they are compatible with the process and reprocessed using validated cycles.<\/td>\n<\/tr>\n<\/tbody>\n<\/table>\n

     <\/p>\n

    REFERENCES<\/h4>\n
      \n
    1. Heuvelmans M, Wunderink HF, van der Mei HC, Monkelbaan JF. A narrative review on current duodenoscope reprocessing techniques and novel developments. Antimicrob Resist Infect Control. 2021;10(1):171. doi:10.1186\/s13756-021-01037-z.<\/li>\n
    2. Rutala, U.S. Food and Drug Administration. Infections associated with reprocessed duodenoscopes [Internet]. Silver Spring (MD): FDA; 2022.<\/li>\n
    3. Pr\u00fcfert-Freese, U.S. Food and Drug Administration. Supplemental measures to enhance duodenoscope reprocessing: FDA safety communication [Internet]. Silver Spring (MD): FDA; 2015.<\/li>\n
    4. Carreras N, V\u00e1zquez DA, Ramirez A, von den Hagen T. VBTF: alcanzando la esterilidad donde otros fracasan. Parte I. La ventaja de la esterilizaci\u00f3n por VBTF de superficies y dispositivos canulados contaminados con materia org\u00e1nica: un estudio in vitro [White Paper]. Matachana; 2025.<\/li>\n
    5. International Organization for Standardization. ISO 25424:2018. Sterilization of health care products \u2014 Low temperature steam and formaldehyde \u2014 Requirements for development, validation and routine control of a sterilization process for medical devices. 2nd ed. ISO; 2018.<\/li>\n
    6. International Organization for Standardization. ISO 15883-5:2021. Washer-disinfectors \u2014 Part 5: Performance requirements and test method criteria for demonstrating cleaning efficacy. ISO; 2021.<\/li>\n
    7. Percival SL, Suleman L, Vuotto C, Donelli G. Healthcare-associated infections, medical devices and biofilms: risk, tolerance and control. J Med Microbiol. 2015;64:323-334. doi:10.1099\/jmm.0.000032.<\/li>\n
    8. Pineau L. Endoscope reprocessing: retrospective analysis of 90,311 samples. Endosc Int Open. 2023;11(3):E247-E257.<\/li>\n
    9. Southworth PM. Infections and exposures: reported incidents associated with unsuccessful decontamination of reusable surgical instruments. J Hosp Infect. 2014;88(3):127-131. doi:10.1016\/j.jhin.2014.08.007.<\/li>\n
    10. SMP GmbH. Examination of low-temperature formaldehyde sterilizer 130 LF with the rapid cycle program 60 \u00b0C using Olympus Video Duodenoscope EVIS EXERA III TJF-Q190V as load. Project No. P22138. Test report. T\u00fcbingen: SMP GmbH; 2024.<\/li>\n
    11. International Organization for Standardization. ISO 11138-5:2017. Sterilization of health care products \u2014 Biological indicators \u2014 Part 5: Biological indicators for low-temperature steam and formaldehyde sterilization processes. ISO; 2017.<\/li>\n
    12. Alfa MJ, DeGagne P, Olson N, Puchalski T. Comparison of ion plasma, vaporized hydrogen peroxide and 100% ethylene oxide sterilizers to the 12\/88 ethylene oxide gas sterilizer. Infect Control Hosp Epidemiol. 1996;17(2):92-100.<\/li>\n
    13. Diab-Elschahawi M, Blacky A, Bachhofner N, Koller W. Challenging the Sterrad 100NX sterilizer with different carrier materials and wrappings under experimental “clean” and “dirty” conditions. Am J Infect Control. 2010;38(10):806-810. doi:10.1016\/j.ajic.2010.05.023.<\/li>\n
    14. Diab-Elschahawi M, Blacky A, Bachhofner N, Koller W. Lumen claims of the Sterrad 100NX sterilizer: testing performance limits when processing equipment containing long, narrow lumens. Am J Infect Control. 2011;39(9):770-774. doi:10.1016\/j.ajic.2011.01.010.<\/li>\n
    15. Pr\u00fcfert-Freese U. H2O2 Sterilisationsprozesse \u2014 neue Erkenntnisse. Presented at: 11. \u00d6GSV-Fachtagung; 2019; Hafnersee, Austria.<\/li>\n
    16. Rutala WA, Gergen MF, Sickbert-Bennett EE, Weber DJ. Comparative evaluation of the microbicidal activity of low-temperature sterilization technologies to steam sterilization. Infect Control Hosp Epidemiol. 2020;41(4):391-395. doi:10.1017\/ice.2020.2.<\/li>\n<\/ol>\n","protected":false},"excerpt":{"rendered":"

      LTSF: REACHING STERILITY WHERE OTHERS FAIL. PART II \u00abTerminal sterilization of duodenoscopes by Low Temperature Steam and Formaldehyde (LTSF) under extreme organic contamination conditions\u00bb ABSTRACT The sterilization of complex flexible endoscopes remains one of the most significant challenges in the reprocessing of reusable medical devices [1-3]. Building on Part I [4] of this series, which […]<\/p>\n","protected":false},"author":382,"featured_media":282138,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":{"_et_pb_use_builder":"","_et_pb_old_content":"","_et_gb_content_width":"","inline_featured_image":false},"categories":[204,4],"tags":[816,815,814,818,813,817,819,812],"acf":[],"yoast_head":"\nLTSF: Reaching Sterility Where Others Fail. Part II | Matachana - Matachana<\/title>\n<meta name=\"robots\" content=\"index, follow, max-snippet:-1, max-image-preview:large, max-video-preview:-1\" \/>\n<link rel=\"canonical\" href=\"https:\/\/www.matachana.com\/en\/ltsf-reaching-sterility-where-others-fail-part-ii\/\" \/>\n<meta property=\"og:locale\" content=\"en_US\" \/>\n<meta property=\"og:type\" content=\"article\" \/>\n<meta property=\"og:title\" content=\"LTSF: Reaching Sterility Where Others Fail. Part II | Matachana - Matachana\" \/>\n<meta property=\"og:description\" content=\"LTSF: REACHING STERILITY WHERE OTHERS FAIL. PART II \u00abTerminal sterilization of duodenoscopes by Low Temperature Steam and Formaldehyde (LTSF) under extreme organic contamination conditions\u00bb ABSTRACT The sterilization of complex flexible endoscopes remains one of the most significant challenges in the reprocessing of reusable medical devices [1-3]. 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