Commentary by Benjamin Tharian , MD
Impact of COVID-19 Pandemic on Gastrointestinal Endoscopy
Coronavirus disease 2019 ( COVID-19 ), caused by severe acute respiratory syndrome coronavirus-2 ( SARS-CoV-2 ), led to an unprecedented strain on health care systems across the globe . As of March 16 , 2021 , more than half a million COVID-19 related deaths were reported in the U . S . Arkansas suffered 5,500 deaths and ranked 30 among all the states in the U . S . COVID-19 remains predominantly a respiratory pathogen . As the experience with COVID-19 evolved , extrapulmonary symptoms were increasingly recognized . 1 Among them , gastrointestinal ( GI ) symptoms such as diarrhea , abdominal pain , and dysgeusia have been reported . 2
Endoscopy Unit and COVID-19
Gastrointestinal endoscopy involves a variety of procedures to diagnose diseases of the alimentary canal ( esophagus , stomach , duodenum , small and large intestine ) with the help of specialized instruments ( fiber optic endoscopes ). Due to widespread stay-at-home orders , endoscopy centers suffered a significant reduction in volume throughout the U . S ., especially during the early stages of the pandemic . Endoscopic procedures involve potential close contact with patients ’ body fluids such as oropharyngeal secretions and gastric , biliopancreatic , and colonic contents . 3 Close proximity to the patient ’ s body fluids places endoscopists and staff at increased risk . There has been an increasing body of literature where SARS-CoV-2 can be isolated from stool specimens making endoscopy procedures at risk of transmission to endoscopy staff . This theoretical risk led to multiple endoscopy societies recommending reducing the elective and semi-elective endoscopic procedures to minimize transmissibility and preserve personal protective equipment . Endoscopy staff were redeployed . This resulted in rescheduling and deferring screening colonoscopies for colorectal cancer ( CRC ) prevention . A few studies showed that CRC screening decreased by 72 % in the United Kingdom and up to 84.5 % in the U . S . The impact of all these changes on cancer surveillance and delayed diagnosis is yet to be determined .
GI endoscopy centers throughout the U . S . adapted to the pandemic in multiple ways . During the early phase of the pandemic , endoscopy units increased enhanced-cleaning protocols , reduced the stay to only essential personnel , decreased contact with family members , and increased utilization of telemedicine . There was increased utilization of negative-pressure ventilation to decrease the viral load and contaminant concentration . Endoscopists were actively involved in prioritizing semi-urgent / urgent procedures and deferring non-urgent endoscopies . Traditionally , endoscopy units are highly efficient units with high procedure volume . The above changes affected the functioning of these units , with increased downtime , the need for conservation of protective equipment , and decreased procedures that could potentially be aerosol-generating . Furthermore , multiple-barrier devices ( aerosol box , endoscopic shields , endoprotector ) were developed to reduce the transmission . 4 Despite the risk , the transmission of SARS-CoV-2 during endoscopy procedures remains low , with an average of < 1 % ( 0.6 % in low prevalence areas and up to 6 % in high prevalence areas during the peak of the pandemic ).
SARS-CoV-2 transmission via contaminated endoscopes has not been proven yet . Nevertheless , a theoretical risk of this transmission exists . Endoscopists adapted to multiple procedural changes such as decreasing spill of GI secretions via working channel use , minimizing the use of accessories , and deferring procedures with incomplete bowel preparation .
Trainee involvement in the endoscopy procedures reduced significantly during the pandemic . This was to minimize risks of transmission and conserve protective equipment . A multicenter , international survey study showed a reduction of procedure volume up to 94 %. While this has impacted the learning process of the trainees , it was partially compensated by reorganizing the learning process via increased involvement in research and educational activities electronically .
The Future
Fortunately , with the COVID-19 pandemic trend moving in the right direction , with widespread adoption of vaccination , the resumption of endoscopy units has led to increased case volume . Pre-procedural screening and testing has been performed for the majority of patients , although this is expected to change in the future . Due to their inherent capability to adapt quickly to this pandemic , endoscopy units were able to maneuver through the intricate challenges . Nevertheless , the journey ahead involves continued effort to compensate for procedure delays , methods to clear the backlog of cases , easier provisions for patients to get their procedures on time , and ( more importantly ) decreased the risk of infection transmission .
During the pandemic , telemedicine use in gastroenterology has been utilized like never before ( an increase of 4000 % noted in the first few weeks of the pandemic ). Moving forward , some of these changes in the endoscopy unit ( enhanced cleaning protocols , safe distancing , use of personal protective equipment ) and patient encounters ( telemedicine ) are expected to continue even after the pandemic resolves . This will likely amplify patient compliance and safety to some extent .
References
1 . Perisetti A , Gajendran M , Mann R , Elhanafi S , Goyal H . COVID-19 extrapulmonary illness - special gastrointestinal and hepatic considerations . Dis Mon . 2020 ; 66 ( 9 ): 101064 .
2 . Perisetti A , Gajendran M , Goyal H . Putative Mechanisms of diarrhea in COVID-19 . Clinical Gastroenterology and Hepatology . 2020 ; S1542-3565 ( 20 ): 30780-1 .
3 . Perisetti A , Gajendran M , Boregowda U , Bansal P , Goyal H . COVID-19 and gastrointestinal endoscopies : Current insights and emergent strategies . Dig Endosc . 2020 ; 32 ( 5 ): 715-22 .
4 . Goyal H , Perisetti A , Tharian B . Percutaneous Endoscopic Gastrostomy tube placement in COVID-19 patients : Multidisciplinary approach . Dig Endosc . 2021 ; 33 ( 1 ): 209 .
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