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 Table of Contents     
COVID-19 GUIDELINES
Year : 2020  |  Volume : 16  |  Issue : 3  |  Page : 201-205
 

Indian Association of Gastrointestinal Endo Surgeons COVID-19 endoscopy recommendations


1 Department of Minimal Access Surgery, Lotus Hospital, Erode, Tamil Nadu, India
2 Indian Association of Gastrointestinal Endo Surgeons, Mumbai, Maharashtra, India

Date of Submission04-May-2020
Date of Acceptance08-May-2020
Date of Web Publication05-Jun-2020

Correspondence Address:
Dr. Easwaramoorthy Sundaram
Department of Minimal Access Surgery, Lotus Hospital, Erode - 638 002, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jmas.JMAS_92_20

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 ¤ Abstract 


These are recommendations from the Indian Association of Gastro Intestinal Endo Surgeons for safe performance of diagnostic and therapeutic endoscopy during the COVID-19 pandemic.


Keywords: COVID-19 pandemic, elective endoscopy, emergency endoscopy, endoscopy disinfection, flexible endoscopy, informed consent, practice guidelines


How to cite this article:
Sundaram E, Manickavasagam K, Goel R, Subhash K, Govindaraj K, Bhimanakunte KR, DeSarkar S, Borgoankar V, Rathod V. Indian Association of Gastrointestinal Endo Surgeons COVID-19 endoscopy recommendations. J Min Access Surg 2020;16:201-5

How to cite this URL:
Sundaram E, Manickavasagam K, Goel R, Subhash K, Govindaraj K, Bhimanakunte KR, DeSarkar S, Borgoankar V, Rathod V. Indian Association of Gastrointestinal Endo Surgeons COVID-19 endoscopy recommendations. J Min Access Surg [serial online] 2020 [cited 2020 Nov 29];16:201-5. Available from: https://www.journalofmas.com/text.asp?2020/16/3/201/284643





 ¤ Introduction Top


COVID-19 pandemic has brought the world to its knee with unimaginable economic, social and health-related issues. While government authorities are making all efforts to flatten the pandemic curve, every endoscopic surgeon should strive to save patients and also safeguard the welfare of fellow health-care professionals (HCPs) by formulating and adhering to strict safety guidelines.

SARS-CoV-2 virus is a highly infectious RNA virus transmitted by droplet infection.[1] We should realise that what we know so far about this dangerous virus is like a drop in the ocean. Hence, we need to be extra vigilant to protect the health of our patients and HCPs. With no possibility of definitive therapy or vaccine in future, we have to adapt strict institution-based infection prevention and control policy.

Basic and advanced endoscopic training programs are one of the key areas of academic activities by Indian Association of Gastrointestinal Endo Surgeons. Hence, it is our responsibility and need of the hour to formulate recommendations for the benefit of all practicing endoscopic surgeons. It is essentially based on opinion from experts and limited literature evidence. For ease of understanding and application, we have indicated the strength of recommendation and quality of literature evidence wherever it is possible.[2]

We should realise that these recommendations are time sensitive and are bound to change in case of additional evidence appearing in the near future with regard to investigation and management of COVID-19 infection.



1.Advice on performing elective endoscopy



Endoscopy is a high-level aerosol-producing procedure akin to endotracheal intubation. Due to proximity of the patient, infection could also spread by touch or conjunctival contamination. It is also possible to have faecal transmission during colonoscopy.

Elective cases are those where delaying an endoscopic procedure for 4–6 weeks is unlikely affect the final outcome. Evaluations of chronic anaemia, dyspepsia and achalasia are some examples. Most of the screening and surveillance endoscopic procedures could also be deferred for some time.

2.Advice on emergency and urgent endoscopy cases



Emergency cases are defined as those needing endoscopic procedure within 24 h. Acute gastrointestinal bleeding and severe cholangitis with organ dysfunction are some classical examples.

Urgent cases are those requiring endoscopic procedure within 30 days. Otherwise, there is a likelihood of worsening of symptoms or progression of disease leading to poor outcome. Infected pancreatic fluid collection and obstructing left colon tumour are some common examples.

We have listed the course of action for various common clinical situations whether to perform the endoscopic procedure or postpone. All endoscopic surgeons should consider them as broad-based guidelines and hence advised to use his/her clinical discretion to make a definitive plan depending on the risk profile of individual patient [Table 1], [Table 2], [Table 3].
Table 1: Recommendations for upper gastrointestinal endoscopy during coronavirus disease-2019 era

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Table 2: Recommendations for colonoscopy: During coronavirus disease-2019 era

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Table 3: Recommendations for therapeutic endoscopic retrograde cholangio pancreatography and advanced endoscopic procedures during the coronavirus disease-2019 era

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3.Review of routine and non-urgent cases in endoscopy outpatient unit



  • We should also prevent unnecessary review of non-urgent cases to mitigate the possible spread of COVID-19 infection. In view of difficulty faced by the patients not able to receive medical attention and advice, the Medical Council of India has recently come out with guidelines to allow doctors for tele-consultation.[3]


4.Health advice for patients at endoscopy outpatient department[4]



We should manage the appointments in such a way to avoid crowding in the waiting room. It is clearly shown that the chance of droplet infection could be significantly minimised if both the patients and all HCPs wear the masks and adhere to rigorous hand hygiene and social distancing.

5.Advice on personal protection equipment for healthcare professionals[5],[6], [7,[8]



Various types of masks are described namely 3-ply surgical masks, N95 masks and powered purified air respirators. N95 mask ensures filtering of up to 95% of aerosol particles of >0.3 μ and widely recommended in several clinical situations. 3M P100 filter with high efficiency particulate air -grade 99% filter can also be useful.

PPE should be composed of hairnet, goggles, N95 masks, coverall, leggings, double gloves and protective face shield. We should look into the composition of each PPE and make sure that they are made up of good-quality non-woven and fluid-resistant material. Every HCP should learn proper donning and doffing method of PPE and also safe disposal of them.[6],[7],[8]

6.Management strategy for patients undergoing endoscopy[9]



Every patient waiting for endoscopy should be evaluated for any COVID-19-related symptoms, recent travel history and contact history with any family members or next-door neighbours diagnosed as COVID-19-positive cases. Accordingly, the patient is classified as low- and high-risk category. We should also realise that a significant percentage of patients remain asymptomatic in spite of COVID-19 infection. Before performing any endoscopic procedure, we should ideally carry out COVID-19 tests and plan accordingly. Hence, we should perform RT-PCR to know the infection status or consider doing rapid serology test to know the immune status prior to any endoscopic procedure. Till we get clear guidelines and facility to perform these tests, we should presume every patient as a COVID-19 suspect and manage accordingly. We should refer high-risk category patients and COVID-19-positive patients to COVID-19-designated hospital for further evaluation and treatment.

7.Importance of COVID-19 endoscopy consent form[10]



  • In addition to the standard endoscopic consent form, we should also include the following points in the disclosure in view of COVID-19 pandemic, namely:
  • Understands the urgency of endoscopic treatment essential for his/her own health benefit
  • Understands about all efforts taken by the hospital authority to prevent any COVID-19 or other infection to the patient while admitted in the hospital
  • The patient should be explained about the additional cost to be incurred during COVID-19 era endoscopy (PPE, GA, disinfection, turnaround delays, etc.)
  • Information about the enhanced risk prior, during or after the procedure to get COVID-19 infection and also higher-than-usual risk of complications following any endoscopic therapy should be clearly explained to the patient prior to the procedure
  • The patient should understand and agree that hospital/HCP will not be held responsible for any COVID-19 infection acquired by the patient.


A model consent form for endoscopy is given in [Table 4].
Table 4: Additional informed consent form for gastrointestinal endoscopy in the coronavirus disease-2019 era

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8.Advice on endoscopy under anaesthesia[11]



All endoscopic procedures are high-level, aerosol-producing procedures with considerable risk of infection for every HCP. Hence, we should adopt a universal policy of GA for all cases, to reduce aerosol generation or retching. In addition to N95 mask and PPE, the healthcare team should also consider using a large plastic hood/sheet to cover the head end of the patient to avoid droplet infection during intubation. Endoscopy team should enter the room 15 min after induction of GA. The team should be comprised of an experienced endoscopic surgeon along with minimum number of knowledgeable HCP. We should avoid any trainee performing such emergency procedure to prevent undue delay. We should adhere to COVID-19 biomedical waste disposal protocol.

9.Cleaning and disinfection of endoscopy and endoscopy room during COVID-19 era[12],[13],[14]



COVID-19 virus could be easily and effectively eliminated with our regular disinfection protocol. However, we should ensure that the HCP wears PPE during washing and disinfecting the endoscopic equipment. Automatic machine disinfection is preferable than manual disinfection. Dilute chlorine solution should be used to clean the endoscopy room, instrument cart, table and anaesthetic machine. A minimum interval of 30 min between the cases is needed to minimise the risk of aerosol infection.

10.Statement on follow-up of endoscopy patients and health status of healthcare professionals[15]



All the patients following endoscopic procedures should preferably be contacted by phone on day 7 and day 14 to ask for any COVID-19 symptoms or any other health issues. We should also routinely monitor the health of every HCP asking for any fever and other COVID-19 symptoms and take their temperature regularly. HCPs should go for self-quarantine in case of any doubt and seek immediate advice regarding COVID-19 testing.

By adapting the above-mentioned recommendations in our endoscopy practice during this COVID-19 era, we should be able to manage our patients well and also safeguard the health status of our staffs. We should be able to confront and conquer this COVID-19 crisis with compassion and common sense.

#Together we can.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.





 
 ¤ References Top

1.
Huang C, Wang Y, Li X, Ren L, Hao J, Hu Y, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China. Lancet 2020;395:497506.  Back to cited text no. 1
    
2.
Corley DA, Peek RM, COVID-19: What Should Clinicians and Scientists Do and When?, Gastroenterology; 2020. doi: https://doi.org/10.1053/j.gastro.2020.03.026.  Back to cited text no. 2
    
3.
Telemedicine Practice Guidelines by MOHFW. Available from: https://www.mohfw.gov.in/pdf/Telemedicine.pdf. [Last accessed on 2020 Apr 24].  Back to cited text no. 3
    
4.
Repici A, Maselli R, Matteo R, Gabbiadini R, Spadaccini M, Anderloni A, et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. Gastrointest Endosc 2020. pii: S0016-5107 (20) 30245-5.  Back to cited text no. 4
    
5.
PPE Guidelines from MoHFH. Available from: https://www.mohfw.gov.in/pdf/GuidelinesonrationaluseofPersonalProtectiveEquipment.pdf. [Last accessed on 2020 Apr 24].  Back to cited text no. 5
    
6.
PPE Sequence Chart by CDC USA can be. Available from: https://www.cdc.gov/coronavirus/2019-ncov/downloads/A_FS_H CP_COV ID19_PPE_11x17.pdf. [Last accessed on 2020 Apr 24].  Back to cited text no. 6
    
7.
The Video Link for Donning Safety by Department of Health, NHS UK. Available from: https://youtu.be/kKz_vNGsNhc. [Last accessed on 2020 Apr 24].  Back to cited text no. 7
    
8.
The Video Link for Doffing. Available from: https://youtu.be/oUo5O1JmLH0. [Last accessed on 2020 Apr 24].  Back to cited text no. 8
    
9.
AGA Directive: COVID-19: What Should Clinicians and Scientists Do and When? Available from: https://www.gastrojournal.org/arti cle/S0016-5085 (20) 30370-X/pdf. [Last accessed on 2020 Apr 24].  Back to cited text no. 9
    
10.
ESGE and ESGENA Position Statement on Gastrointestinal Endoscopy and the COVID-19 Pandemic. Available from: https://www.esge.com/assets/downloads/pdfs/general/ESGE_ESGE NA_Position_Statem ent_gastroi ntestinal_endoscopy_COVID_19_pandemic.pdf. [Last accessed on 2020 Apr 24].  Back to cited text no. 10
    
11.
Joint Indian Societies Guidelines. Available from: https://www.sgei.co.in/pdf/COVID-19%20and%20t he%20Endoscopy%20Unit.pdf. [Last accessed on 2020 Apr 24].  Back to cited text no. 11
    
12.
Gu J, Han B, Wang J. COVID-19: Gastrointestinal manifestations and potential fecal-oral transmission. Gastroenterology 2020. pii: S0016-5085 (20) 30281X.  Back to cited text no. 12
    
13.
Xiao F, Tang M, Zheng X, Liu Y, Li X, Shan H. Evidence for gastrointestinal infection of SARS-CoV. Gastroenterology 2020. pii: S0016-5085 (20) 30282-1.  Back to cited text no. 13
    
14.
British Society of Gastroenterology Guidelines. Available from: https://www.bsg.org.uk/covid-19-advice/bsg-and-basl-cov id-19-advice-for-healthcare-professionals-in-gastroenterology-an d-hepatology/. [Last accessed on 2020 Apr 24].  Back to cited text no. 14
    
15.
What Should a Gastroenterologist know About COVID 19? Available from: https://www.cghjournal.org/article/S1542-3565 (20) 30330-X/pdf. [Last accessed on 2020 Apr 24].  Back to cited text no. 15
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4]



 

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