Keywords
elective endoscopy - COVID-19 - risk
Introduction
Coronaviruses are enveloped positive-strand RNA viruses. They include six species
that cause diseases in humans.[1] Among these, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) was detected
for the first time in December 2019 in China and subsequently caused an epidemic by
spreading to more than 40 million people in more than 200 countries. WHO declared
a global health emergency in January 2020 and also declared the novel Coronavirus
outbreak a pandemic on March 2020; further, the disease name was determined as COVID-19.
COVID-19 is a disease that can progress in a broad spectrum from asymptomatic or mild
disease to severe respiratory disease.[2]
[3] The most common symptoms of disease are fever, cough, and shortness of breath.[2] Patients may also experience nausea, vomiting, abdominal pain, and diarrhea as gastrointestinal
(GI) system symptoms.[4] The incubation period of the disease is 2 to 14 (median 5) days.[5] The virus was detected in the stools of infected patients at a rate of up to 51%
in 1 to 7 days.[6] Transmission occurs by contact with droplets and aerosols containing viruses of
infected person.[7] It has also been found that the disease is transmitted through the fecal-oral route.[8] Patients and health care workers may be exposed to potentially infectious biological
material during endoscopic procedures.[9] Therefore, endoscopy units are at increased risk of health care workers in terms
of airway droplet infection, conjunctival contact, and potential fecal-oral transmission.[3]
[8] Since the COVID-19 outbreak, all endoscopic procedures except emergency cases have
been cancelled or postponed in our center, as in many other centers. We evaluated
the frequency of COVID-19 that may occur in the postprocedure period in patients who
underwent an elective (in all nonemergency indications) endoscopic procedure during
the normalization process that started with leaving the peak period of the disease
behind.
Materials and Methods
The study included 351 patients who underwent an endoscopic procedure for all indications
except emergency cases between June 1 and August 21, 2020, at the endoscopy unit of
the gastroenterology department of the Istanbul Kanuni Sultan Suleyman Training and
Research Hospital. Procedures performed due to emergency indications (GI bleeding
and foreign body removal) were excluded from the study. All patients were evaluated
for risk stratification for COVID-19 before the procedure.[10] All patients’ temperature were checked before the procedure. Patients with normal
fever were questioned in terms of shortness of breath, cough, and history of contact
with COVID-19 patient or suspect. Patients with negative answers to all questions
were considered to be at low risk and were included in the study. Patients who responded
positively to one of these questions or had fever were included in the high-risk group
and excluded from the study. All patients were sedated with 1 to 5 mg of midazolam.
In addition, topical pharyngeal anesthesia with xylocaine was applied to patients
who underwent upper GI endoscopy. All endoscopic procedure times were recorded. All
patients were questioned by inviting them to the outpatient clinic or calling by phone
in terms of development of any symptoms such as fever, cough, and shortness of breath
which is associated with COVID-19 or having a COVID-19 PCR test within 14 days after
the procedure. All patients included in the study were followed in terms of COVID-19
testing status and results from the National Health Database. Personal protective
equipment (PPE) of the entire health care staff were provided consummately (N95 respirator
mask, disposable hairnet, booties/shoe covers, two pairs of gloves, waterproof disposable
gowns, goggles and disposable face shield) during the endoscopic procedures. The “2-meter
distance” rule was applied in patient waiting and recovery rooms. Permission was obtained
from the Ministry of Health Scientific Research Platform and the local ethics committee
for the study (No: 2020–07–08T12_58_15).
Statistical Analysis
All analyses were performed using SPSS version 20.0 for Windows (IBM Inc., Chicago,
Illinois, USA). Chi-square test was used for comparisons of categorical variables.
A value of p < 0.05 (2-sided) was considered statistically significant.
Results
A total of 351 patients were included in the study. A total of 445 procedures were
performed: upper GI system endoscopy in 180 patients, colonoscopy in 74 patients,
double procedure (upper GI endoscopy + colonoscopy) in 94 patients, and percutaneous
endoscopic gastrostomy (PEG) in 3 patients. A total of 181 male and 170 female patients
were included in the study. The mean age of patients was 49.7. Upper GI endoscopy
procedures were performed in the range of 4 to 15 (median: 6) minutes. Colonoscopy
procedures were performed in the range of 9 to 43 (median: 15) minutes. At least one
of the complaints such as cough, shortness of breath, and fever developed in 33 (9.4%)
patients during the inquiry and evaluation made by phone call or during the outpatient
clinic control 14 days after the procedure. It was observed that 20(5.6‰)of these
33 patients were tested for COVID-19 and the test results were reported as positive
in two (5.6‰) patients. There was no statistically significant difference between
the 2.9% COVID-19 PCR test positivity found in community screening studies and the
PCR positivity rate in our study (p = 0,328). Thirteen patients did not have the test, although they had suspicious symptoms
and were advised to be tested. In the endoscopy unit, one doctor, two nurses and two
assistant health workers did not develop any symptoms that could be due to COVID-19
during the study time . After it was detected that the patient was underwent procedure
with COVID-19 PCR positivity (two times), all health care workers were tested for
COVID-19 PCR, and all tests resulted negative. Demographic data, frequency of symptoms,
and COVID-19 test results about the patients are presented in [Table 1].
Table 1
Demographic data, frequency of symptoms and COVID-19 test results about the patients
|
Total
|
Upper GI Endoscopy
|
Colonoscopy
|
Endoscopy + Colonoscopy
|
PEG
|
|
Abbreviations: GI, gastrointestinal; PEG, percutaneous endoscopic gastrostomy.
|
|
Number of patients
|
351
|
180
|
74
|
94
|
3
|
|
Number of procedures
|
445
|
180
|
74
|
188
|
3
|
|
Age (mean)
|
49.8
|
46.5
|
50.05
|
52.4
|
77.3
|
|
Gender
M/F
|
181/170
|
91/89
|
43/31
|
46/48
|
1/2
|
|
Presence of symptoms (n%)
|
33 (9.4%)
|
16 (9.4%)
|
6 (8.1%)
|
11 (11.7%)
|
0 (0%)
|
|
Patients tested for COVID-19 (n%)
|
20 (5.6%)
|
9 (5%)
|
3 (4%)
|
7 (7.4%)
|
1 (33.3%)
|
|
COVID-19 test positivity (n%)
|
2 (5.6‰)
|
0 (0%)
|
0 (0%)
|
2 (2.1%)
|
0 (0%)
|
Discussion
By the normalization process, elective endoscopic procedures began to be performed
again, although they were less in number compared with the prepandemic period. In
this study, 445 procedures were performed on 351 patients in our center, while in
the same time period as this study in 2019, 811 endoscopic procedures were performed
on 618 patients. Our study is the first study in the literature evaluating the risk
of endoscopic procedures during the normalization period of the COVID-19 pandemic.
In a study which is similar to our study and was conducted in Italy during the onset
of the outbreak (January 27 to March 13, 2020), 8 of 802 patients who underwent endoscopy
had suspicious symptoms, and one patient who was tested was positive. Additionally,
in the other part of that study, in the same period, the health care workers working
in 968 endoscopy units were tested and 4.3% of them were positive for COVID-19. In
that study, the relatively high positivity in health care workers was attributed to
the insufficiency of PPE supply to health care workers and the lack of attention to
the use of PPE in the early period of the epidemic. Also, endoscopic procedures were
considered as low-risk interventions for the patient and health care workers when
attention was paid to appropriate use of PPE.[11] In another study, no transmission was detected among health care workers in a procedure
of a patient with severe respiratory symptoms with the use of a surgical mask at a
distance of less than 2 m and performed in less than 10 minutes.[12] In our study, no transmission was detected in the endoscopy unit workers. In our
study, the rate of developing suspicious symptoms in patients who underwent the procedure,
the rate of testing, and the frequency of COVID-19 positivity were found to be higher
than the other study. This can be explained by the fact that the other study was conducted
very early in the pandemic. In a screening study which was conducted throughout our
country, the rate of COVID-19 positivity in the asymptomatic population was detected
to be 2.5‰. In Istanbul, the city where our study was conducted, this rate was found
to be 2.9‰.[13] Therefore, the rate of COVID-19 occurrence (5.6‰) in patients who underwent endoscopy
in our study is an expected result. Although our results are data from a single center,
they may be useful in other centers when evaluated by considering community screening
studies. In a study conducted in China, it was recommended that all patients before
the endoscopic procedure should be screened for symptoms; also, thorax CT imaging
and then COVID-19 test should be performed if there is any doubt.[14] In another study, preprocedure testing is conditionally recommended with very low
level of evidence in areas where asymptomatic SARS-CoV-2 infection rate is < 0.5%.[15] In other different guidelines, screening test is recommended for all patients, if
it is in accordance with the country's resources and health policy.[16] Considering all the departments where endoscopic procedures are performed and testing
capacity of countries, pre-procedure testing for all patients can be difficult and
expensive. Considering the conditions of our country, we carried out the procedure
among patients who were found to be at low risk by only examining symptoms, contact
and fever, without testing, and included these patients into the study. Since the
start of pandemic, a postponement was recommended for elective endoscopic procedures
in the guidelines.[10]
[17] Although this postponement varies according to the indication for the procedure,
guidelines recommend re-evaluation of patients after 8 weeks to 12 weeks for elective
procedures.[10]
[17] When the guidelines are evaluated in terms of the priority of the indication, the
endoscopic procedure is considered as high priority in some guidelines,[10] and low priority in others,[17] and in patients with FOBT positive, which constitutes a significant amount of the
patients. Therefore, it is controversial which process has higher priority and how
long it can be postponed. Considering the uncertainty of the pandemic duration, we
think that the procedures can be continued without any delay in low-risk patients
as in our study. Limitations of our study are that it was conducted in a single center,
and all patients who underwent endoscopic procedures were not tested regardless of
the symptoms.
Conclusion
In the normalization process of COVID-19, elective endoscopic procedures can be performed
by examining the presence of symptoms, contact and fever, and paying attention to
the consummate use of PPE in patients who are found to be at low risk. Further studies
on this subject, which are conducted in different countries and cities, are needed.
