Gastrointestinal endoscopy and the COVID-19 pandemic: Urgent issues in endoscopic retrograde cholangio-pancreatography and endoscopic training

The European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) Position Statement on gastrointestinal endoscopy and the coronavirus disease 2019 (COVID-19) pandemic came at the right moment. Documents such as this are really welcome, especially these days when we are treating patients on the front line and there is a lot of confusion. ¹ Europe, especially Italy, has been stricken by the pandemic with all its negative effects, and to date, in Italy alone, more than 150 doctors have died. Moreover, all scheduled and screening procedures have been stopped, and we are authorized to do only urgent endoscopies. The delay in performing scheduled procedures will increase complications, while the postponement of screenings will delay cancer diagnoses.

The ESGE and ESGENA Position Statement sheds some light on the correct personal protection and patient management in endoscopy. However, there are several considerations that need urgent attention. First, considering that we are now in a pandemic, all places across the world should be considered high risk, not only those with outbreaks of the infection. Moreover, there are many asymptomatic patients who are highly contagious. Taking into account that there are no effective, fast and cheap tests for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) positivity, in our opinion, high levels of protection should be adopted during all types of endoscopies. This might be expensive, but this currently seems the most reasonable approach. Second, it is true that different endoscopic procedures may have different levels of risk, especially gastroscopy, but it is important to note that endoscopic retrograde cholangio-pancreatography (ERCP) is the procedure that carries the highest risk of all. There are several reasons for this. In most of centres across Europe, ERCP is done under general anaesthesia, and orotracheal intubation raises the risk of aerosolisation of the virus. In the ERCP room, several people are present at the same time (e.g. in our centre, the anaesthesiologist, one anaesthesiology resident, one or two endoscopists and two nurses). Patients requiring ERCP are inpatients at high risk of SARS-CoV-2 infection. During ERCP, guidewires, catheters and all types of accessories are in direct contact with the bilio-pancreatic juices, saliva and gastric liquids that are at high potential for aerosolisation. Just a few days ago, Wölfel et al. showed that SARS-CoV-2 is replicating RNA. Therefore, it is active only in upper respiratory tract tissues, and is completely inactive in faeces, urine and blood. ² Does this mean that colonoscopy is a lower risk in COVID-19 patients? Currently, there are no studies on the activity of SARS-CoV-2 in bilio-pancreatic juices, and until there are, ERCP should be considered the highest risk.

Finally, we draw attention to a hidden emergency that probably no one is aware of: training in endoscopy has literally stopped – at least that is the case in our centre. In 2019, 33 doctors and 4 nurses from many different countries around the world were trained in endoscopy in our unit. With the COVID-19 outbreak, this number is now zero. Moreover, like in the rest of Europe and across the world, all masterclasses and teaching events are cancelled. The impact of this will be tremendous, not only on trainees in endoscopy but foremost on patients. While waiting for a SARS-CoV-2 vaccine or a target therapy, we desperately need a fast, cheap and reliable test in order to diagnose positive patients and, with this, to stratify the risk. Probably this will also reduce costs, and we will finally be able to restart routine procedures, especially screening colonoscopies. Alea iacta est!