Lay-off of Endoscopy Services for the COVID-19 Pandemic: How Can We Resume the Practice of Routine Cases?

Dear Editors:

We read with interest the American Gastroenterological Association (AGA) Institute Rapid Recommendations for Gastrointestinal Procedures During the coronavirus disease 2019 (COVID-19) pandemic,¹ in which AGA aims to provide timely guidance on appropriate personal protective equipment and triage of gastrointestinal (GI) endoscopy in context of the COVID-19 pandemic in the United States.

Because the COVID infection is spreading all over the world, this rapid recommendation document offers reliable guidance for all physician who are dealing with the same issues.

In Italy, where the emergency began at the end of February, different measures to contain the infection were taken until a complete national lockdown on March 9, 2020, was instituted (phase 1). As of April 2021, the results of this strategy are emerging, with an initial decrease in the number of infected patients, hospitalizations, intensive care unit admissions, and virus-related mortality.

As a consequence of the lockdown, social distancing measures, and hospital reorganization, endoscopy centers have drastically decreased the number of outpatients examinations and are now delivering emergency and urgent procedures only. Being now in the contagion reduction phase, we are starting to work on the restart of the activities (phase 2). Although the number of endoscopic examinations to be rescheduled is currently not foreseeable because the restart of normal activities has not been established yet, the protocol for rescheduling the canceled examinations that will be delegated to the endoscopy services is included in the preparation of phase 2 management. As concerns the strategies to adopt, one could be to extend the working hours of the endoscopy services. However, this is likely unrealistic, because it implies the need for additional health care personnel and economic resources in a time where financial resources are limited. Postponing all the already scheduled procedures to give priority to the cancelled ones might be another option, but this strategy carries the risk of deferring a procedure that has been correctly scheduled, favoring another procedure that does not need any priority. Therefore, the strategy of rescheduling the appointments based on the stratification of the procedure indication might represent a valuable and reasonable alternative. We describe the policy we are adopting in our endoscopy service.

At the time of cancelling the endoscopy appointment, the nurse and medical staff performed a brief interview on the indication to the procedure, and double checked it with the medical prescription, registered in the hospital database, categorizing them as time-sensitive or not time-sensitive, as suggested by the AGA. In the first group, we arbitrarily included examinations required for symptoms of recent onset (4–6 weeks). In the not time-sensitive group we included the following two subgroups: subgroup A, chronic symptoms or postpolypectomy surveillance for high-risk lesions, according to published guidelines,² or for any dysplastic lesion in the upper GI tract (ie, dysplastic Barrett’s esophagus, or advance stages of gastritis with dysplasia); and subgroup B, postpolypectomy surveillance for low-risk lesions and for screening or surveillance of an upper GI preneoplastic risk condition without dysplasia. The rationale was to identify a priority scale to be used to reorganize the timetable for the phase 2.

Our endoscopy service carries out about 8000 procedures per year, including 4100 colonoscopies, 3150 gastroscopies, and 400 endoscopic ultrasound examinations. In the first 4 weeks of the lockdown, we have canceled 232 colonoscopies, 183 gastroscopies, and 15 endoscopic ultrasound examinations (we are continuing to perform oncologic endoscopic ultrasound examinations). In accordance with the proposed strategy of rescheduling, we as time-sensitive procedures 58 colonoscopies and 57 gastroscopies, whereas we had categorized 174 colonoscopies (50 and 124 in subgroups A and B, respectively) and 126 gastroscopies (104 and 22 in subgroups A and B, respectively) as not time-sensitive. Considering our usual daily case volume and the gradual resumption of activity, we should be able to allocate all the canceled procedures categorized within 3–4 months from the previous appointment, also in relation to the estimates for the start of phase 2 (probably within 2 weeks) .

As pointed out by the AGA recommendation, there is evidence supporting that delays of up to a few months also in some cancer diagnoses³ and up to 6 months in colonoscopy for positive fecal immunochemical testing may not lead to worse clinical outcomes.⁴ Therefore, this strategy seems to be reasonable, balancing the risks of missing lesions and the need not to overload the endoscopy services and not to put the staff at risk of contagion. However, this policy offers an opportunity to improve the appropriateness of particular procedures in an open access system. Upon resumption of activity, we will systematically record the effective appropriateness of the both rescheduled and already planned procedures to check the effectiveness of the proposed policy.