Dear Editor in Chief
We read with interest the systematic review “Gastrointestinal Malignancies and the COVID-19 Pandemic: Evidence-Based Triage to Surgery” published in Journal of Gastrointestinal Surgery.1 The authors have done a commendable job outlining the consequences of delaying scheduled surgeries for gastrointestinal malignancies and need for prioritisation of procedures. The authors have analysed various published studies in literature to assess the impact of time to surgery and oncological outcomes in gastric, pancreatic, and colorectal malignancies. It is commendable that authors have clearly mentioned the limitations of the study that equivocal results in gastric and pancreatic malignancies may be due to patient selection rather than time to surgery.
We would like to present a different perspective to what the authors have put forth. We fear it will be the delay in diagnosis of gastrointestinal cancers rather than time to surgery after diagnosis which will have a major impact. Being one of the countries most affected by the corona virus pandemic next only to the USA and Brazil, India faces a unique set of problems. The COVID-19 pandemic has disrupted the diagnostic/screening endoscopy, colonoscopy, and imaging services in India and the rest of the developing world. Even before the pandemic, the patients of gastrointestinal malignancies are diagnosed at advanced stage in the absence of screening programmes as the developing world lacks access to universal healthcare. The COVID-19 pandemic has disrupted the already frail health infrastructure particularly the diagnostic and screening services like endoscopy, colonoscopy, and imaging. A multicentre survey suggested that the number of endoscopic and colonoscopy procedures have drastically reduced to 10% of the pre-COVID era (in more than 75% of the centres surveyed)2. Guidelines issued by international bodies/consensus groups are difficult to implement in a country like India with limited resources. Peripheral endoscopy centres, catering majority of the population lack of negative pressure units, have limited access to PPE; hence, many have completely stopped endoscopic procedures. Escalating cost of the procedure due to pre-procedure COVID test, PPE coupled with loss of jobs and livelihood, travel restrictions also have a cascading effect on the drastic reduction in number of procedures.
We being a tertiary care centre for gastrointestinal services cater to a huge demographic area with patients travelling 300–400 km to avail our services. Since the onset of the pandemic, the centre is geared up to perform all scheduled surgeries for gastrointestinal malignancies without undue delay. The real issues are the economic disruption and the travel restrictions taking a toll on early diagnosis and optimal care. The patients are delaying/postponing the hospital visit which we feel might have a catastrophic affect with many presenting with advanced stage of disease. We are presenting our data (Table 1) on the number of screening/diagnostic procedures undertaken during the period of COVID-19 pandemic (2020) compared with the corresponding period in the previous year (2019). The procedures reduced to less than 10% of the corresponding period of previous year in the months of April–May 2020. The number of procedures are gradually showing an increasing trend over the last 2 months(June–July 2020) but still are at 30–35% compared with that of the corresponding period of the past year. Various studies and observations published worldwide also have shown similar trends in screening and diagnostic procedures.
Table 1.
Comparision of number of screening/diagnostic procedures during COVID-19 pandemic (2020) vs corresponding period in 2019
| Procedure | 2019 (Feb–July) | 2020 (Feb–July) | Percentage reduction |
|---|---|---|---|
| Upper GI endoscopy | 737 | 163 | 22.1% |
| Colonoscopy and sigmoidoscopy | 184 | 35 | 19% |
| EUS/ERCP | 148 | 29 | 19.5% |
| Total procedures | 1069 | 227 | 24.2% |
The results of a recently published UK endoscopy database analysis have revealed that endoscopic activity reduced to 12% of pre-COVID levels, and at its low point, activity was only 5%.3 The weekly number of cancers detected decreased by 58% and the proportion of missing cancers ranged from 19% (pancreatobiliary) to 72% (colorectal) according to the database analysis.3 A multicentre survey in Italy conducted at the peak of the pandemic also revealed that majority of the units (60.5%) which had normal endoscopic activities reduced by 75–99%.4 The results of web-based survey of gastroenterologists across North America also suggest that at the time of response (April 2020), most centres (46/71, 65%) were operating at ≤ 10% of their normal endoscopy volume.5
The published surveys and our observations suggest that there is a major disruption in endoscopic/screening activity due to COVID-19 pandemic which may lead to delay in gastrointestinal cancer diagnosis. This may result in a perilous situation where in many patients could present with advanced gastrointestinal cancers leading to adverse outcomes.
Compliance with Ethical Standards
Conflict of Interest
The authors declare that they have no conflict of interest.
Footnotes
Publisher’s Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
References
- 1.Fligor, S.C., Wang, S., Allar, B.G.et al. Gastrointestinal Malignancies and the COVID-19 Pandemic: Evidence-Based Triage to Surgery. J Gastrointest Surg (2020). 10.1007/s11605-020-04712-5 [DOI] [PMC free article] [PubMed]
- 2.Goenka MK, Afzalpurkar S, Ghoshal UC, Guda N, Reddy N. Impact of COVID-19 on gastrointestinal endoscopy practice in India: a cross-sectional study. Endosc Int Open. 2020;8(7):E974–E979. doi: 10.1055/a-1181-8391. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 3.Rutter MD, Brookes M, Lee TJ, et al Impact of the COVID-19 pandemic on UK endoscopic activity and cancer detection: a National Endoscopy Database Analysis. Gut Published Online First:20 July 2020. 10.1136/gutjnl-2020-322179 [DOI] [PubMed]
- 4.Manes G, Repici A, Radaelli F, Bezzio C, Colombo M, Saibeni S. Planning phase two for endoscopic units in Northern Italy after the COVID-19 lockdown: An exit strategy with a lot of critical issues and a few opportunities [published online ahead of print, 2020 Jun 19] Dig Liver Dis. 2020;S1590-8658(20):30249–8. doi: 10.1016/j.dld.2020.05.042. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 5.Forbes N, Smith ZL, Spitzer RL, et al. Changes in Gastroenterology and Endoscopy Practices in Response to the Coronavirus Disease 2019 Pandemic: Results From a North American Survey [published online ahead of print, 2020 May 4] Gastroenterology. 2020;S0016-5085(20):30592–8. doi: 10.1053/j.gastro.2020.04.071. [DOI] [PMC free article] [PubMed] [Google Scholar]