Gastrointestinal Endoscopy in the Era of COVID-19

Using saliva epigenetic data to develop and validate a multivariable predictor of esophageal cancer status

Background: Salivary epigenetic biomarkers may detect esophageal cancer. Methods: A total of 256 saliva samples from esophageal adenocarcinoma patients and matched volunteers were analyzed with Illumina EPIC methylation arrays. Three datasets were created, using 64% for discovery, 16% for testing and 20% for validation. Modules of gene-based methylation probes were created using weighted gene coexpression network analysis. Module significance to disease and gene importance to module were determined and a random forest classifier generated using best-scoring gene-related epigenetic probes. A cost-sensitive wrapper algorithm maximized cancer diagnosis. Results: Using age, sex and seven probes, esophageal adenocarcinoma was detected with area under the curve of 0.72 in discovery, 0.73 in testing and 0.75 in validation datasets. Cancer sensitivity was 88% with specificity of 31%. Conclusion: We have demonstrated a potentially clinically viable classifier of esophageal cancer based on saliva methylation.

Up-to-date literature review and issues of sedation during digestive endoscopy

Sedation is common during digestive endoscopy to provide comfort and pain relief for patients. However, the use of sedation in endoscopy also poses potential risks, and recent issues have been raised regarding its safety and administration. This literature review paper will discuss the most recent developments in the field of sedation in digestive endoscopy, including the adverse events that might be associated with sedation and how to manage it, the legal issues associated with administration, the impact of COVID-19 on sedation practices, and sedation in special situations. It will also touch upon the current guidelines and recommendations for sedation, including the importance of patient selection and monitoring and the need for training and certification for endoscopists administering sedation. The review will also analyse studies evaluating the safety and efficacy of various sedation techniques, including propofol, midazolam, and others. It will examine the benefits and drawbacks of these agents.

Effect of the SARS-CoV-2 Pandemic on Gastrointestinal Endoscopy Procedures: Experience of a Tertiary Care Center From Eastern India

Background To contain the spread of infection and reduce the burden on healthcare infrastructure, many countries globally adopted a lockdown strategy during the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) pandemic. Hospitals were converted to dedicated coronavirus disease 2019 (COVID-19) centers, and non-COVID-19 patients were intervened on a triage basis. During this time, only emergency procedures were performed. The impact of this lockdown strategy during the first wave of the SARS-CoV-2 pandemic on various gastrointestinal endoscopy interventions remains unknown. Methodology In this retrospective, observational study conducted in the Department of Gastroenterology, Indira Gandhi Institute of Medical Sciences, Patna, Bihar from March 25 to September 30, 2020, data related to clinical profile, indication, and endoscopic interventions performed in reverse transcriptase-polymerase chain reaction (RT-PCR)-negative patients with the use of personal protective kits were analyzed and compared with the historical controls. Results A total of 2,282 patients were admitted and 422 endoscopic procedures were performed during the six-month study period with an intervention rate of 18.49%. The most common procedure was upper gastrointestinal endoscopy (228, 58.13%), followed by endoscopic retrograde cholangiopancreatography (ERCP) (88, 22.50%). Chronic liver disease (CLD) (144 patients) followed by malignancy (111 patients) were the most common diagnosis. During the first phase of the lockdown (March to May), only 52 procedures were performed (52 vs. 506). None of the patients underwent endoscopic ultrasound. In 2019, 4,501 patients were admitted and 1,224 procedures were performed with an intervention rate of 27.19 (p < 0.0001). None of the staff of the Department of Gastroenterology developed symptomatic SARS-CoV-2 infection during this period. Conclusions There was a significant drop in endoscopic procedures during the lockdown and most of the esophagoduodenoscopy procedures were done for CLD and ERCP for biliary tract malignancy. Endoscopic procedures done on RT-PCR for COVID-19-negative patients were safe using personal protective kits.

Gastrointestinal Endoscopy in Patients with Coronavirus Disease 2019: Indications, Findings, and Safety

The coronavirus disease 2019 (COVID-19) pandemic has changed the practice of gastroenterology and how we perform endoscopy. As with any new or emerging pathogen, early in the pandemic, there was limited evidence and understanding of disease transmission, limited testing capability, and resource constraints, especially availability of personal protective equipment (PPE). As the COVID-19 pandemic progressed, enhanced protocols with particular emphasis on assessing the risk status of patients and proper use of PPE have been incorporated into routine patient care. The COVID-19 pandemic has taught us important lessons for the future of gastroenterology and endoscopy.

Worsened Fibrostenotic Outcomes in Eosinophilic Esophagitis Patients Due to COVID-19-Related Endoscopy Cancellations

BACKGROUND

Indirect consequences of COVID-19 in eosinophilic esophagitis (EoE) are not known.

AIM

To determine the impact of COVID-19-related endoscopy cancellations on outcomes in EoE patients.

METHODS

In this retrospective cohort study, we assessed whether adult EoE patients who had routine endoscopy scheduled from mid-March 2020 to May 2020 (pandemic start) were canceled or proceeded, and if canceled, ultimately returned. We extracted clinical, endoscopic, and histologic data for their pre-COVID procedure as well as the next procedure performed, if a patient returned. Outcomes included histologic response (< 15 eos/hpf) and endoscopic severity. Those with delayed care were compared to those who returned as scheduled.

RESULTS

Of 102 patients identified, 75 had procedures canceled, and 20 (27%) never returned. For the 55 who were canceled but returned, mean time between procedures was 1.1 ± 0.7 years with a delay of 0.5 ± 0.3 years. While treatment rates were similar between the pre- and delayed post-COVID EGD, more patients required a dilation after their return (71% vs 58%; p = 0.05) and their esophageal diameter had significantly decreased (16.8 mm to 15.0 mm; p < 0.001). Of 17 individuals who did not have stricture, narrowing, or dilation pre-pandemic, during their next endoscopy 5 (29%) had a stricture, 1 (6%) had a narrowing, and 7 (41%) required dilation.

CONCLUSION

Of EoE patients with canceled endoscopies during the beginning of the COVID-19 pandemic, > 25% never returned for care, which is a previously unmeasured impact of the pandemic. Those who returned had > 1 year between procedures with progression of fibrotic features and need for esophageal dilation.

Factors Influenced the Endoscopic Services Volume during the COVID-19 Pandemic at National Tertiary Referral Hospital in Indonesia: Dr. Cipto Mangunkusumo Hospital

The impact of the COVID-19 pandemic caused a decrease in healthcare services, the intervention of non-surgical procedures, and endoscopy. This study examined the volume of endoscopy at Dr. Cipto Mangukusumo Hospital, the highest referral hospital in Indonesia. A cross-sectional mixed method was used to assess the relationship between endoscopy volume, age, gender, number of COVID-19 cases, type of patient's case, the origin of treatment, and the kind of endoscopic procedure before and during the pandemic. The secondary data were collected through the hospital's Electronic Health Record (EHR) System and "Kawal COVID-19" Websites, while the primary data were collected through observation, document reviews, and in-depth online interviews with doctors at endoscopic units. This study period was divided into six intervals of three months, respectively, from January 2020 to September 2021, and 5030 endoscopic procedures were collected. The data were analyzed both quantitatively through the SPSS statistics and qualitatively. The quantitative data presented as descriptive and bivariate results in an Independent T-Test and a Chi-Square test. The results showed there was a significant difference (p = 0.004) in the volume of endoscopes before (the highest volume) and during the pandemic (the lowest volume during April-June 2020 period). The mean age of the patients was higher before the pandemic. There was a significant difference between patient admissions from outpatient and emergency procedures before and during the pandemic. There are changes in the flow of outpatient to do endoscopies which were different from the flow of emergency patients during the pandemic, which focused on the long waiting list for inward entry queues, the mandatory COVID-19 PCR swab, and the criteria of emergency cases for fast-track procedures, the reduced bed capacity, and the expired date of laboratory examinations. The decreased volume was also caused by the limitation of patient intervention by the doctors. However, the duration of the action procedure was accelerated without reducing its quality. Furthermore, there was a high wave of Delta Variant cases from May to July 2021. In addition, the factors of age, type of patient's case, origin, and treatment showed significant differences before and during the COVID-19 pandemic. Finally, changes in the flow of services also influenced various impacts on endoscopy and service costs. Therefore, further study is required to calculate the unit costs.

Safe oesophageal stent deployment using a checklist system instead of fluoroscopy

BACKGROUND

Stenting is the management of choice for many benign and malignant oesophageal conditions and in the interest of safety stent insertion has traditionally been performed under fluoroscopic guidance. But this incurs additional expense, time, radiation risk and for the foreseeable future, an increased risk of Covid infection to patients and healthcare personnel. We describe a protocol that obviates the need for fluoroscopic guidance, relying instead on a systematic checklist to ensure safe positioning of the guidewire and the accurate positioning of the stent. The aim of this retrospective study was to review our experience of stent insertion employing a checklist system and compare our outcomes with outcomes using fluoroscopy in the literature.

METHODS

We performed a retrospective review of a prospectively collected dataset of all patients undergoing oesophageal stent insertion between December 2007 and October 2019. The primary end points were patient safety parameters and complications of stent insertion.

RESULTS

Total of 163 stents were deployed of which 93 (57%) were in males and the median age was 67.9 years (25-92 years). Partially covered self-expanding metallic stents (SEMS) were used in 80% of procedures (130/163). One hundred nineteen stents (73%) were for malignant strictures and 127 (78%) were deployed for strictures in the lower third of the oesophagus. There was no stent misplacement, injury, perforation or death associated with the procedure. Vomiting was the main post-operative complication (14%). Severe odynophagia necessitated stent removal in 3 patients. Stent migration occurred in 17 (10%) procedures with a mean time to stent migration of 6.4 weeks (range 1-20 weeks).

CONCLUSIONS

Oesophageal stent placement without fluoroscopy is safe provided that a strict checklist is adhered to. The outcomes are comparable to the results of fluoroscopic stent placement in the literature, with considerable saving in time, cost, personnel, and risks of radiation and Covid exposure.

Effect of enhanced personal protective equipment on colonoscopy performance and pain linked to procedure during the COVID-19 pandemic

Background and study aim: During the COVID-19 pandemic, the use of standard personal protective equipment (SPPE) reduces transmission risks during endoscopic procedures. Our aim was to assess the effect of enhanced personal protective equipment (EPPE) on colonoscopy performance and pain linked to the procedure compared with SPPE. Patients and methods: During two similar periods with three- month duration (in 2019 and in 2020 during the COVID-19 pandemic), electronic medical records and colonoscopy reports were investigated for sequential patients undergoing colonoscopy. SPPE was used in 2019 and EPPE in 2020. The patients’ clinical data and information related to the procedure were collected and analyzed. Primary outcomes were the duration to intubate the cecum, total procedure duration and patient pain score at the end of the procedure. Secondary outcomes were adenoma detection rate (ADR), polyp detection rate (PDR) and cecal intubation rate (CIR). Results: A total of 426 patients with colonoscopy performed were analyzed. The demographic features and indications for colonoscopy were similar for patients in both groups. The EPPE group had higher values for the parameters assessed as primary endpoints of cecal intubation time, withdrawal time, total procedure time and pain at the end of the procedure compared to the SPPE group and the differences were statistically significant. Conclusion: Our findings show that though the use of EPPE negatively affected colonoscopy performance and patient pain at the end of the procedure, it had no effect on the colonoscopy quality indices such as ADR, PDR and CIR.

Gastrointestinal Endoscopy and Coronavirus Disease-2019 Pandemic

Coronavirus disease-2019 (COVID-19) is a disease caused by severe acute respiratory syndrome-Coronavirus-2 (SARS-CoV-2). It has become a pandemic since March 11, 2020. It carries a significant burden and hampers gastrointestinal endoscopy practice. Since SARS-CoV-2 receptors are found in the gastrointestinal tract, COVID-19 also manifests as gastrointestinal symptoms. The viable virus is also detected in stool, carrying a high risk of transmission. Therefore, gastrointestinal endoscopy practice needs to be changed to prevent spreading from patients and medical personnel. All patients should be screened for the possibility of infection. Triage is done to determine the urgency of cases. Elective cases are postponed while semi-urgent and urgent cases are treated accordingly. A level 2 personal protective equipment (PPE) should be used for negative/suspected COVID-19 and a level 3 PPE is used for the confirmed case. Endoscopy unit should have negative-pressure room or proper ventilation, separated unit between negative/suspected and confirmed cases, exclusive equipment for COVID-19 case, and proper disinfection of equipment and room. Medical personnel must be screened regularly and positive information regarding gastrointestinal endoscopy practice should be spread to patients.

Gastrointestinal implications in COVID-19

Background

Coronavirus disease 2019 (COVID-19 patients mostly present with respiratory symptoms; however, gastrointestinal (GI) manifestations can also be seen either alone or along with respiratory symptoms. We aimed to evaluate the GI symptoms related to COVID-19.

Methods

This cross-sectional study retrospectively evaluated the medical files of 507 patients with confirmed or highly probable COVID-19. Based on their symptoms, patients were categorized into four groups: with GI symptoms alone (GIA), with respiratory symptoms alone (RA), with both GI and respiratory symptoms (GIR), and without GI or respiratory symptoms (WGIR).

Results

Of the 507 COVID-19 patients, 47.9% had at least one GI symptom; the most common was nausea and/or vomiting (31.6%). Patients in the GIA group were significantly older than those in the RA (P = 0.041) and GRI (P = 0.004) groups (54.70 ± 18.14 vs. 48.68 ± 14.67 and 46.80 ± 17.17 years, respectively). Groups were homogeneous with respect to gender. Leukopenia and lymphopenia were both less frequent in patients with GI symptoms compared to those without GI symptoms. Positive RT-PCR was significantly less frequent among patients with GI symptoms (44% vs. 100%, P < 0.001). Although mortality was lower in patients with GI symptoms (9.1%) in comparison with those without GI symptoms (13.3%), the difference was not statistically significant (P = 0.134).

Conclusion

The typical respiratory symptoms of COVID-19 are quite commonly accompanied by GI symptoms, with nausea and/or vomiting being the most prevalent. A subgroup of COVID-19 patients may exclusively present with GI symptoms. Special attention should be paid to these patients in order to avoid misdiagnosis or delayed treatment.

The impact of COVID-19 pandemic on insurance demand: the case of China

The COVID-19 has been a worldwide pandemic and it needs for studies related to effect on people's demand for insurance during the pandemic which is an important way to transfer risk. However, there is a lack of research linking COVID-19 and people's demand for insurance. The objective of this paper is to investigate the impact of COVID-19 pandemic on issuance demand, using data covering 241 cities on confirmed COVID-19 cases and insurance company revenue in China. The empirical results show that more confirmed COVID-19 cases are associated with greater per capita insurance revenue and the results are robust when considering endogeneity concern. Economically, the per capita insurance revenue increases by 0.896 Yuan for each more confirmed case. In terms of insurance type, the greatest increased insurance revenue is for life insurance, followed by health insurance. We further consider the heterogeneity of regions and find that the impact of COVID-19 on insurance revenue only exists in regions with worse medical treatment conditions or higher medical burden.

Commonly available but highly effective protection against SARS-CoV-2 during gastrointestinal endoscopies

BACKGROUND AND AIMS

SARS-CoV-2 is a worldwide serious health problem. The aim of this study was to demonstrate the number of potentially infectious particles present during endoscopic procedures and find effective tools to eliminate the risks of SARS-CoV-2 infection while performing them.

METHODS

An experimental model which focused on aerosol problematics was made in a specialized laboratory. This model simulated conditions present during endoscopic procedures and monitored the formation of potentially infectious fluid particles from the patient's body, which pass through the endoscope and are then released into the environment. For this reason, we designed and tested a prototype of a protective cover for the endoscope's control body to prevent the release and spread of these fluid particles from its working channel. We performed measurements with and without the protective cover of the endoscope's control body.

RESULTS

It was found that liquid coming through the working channel of the endoscope with forceps or other instruments inside generates droplets with a diameter in the range of 0.1-1.1 mm and an initial velocity of up to 0.9 m/s. The average number of particles per measurement per whole measured area without a protective cover on the endoscope control body was 51.1; with this protective cover on, the measurement was 0.0, p<0.0001.

CONCLUSIONS

Our measurements proved that fluid particles are released from the working channel of an endoscope when forceps are inserted. A special protective cover for the endoscope control body, made out of breathable material (surgical cap) and designed by our team, was found to eliminate this release of potentially infectious fluid particles.

COVID-19 and the digestive system: A comprehensive review

The coronavirus disease 2019 (COVID-19) pandemic caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) is spreading at an alarming rate, and it has created an unprecedented health emergency threatening tens of millions of people worldwide. Previous studies have indicated that SARS-CoV-2 ribonucleic acid could be detected in the feces of patients even after smear-negative respiratory samples. However, demonstration of confirmed fecal-oral transmission has been difficult. Clinical studies have shown an incidence rate of gastrointestinal (GI) symptoms ranging from 2% to 79.1% in patients with COVID-19. They may precede or accompany respiratory symptoms. The most common GI symptoms included nausea, diarrhea, and abdominal pain. In addition, some patients also had liver injury, pancreatic damage, and even acute mesenteric ischemia/thrombosis. Although the incidence rates reported in different centers were quite different, the digestive system was the clinical component of the COVID-19 section. Studies have shown that angiotensin-converting enzyme 2, the receptor of SARS-CoV-2, was not only expressed in the lungs, but also in the upper esophagus, small intestine, liver, and colon. The possible mechanism of GI symptoms in COVID-19 patients may include direct viral invasion into target cells, dysregulation of angiotensin-converting enzyme 2, immune-mediated tissue injury, and gut dysbiosis caused by microbiota. Additionally, numerous experiences, guidelines, recommendations, and position statements were published or released by different organizations and societies worldwide to optimize the management practice of outpatients, inpatients, and endoscopy in the era of COVID-19. In this review, based on our previous work and relevant literature, we mainly discuss potential fecal-oral transmission, GI manifestations, abdominal imaging findings, relevant pathophysiological mechanisms, and infection control and prevention measures in the time of COVID-19.

Characteristics of Viral Shedding Time in SARS-CoV-2 Infections: A Systematic Review and Meta-Analysis

Background: The viral shedding time (VST) of SARS-CoV-2 mainly determines its transmission and duration of infectiousness. However, it was heterogeneous in the existing studies. Here, we performed a meta-analysis to comprehensively summarize the VST of SARS-CoV-2. Methods: We searched PubMed, Web of Science, MedRxiv, BioRxiv, CNKI, CSTJ, and Wanfang up to October 25, 2020, for studies that reported VSTs of SARS-CoV-2. Pooled estimates and 95% CIs for the VSTs were calculated using log-transformed data. The VSTs in SARS-CoV-2 infections based on different demographic and clinical characteristics, treatments and specimens were stratified by subgroup analysis. Results: A total of 35 studies involving 3,385 participants met the inclusion criteria. The pooled mean VST was 16.8 days (95% CI: 14.8-19.4, I2 = 99.56%) in SARS-CoV-2 infections. The VST was significantly longer in symptomatic infections (19.7 days, 95% CI: 17.2-22.7, I2 = 99.34%) than in asymptomatic infections (10.9 days, 95% CI: 8.3-14.3, I2 = 98.89%) (P < 0.05). The VST was 23.2 days (95% CI: 19.0-28.4, I2 = 99.24%) in adults, which was significantly longer than that in children (9.9 days, 95% CI: 8.1-12.2, I2 = 85.74%) (P < 0.05). The VST was significantly longer in persons with chronic diseases (24.2 days, 95% CI: 19.2-30.2, I2 = 84.07%) than in those without chronic diseases (11.5 days, 95% CI: 5.3-25.0, I2 = 82.11%) (P < 0.05). Persons receiving corticosteroid treatment (28.3 days, 95% CI: 25.6-31.2, I2 = 0.00%) had a longer VST than those without corticosteroid treatment (16.2 days, 95% CI: 11.5-22.5, I2 = 92.27%) (P = 0.06). The VST was significantly longer in stool specimens (30.3 days, 95% CI: 23.1-39.2, I2 = 92.09%) than in respiratory tract specimens (17.5 days, 95% CI: 14.9-20.6, I2 = 99.67%) (P < 0.05). Conclusions: A longer VST was found in symptomatic infections, infected adults, persons with chronic diseases, and stool specimens.

Pediatric Endoscopy During COVID-19 Times

The global COVID-19 pandemic has led to healthcare resources being diverted or stretched, especially during periods of lock-down in affected countries. Disruptions to normal services have resulted in reduced or delayed provision of endoscopy in many countries, with consequent impacts on diagnosis or management of digestive diseases and upon endoscopy training. This review article aims to highlight key aspects of the impact of the pandemic upon endoscopy services, with a focus upon endoscopy in children.