Recommendations for Essential Esophageal Physiologic Testing During the COVID-19 Pandemic

The new normal: a review of the impact of COVID-19 on gastroenterology fellowship training

The COVID-19 pandemic had a significant impact on medical education and gastroenterology fellowship training. As a result of the pandemic, a trainee's physical safety, mental health and wellness, clinical and procedural training, and educational opportunities were all potentially altered. Changes necessitated at the start of the pandemic were different than those needed further along in the pandemic course. Fellowship programs were required to modify policies and adapt to changes rapidly to advocate for their trainees and ensure quality education. Much of COVID-19's initial impact on education - decreased endoscopic procedures and the loss of educational conferences - has largely returned to pre-pandemic form. However, other changes made during the pandemic have persisted and likely will continue in the future. This includes a virtual interview format for fellowship matches, a virtual option for many national conferences, and an expansion of simulation training. This article reviews the impact that COVID-19 had on medical education with a specific focus on gastroenterology fellowship. The paper highlights the initial impact of COVID-19, the lingering effects, and discusses the areas needed for further research to best understand the total impact COVID-19 had on our trainees' education.

Same day barium esophagography and high-resolution manometry during the COVID-19 pandemic

PURPOSE

Double contrast barium esophagography (BAS) and high-resolution manometry (HRM) are traditionally performed on separate days to allow for pre-procedural fasting. In an effort to minimize COVID-19 exposure and improve appointment efficiency with required pre-procedure testing, we permitted same day HRM prior to BAS. Our study aimed to evaluate the adequacy of barium mucosal coating with same day HRM prior to BAS compared to BAS alone.

METHODS

We performed a retrospective pilot cohort study including 14 patients undergoing same day HRM prior to BAS and 20 patients undergoing BAS alone over an 8-month interval during the COVID-19 pandemic. Three abdominal imaging subspecialty-trained radiologists blindly reviewed the images and graded adequacy of esophageal coating on a 4-point scale with a score of 1 representing inadequate coating and 4 representing optimal coating.

RESULTS

For the cohort studied thus far, the mean grade of the HRM and BAS group was 3.17 with a standard deviation of 0.66. The mean grade of the BAS alone group was 3.13 with a standard deviation of 0.79. There was no statistical difference in the adequacy of esophageal coating between the two groups (p-value 0.97).

CONCLUSION

Same day HRM prior to BAS has no detrimental effect on barium mucosal coating compared to BAS alone. Though created to limit patient exposures during the COVID pandemic, same day BAS and HRM may prevent delays in care and improve convenience towards improved patient-centered care beyond the pandemic.

Evaluating the impact of an enhanced triage process on the performance and diagnostic yield of oesophageal physiology studies post COVID-19

OBJECTIVES

The COVID-19 pandemic significantly impacted on the provision of oesophageal physiology investigations. During the recovery phase, triaging tools were empirically recommended by national bodies for prioritisation of referrals amidst rising waiting lists and reduced capacity. We evaluated the performance of an enhanced triage process (ETP) consisting of telephone triage combined with the hierarchical 'traffic light system' recommended in the UK for prioritising oesophageal physiology referrals.

DESIGN

In a cross-sectional study of patients referred for oesophageal physiology studies at a tertiary centre, data were compared between patients who underwent oesophageal physiology studies 6 months prior to the COVID-19 pandemic and those who were investigated within 6 months after service resumption with implementation of the ETP.

OUTCOME MEASURES

Adjusted time from referral to investigation; non-attendance rates; the detection of Chicago Classification (CC) oesophageal motility disorders on oesophageal manometry and severity of acid reflux on 24 hours pH/impedance monitoring.

RESULTS

Following service resumption, the ETP reduced non-attendance rates from 9.1% to 2.8% (p=0.021). Use of the 'traffic light system' identified a higher proportion of patients with CC oesophageal motility disorders in the 'amber' and 'red' triage categories, compared with the 'green' category (p=0.011). ETP also reduced the time to test for those who were subsequently found to have a major CC oesophageal motility diagnosis compared with those with minor CC disorders and normal motility (p=0.004). The ETP did not affect the yield or timing of acid reflux studies.

CONCLUSION

ETPs can effectively prioritise patients with oesophageal motility disorders and may therefore have a role beyond the current pandemic.

The Impact of COVID-19 Pandemic on Neurogastroenterologists in Latin America: Results of an Online Survey

BACKGROUND

The COVID-19 pandemic has affected medical practice in fields not related to the infection. Neurogastroenterology is a subspecialty of gastroenterology focused on motility and functional gastrointestinal disorders, including consultations, and conducting procedures (eg, endoscopies, manometries/pH-monitoring).

AIM

The aim of this study was to determine the impact of COVID-19 on Neurogastroenterology in Latin America.

METHODS

Members of the Latin American Society of Neurogastroenterology were invited by e-mail and social networks to participate in an online anonymous survey. It included 24 questions on demographics, clinical practice and procedure characteristics, impact of the pandemic, Telemedicine, and involvement in COVID-19 patient care.

RESULTS

Sixty-one members mainly from Colombia, Mexico, and Brazil answered the survey. All reported a negative impact on their practice (88.6%: a 61% to 100% decrease), mainly in office consultations and elective endoscopies. Interestingly, emergency endoscopies decreased by 33.3%, while only 4% stopped performing manometries/pH-monitoring. The main reasons were patients' fear for consulting, country's lockdown, and physician's decision to prevent infection spread. Telemedicine was implemented by 83% but only 64.7% were being remunerated. Almost 46% had to reduce salaries and working hours of their personnel. Fifty-nine percent had colleagues diagnosed with COVID-19, 24.6% were involved in these patients' care, and 11.5% were mobilized to COVID-19 wards. There were country differences: Colombia, lockdown (P=0.001); Mexico, COVID-19 patient-care (P=0.053); Mexico/Colombia, working in COVID-19 wards, (P=0.012); Brazil, less common elective procedures' ban (P=0.012) and Telemedicine/reimbursement (P=0.034).

CONCLUSIONS

The COVID-19 pandemic has negatively impacted the practice and wellness of Neurogastroenterologists in Latin America. Guidelines to resume activities and policies for Telemedicine practice and reimbursement are warranted.

Risk of COVID-19 transmission in esophageal, anorectal manometry and 24-hour impedance-pH monitoring

BACKGROUND

the impact of the COVID-19 pandemic has led to the interruption of most manometry or impedance-pH monitoring studies. The risk of restarting activities is unknown.

OBJECTIVE

assess the risk of SARS-CoV-2 virus infection, both to patients and healthcare workers, in relation to esophageal and anorectal functional tests during the pandemic without protective measures.

METHOD

a questionnaire was designed to determine whether patients and healthcare workers had COVID-19, confirmed by either a test or compatible symptoms, after functional studies were performed from January until March 2020.

RESULTS

the survey was answered by 263 (92.9 %) patients. Four (1.52 %) patients had confirmed COVID-19 in the two weeks after the functional test (adjusted rate 8.34 cases per 1,000 [95 % CI -0.06-16.74], OR 0.84 [95 % CI: 0.83-0.85], p < 0.001) and no patient after anorectal manometry. Another five had only compatible symptoms, for a total of nine patients (3.42 %) (adjusted rate 27.50 cases/1,000 [95 % CI: 7.27-47.74], OR 2.84 [95 % CI: 2.81-2.87]). In the total study period, 18.25 % had confirmed COVID-19 or compatible symptoms. The average number of days between the procedure and the first day of symptoms was progressively shortened (January: 56 days, February: 33 days, March: 10.5 days). Two of ten healthcare workers (20 %) had confirmed COVID-19.

CONCLUSIONS

the risk of COVID-19 infection when performing functional tests is low and more related to the evolution of the pandemic rather than to the procedure itself. The small number of healthcare workers included in the study does not allow a definitive conclusion to be drawn on their risk of infection.

[Consequences of the COVID-19/SARS-CoV-2 pandemic for gastroenterology in Germany]

The recommendations of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) on coronavirus disease 2019 (COVID-19) in gastroenterological patients are accessible on the homepage of the Society under information at https://www.dgvs.de/covid-19/. Recommendations for protection against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) have been published by the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA). Separate endoscopy rooms for high-risk patients and negative pressure rooms should be included in the planning of future endoscopy unit projects. It is unclear whether a continuing prioritization of gastroenterological services after the first wave of COVID-19 is necessary in the future. The report of the Scientific Institute of the AOK health insurance company (WldO) and surveys of the Working Group of Clinical Gastroenterologists (ALGK) and the Professional Association of Private Gastroenterologists in Germany (bng) demonstrated that the coronavirus lockdown led to a significant reduction of gastrointestinal diseases and gastroenterological services including screening colonoscopy. It is likely that the reduction of the overcapacity of the German healthcare system will also be continued by reduction of inpatient services after the corona pandemic has been overcome. It is essential to keep the medical profession attractive for young colleagues. The high rates of burnout and suicide and the difficult compatibility with the requirements of a life balance are alarm signals that have to be solved.

Recommendations for the reopening and activity resumption of the neurogastroenterology units in the face of the COVID-19 pandemic. Position of the Sociedad Latinoamericana de Neurogastroenterología

The COVID-19 pandemic has forced the establishment of preventive measures against contagion during the performance of diagnostic and therapeutic tests in gastroenterology. Digestive tract motility tests involve an intermediate and elevated risk for the transmission of COVID-19 infection. Given their elective or non-urgent indication in the majority of cases, we recommend postponing those tests until significant control of the infection rate in each Latin American country has been achieved during the pandemic. When the health authorities allow the return to normality, and in the absence of an effective treatment for or preventive vaccine against COVID-19 infection, we recommend a strict protocol for classifying patients according to their infectious-contagious status through the appropriate use of tests for the detection of the virus and the immune response to it, and the following of protective measures by the healthcare personnel to prevent contagion during the performance of a gastrointestinal motility test.

American Neurogastroenterology and Motility Society Task Force Recommendations for Resumption of Motility Laboratory Operations During the COVID-19 Pandemic

The American Neurogastroenterology and Motility Society Task Force recommends that gastrointestinal motility procedures should be performed in motility laboratories adhering to the strict recommendations and personal protective equipment (PPE) measures to protect patients, ancillary staff, and motility allied health professionals. When available and within constraints of institutional guidelines, it is preferable for patients scheduled for motility procedures to complete a coronavirus disease 2019 (COVID-19) test within 48 hours before their procedure, similar to the recommendations before endoscopy made by gastroenterology societies. COVID-19 test results must be documented before performing procedures. If procedures are to be performed without a COVID-19 test, full PPE use is recommended, along with all social distancing and infection control measures. Because patients with suspected motility disorders may require multiple procedures, sequential scheduling of procedures should be considered to minimize need for repeat COVID-19 testing. The strategies for and timing of procedure(s) should be adapted, taking into consideration local institutional standards, with the provision for screening without testing in low prevalence areas. If tested positive for COVID-19, subsequent negative testing may be required before scheduling a motility procedure (timing is variable). Specific recommendations for each motility procedure including triaging, indications, PPE use, and alternatives to motility procedures are detailed in the document. These recommendations may evolve as understanding of virus transmission and prevalence of COVID-19 infection in the community changes over the upcoming months.

Recommendations for the reopening and activity resumption of the neurogastroenterology units in the face of the COVID-19 pandemic. Position of the Sociedad Latinoamericana de Neurogastroenterología

The COVID 19 pandemic has forced the establishment of measures to avoid contagion during diagnostic and therapeutic tests in gastroenterology. Gastrointestinal motility studies involve a high and intermediate risk of transmission of infection by this virus. Given its elective or non-urgent indication in most cases, we recommend deferring the performance of these tests until there is a significant control of the infection rate in each country, during the pandemic. When health authorities allow a return to normalcy and in the absence of effective treatment or a preventive vaccine for COVID 19 infection, we recommend a strict protocol to classify patients according to their infectious-contagious status through the appropriate use of tests to detect the virus and its immune response, as well as the use of protective measures to be followed by health personnel to avoid contagion during the performance of a gastrointestinal motility test.