Risk of bacterial exposure to the endoscopist's face during endoscopy

The new 222-nm far ultraviolet-C lowers bacterial contamination to endoscopists during esophagogastroduodenoscopy

Objectives

This study aimed to clarify the disinfectant efficacy of the 222-nm far ultraviolet-C (UV-C) during esophagogastroduodenoscopy using bacterial cultures.

Methods

The endoscopists performed esophagogastroduodenoscopy wearing a gown with a tryptic soy agar medium plate on their epigastric region and were divided into two groups: 222-nm far UV-C irradiation (UV group) and non-UV irradiation (non-UV group). As a control group, tryptic soy agar medium plates were placed about 110 cm above the floor. The incidence of bacterial contamination was determined by positive bacterial culture. The cultured bacteria were identified by 16S rRNA sequencing. Additionally, the actual UV exposure dose was measured using the UV-indicator card which changed colors upon exposure to 222 nm far UV-C.

Results

The bacterial culture positivity in the UV group (5.03%) was significantly lower than that in the non-UV group (25.76%), p < 0.0001. Most of the bacteria identified in the UV and non-UV groups were normal constituents of the oral flora, including Streptococcus salivarius and Staphylococci. Conversely, pathogenic microbes were found in the control group. The actual exposure doses of 222-nm far UV-C at the endoscopists' face, neck, and epigastric region were 2.09 ± 0.29, 5.89 ± 0.49, and 7.36 ± 0.58 mJ/cm2, respectively.

Conclusions

The 222-nm far UV-C irradiation reduced bacterial contamination for endoscopists. It can be used with conventional physical coverings to provide more effective infection control.

Bacterial contamination of endoscopist and assistant face visors during gastrointestinal endoscopy: a pilot study

Background and aim

During the COVID-19 pandemic, health workers' facial exposure to pathogens has been brought into focus. In this study, we aimed to determine the occurrence and degree of facial contamination to both endoscopists and their assistants during endoscopic procedures to help inform future safety measures.

Methods

Non-sterile visors worn by endoscopist, assistant and room control visors from 50 procedures were swabbed post procedure for culture. Procedure type, therapy, duration and evidence of visible visor contamination were recorded. After 48-hour incubation, all bacterial colonies were identified using matrix-assisted laser desorption/ionisation time-of-flight mass spectrometry. Organisms were classified into skin/environmental, oronasal and enteric.

Results

A total of 104 visors were available for assessment (93 staff; 11 control). In worn visors, skin/environmental flora were isolated from 70, oronasal flora from 8, and enteric flora from 3 with an average colony count of >9.5. Notably, bacteria of enteric origin (Escherichia coli and Enterobacter cloacae) were isolated from three worn visors. In room control, skin/environmental flora were isolated from seven and oronasal flora from one with average colony count of five. No room control visors grew enteric flora. Overall, 9.1% room control and 10.8% worn visors were contaminated with organisms that could possibly have originated from patients. However, enteric flora were only obtained from worn visors. No visors were visibly contaminated.

Conclusion

This pilot study demonstrates risk of contamination to faces of endoscopists and assistants. Larger studies are required to determine degree of risk and to give guidance on facial protection during gastrointestinal endoscopy.

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.

Airborne transmission of SARS-Cov2: What consequences for digestive endoscopy?

The SARS-Cov-2 disease disrupted essential hospital procedures, such as gastrointestinal (GI) endoscopy, due to concerns about air transmission and the risk of exposing health care workers. With the spread of the pandemic, air transmission was considered as the main source of SARS-Cov2 transmission. This raised the problem of transmission by aerosolization of viral particles in operating rooms as well as endoscopy units. This is in line with the known airborne transmission of many other respiratory viruses. The risk of SARS-Cov-2 transmission during GI endoscopy was initially reduced by controlled measures, involving personal protections (mask…), restricted access to endoscopy rooms, and detection of infected patients. Gastrointestinal endoscopy generates aerosols, which may carry viruses. In addition, the endoscopy system may facilitate the diffusion of virus particles or fomites considering the forced-air cooling system used to maintain a stable temperature inside the box (25°C). The volume of air that goes through the light source box is high (240-300 m³ for a 1-h period). Moreover, the light system contains an air pump to inflate air inside the gut lumen. In order to isolate people from hazard, different levels of protection and solutions to avoid airborne transmission of microorganisms should be proposed, such as the reinforcement of personal protective equipment, the change in the way people work and engineering control of the risk.

Bacterial exposure risk to the endoscopist's face while performing endoscopy

Objectives

Gastrointestinal endoscopy increases the risk of bacterial exposure to endoscopists. However, before 2019, most endoscopists did not pay attention to microorganism transmission from patients. This study aimed to investigate the incidence of bacterial exposure to endoscopists' faces during gastrointestinal endoscopic procedures using the bacterial culture method.

Methods

This was a single-centered, retrospective study including endoscopists who performed various gastrointestinal endoscopy procedures at the Division of Endoscopy, Hirosaki University Hospital between August 31 and October 6, 2020. Endoscopists wore surgical masks and affixed pre-sterilized films over them. Following the gastrointestinal endoscopic procedures, attached microbes were collected from the endoscopists' surface films using sterilized swabs. Collected microorganisms were cultured on tryptic soy agar and 5% sheep blood agar, and the incidence of bacterial exposure was determined by bacterial culture positivity. Cultured bacteria were identified by gram staining and 16S rRNA gene sequencing.

Results

Bacterial culture positivity was 12.6%, and it was significantly higher in therapeutic than in diagnostic endoscopy. Notably, therapeutic endoscopy increased bacterial culture positivity in colonoscopy, but not in esophagogastroduodenoscopy. Staphylococci, including Staphylococcus epidermidis and Staphylococcus capitis, were the most commonly found bacteria in samples identified through 16S rRNA gene sequencing.

Conclusions

The risk of bacterial exposure to the endoscopist's face was increased in colonoscopy treatment procedures. Therefore, endoscopists should be aware of the significant risk of microbial infection from scattering fluid that comes from the endoscopy's working channel.

Risk of Bacterial Exposure to the Anesthesiologist's Face During Intubation and Extubation

Introduction

Anesthesiologists are exposed to the risk of infection from various secretions or droplets from the respiratory tract of patients. We aimed to determine bacterial exposure to anesthesiologists' faces during endotracheal intubation and extubation.

Methods

Six resident anesthesiologists performed 66 intubation and 66 extubation procedures in patients undergoing elective otorhinolaryngology surgeries. Sampling was performed by swabbing the face shields twice in an overlapping slalom pattern, before and after each procedure. Samples for pre-intubation and pre-extubation were collected immediately after wearing the face shield at the time of anesthesia induction and at the end of the surgery, respectively. Post-intubation samples were collected after the injection of anesthetic drugs, positive pressure mask ventilation, endotracheal intubation, and confirmation of intubation success. Post-extubation samples were collected after endotracheal tube suction, oral suction, extubation, and confirmation of spontaneous breathing and stable vital signs. All swabs were cultured for 48 h, and bacterial growth was confirmed by colony forming unit (CFU) count.

Results

There was no bacterial growth in either pre- or post-intubation bacterial cultures. In contrast, while there was no bacterial growth in pre-extubation samples, 15.2% of post-extubation samples were CFU+ (0/66 [0%] vs 10/66 [15.2%], p=0.001). All the CFU+ samples belonged to 47 patients with post-extubation coughing, and the CFU count was correlated with the number of coughing episodes during the process of extubation (P < 0.01, correlation coefficient= 0.403).

Conclusion

The current study shows the actual chance of bacterial exposure to the anesthesiologist's face during the patient awakening process after general anesthesia. Given the correlation between the CFU count and the number of coughing episodes, we recommend anesthesiologists to use appropriate facial protection equipment during this procedure.

Visualizing endoscopy-generated aerosols with laser light scattering (with videos)

BACKGROUND AND AIMS

Upper GI endoscopy is speculated to be an aerosol-generating procedure (AGP). Robust evidence exists for aerosol transmission of severe acute respiratory syndrome coronavirus 2. The quality of data available confirming aerosol generation during GI endoscopy is limited. We aimed to objectively demonstrate that GI endoscopy is an AGP and illustrate the mechanism by which the greatest risk for aerosolization of droplets during endoscopy may occur.

METHODS

Aerosolized droplets generated during insertion and withdrawal of an endoscope and with passage of various tools through the endoscopic working channel using 2 experimental apparatuses modeling an upper GI tract (ie, a fluid-filled tube and a lamb esophagus) were qualitatively assessed by laser light scattering.

RESULTS

Insertion and withdrawal of the upper endoscope into the upper GI tract models generated numerous aerosolized particles. A large number of brightly scattering particles were observed at the site of insertion and withdrawal of the endoscope. Passage of a cytology brush, biopsy forceps, and hemostatic clip through the working endoscope channel also generated aerosolized particles but in fewer numbers. There was no significant variation in quantity or brightness of droplets generated on testing different biopsy valve cap models or when suctioning fluid with an open versus closed biopsy valve cap. These results were reproducible over several trials.

CONCLUSIONS

We illustrate in an objective manner that upper GI endoscopy is an AGP. These findings may have implications for transmission of infectious airborne pathogens outside of severe acute respiratory syndrome coronavirus 2 and can help to inform guidance on appropriate personal protective equipment use and other measures for transmission risk mitigation during GI endoscopy.

Biopsy channel of the endoscope as a potential source of infectious droplets during GI endoscopy

BACKGROUND AND AIMS

During endoscopy, droplets with the potential to transmit infectious diseases are known to emanate from a patient's mouth and anus, but they may also be expelled from the biopsy channel of the endoscope. The main goal of our study was to quantify droplets emerging from the biopsy channel during clinical endoscopy.

METHODS

A novel light-scattering device was used to measure droplets emanating from the biopsy channel. An endoscopy model was created, and in vitro measurements were carried out during air insufflation, air and water suctioning, and the performance of biopsy sampling. Similar measurements were then made on patients undergoing endoscopy, with all measurements taking place over 2 days to minimize variation.

RESULTS

During in vitro testing, no droplets were observed at the biopsy channel during air insufflation or air and water suctioning. In 3 of 5 cases, droplets were observed during biopsy sampling, mostly when the forceps were being removed from the endoscope. In the 22 patients undergoing routine endoscopy, no droplets were observed during air insufflation and water suctioning. Droplets were detected in 1 of 11 patients during air suctioning. In 9 of 18 patients undergoing biopsy sampling and 5 of 6 patients undergoing snare polypectomies, droplets were observed at the biopsy channel, mostly when instruments were being removed from the endoscope.

CONCLUSIONS

We found that the biopsy channel may be a source of infectious droplets, especially during the removal of instruments from the biopsy channel. When compared with droplets reported from the mouth and anus, these droplets were larger in size and therefore potentially more infectious.

An overview of gastrointestinal diseases in patients with COVID-19: A narrative review

Coronavirus disease-2019 (COVID-19), caused by severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2), has emerged as a global health concern. This study aimed to review the epidemiology and pathophysiology of COVID-19 and provide evidence for the implementation of control measures. We utilized several online databases, including MEDLINE (National Library of Medicine, Bethesda, Maryland, USA), PubMed, EMBASE, Web of Science, and Google Scholar, to collect relevant published papers using a combination of the following keywords: "COVID-19," "SARS-CoV-2," "novel coronavirus," "epidemiology," and "pathophysiology." The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used in this study. Globally, approximately 3-46% of patients with SARS-CoV-2 infection experience gastrointestinal symptoms. The clinical spectrum of COVID-19 is wide, ranging from mild to severe, and even fatal. COVID-19 was initially reported as a respiratory tract disease; however, gastrointestinal symptoms have only recently been reported. COVID-19 Patients with gastrointestinal symptoms may have more severe clinical manifestations and poor prognosis. This study highlights the need to better understand the mechanisms involved in the development of gastrointestinal symptoms in patients with COVID-19 to prevent the further spread of this pathogen.

The Effect of Covid-19 Pandemic on Current and Future Endoscopic Personal Protective Equipment Practices: A National Survey of 77 Endoscopists

Introduction

The COVID-19 pandemic has raised awareness about the importance of personal protective equipment (PPE). We aimed to study and compare PPE practices among Canadian endoscopists before and after the COVID-19 pandemic.

Methods

A 74-item questionnaire was emailed from June 2020 to September 2020 to practicing endoscopists in Canada. Survey questions collected basic demographics and differences between PPE practices pre- and post-COVID-19. PPE practices were categorized into four endoscopic procedure types including upper or lower endoscopy and diagnostic or interventional. Outcomes for specific procedures were reported as rates, with ranges shown when evaluating all procedure types together.

Results

A total of 77 respondents completed the survey with the majority of respondents aged 40 to 49 (44%) and identifying as Gastroenterologists (70%). Gender was evenly split (49% females versus 51% males). In the pre-pandemic era, the majority of endoscopists wore gowns (91 to 94%) and all endoscopists wore gloves (100%). However, the majority of endoscopists did not wear surgical masks (21 to 31%), face shields (13 to 34%), eye protection (13 to 21%), hair protection (11 to 13%), or N95 respirators (2 to 3%). In the post-pandemic era, more surgeons plan on wearing face shields (33 to 47%, P = 0.001 to 0.045), goggles (38.5 to 58.7%, P < 0.001), hair protection (33 to 36%, P = 0.011 to 0.024), and a trend suggests more surgeons will wear surgical masks (51 to 61%, P = 0.163 to 0.333). More endoscopists also plan on wearing N95 respirators during lower endoscopy (6 to 7%, P < 0.005).

Conclusion

The COVID-19 pandemic has changed the attitudes of many endoscopists regarding future PPE use in routine endoscopy. Ongoing studies are needed to inform new post-pandemic PPE consensus guidelines.

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.

Appropriateness of high-priority criteria and safety of endoscopy procedures during the COVID-19 lockdown

Background

During the coronavirus-19 disease (COVID-19) pandemic, gastroenterology guidelines recommended the suspension or reduction of non-urgent endoscopy. We aimed to assess the appropriateness and safety of endoscopic activity during the pandemic first wave lockdown using European Society of Gastrointestinal Endoscopy (ESGE) recommendations.

Methods

We identified scheduled patients from the onset of the lockdown in Spain since March 16, 2020) to April 14, 2020. Daily hospital COVID-19-related burden was also registered. A similar cohort from a period immediately before the lockdown was studied (pre-lockdown cohort) to compare appropriateness.

Results

454 endoscopy procedures were performed during the studied period, comprising a 49.7% reduction compared to the pre-lockdown cohort (n = 913). There was a significant increase in ESGE high-priority indications (62.1% vs. 45.6%, p<0.001) associated with an increase in relevant endoscopic findings (p = 0.006), advanced neoplasia/cancer (p = 0.004) and cancer detection rate (p = 0.010). There were no differences in the rate of admissions or infection among scheduled patients in the lockdown cohort. None of the staff members tested positive for COVID-19 in the 7 days after the adoption of protective measures.

Conclusion

A prioritized endoscopic activity is not associated with higher contagion after adopting protective measures. In addition, a triage of procedures that follow the ESGE criteria increases the rate of relevant endoscopic findings. These considerations may reduce the impact of the delays of diagnosis after the pandemic.

The Impact of COVID-19 on Surgical Training: the Past, the Present and the Future

The COVID-19 pandemic and infection control measures had an unavoidable impact on surgical services. During the first wave of the pandemic, elective surgery, endoscopy, and 'face-to-face' clinics were discontinued after recommendations from professional bodies. In addition, training courses, examinations, conferences, and training rotations were postponed or cancelled. Inadvertently, infection control and prevention measures, both within and outside hospitals, have caused a significant negative impact on training. At the same time, they have given space to new technologies, like telemedicine and platforms for webinars, to blossom. While the recovery phase is well underway in some parts of the world, most surgical services are not operating at full capacity. Unfortunately, some countries are still battling a second or third wave of the pandemic with severely negative consequences on surgical services. Several studies have looked into the impact of COVID-19 on surgical training. Here, an objective overview of studies from different parts of the world is presented. Also, evidence-based solutions are suggested for future surgical training interventions.

Impact of Infection Control Education on Gastrointestinal Endoscopy Procedural Staff

To date, minimal research has been conducted on proper use of personal protective equipment and hand hygiene within endoscopy. The American Society for Gastrointestinal Endoscopy has developed guidelines for infection control within the endoscopy suite. A practice change based upon these guidelines was implemented. Education was provided to endoscopy procedural staff within a Midwestern hospital based upon the World Health Organization 5 Moments for Hand Hygiene initiative and included personal protective equipment. Knowledge, skills, and attitudes of the participant group were compared from paired pre- to posteducation surveys pertaining to hand hygiene and personal protective equipment. Observation of personal protective equipment use and hand hygiene implementation during procedures was also documented pre- to posteducation. The project results revealed both willingness to implement proper donning and doffing of personal protective equipment and improved technique as evidenced by improved observed technique with the endoscopy suite and moderately improved hand hygiene questionnaire results. Although conducted as a quality improvement project, clinical significance was found via observation following education. These practices can aid in reduction of organism transmission from patients to staff.

Droplet dispersal in decontamination areas of instrument reprocessing suites

BACKGROUND

Personnel working in sterile processing or endoscope reprocessing departments are at high risk of exposure to tissue, blood, and patient fluids when decontaminating reusable medical instruments and equipment. The effectiveness of protective measures for reprocessing personnel has not yet been systematically evaluated in real-world settings.

OBJECTIVE

This pilot project aimed to identify reprocessing activities that generate splashes, determine how far droplets can travel in decontamination areas, and assess personal protective equipment exposure during routine activities.

METHODS

Moisture-detection paper was affixed to environmental surfaces and personal protective equipment in a sterile processing department. Droplet dispersal was assessed after personnel simulated performance of routine reprocessing tasks.

RESULTS

Visible droplets were generated during every reprocessing activity except running the sonication sink. Droplets traveled at least 3 feet when filling a sink, brushing a ureteroscope, and using a power sprayer to rinse a basin. Some activities dispersed droplets up to 5 feet from the sink. Personal protective equipment was splashed during most activities and did not prevent skin exposure even when properly donned and doffed.

CONCLUSION

This hypothesis-generating pilot project found that routine reprocessing activities generated substantial splashing, and currently recommended personal protective equipment did not adequately protect sterile processing personnel from exposure.

The impact of face shields on the quality of gastrointestinal endoscopy during the COVID-19 pandemic

Background

Coronavirus disease 2019 (COVID-19) has become a global pandemic, with healthcare workers at a high risk of exposure. During this pandemic, endoscopists must wear personal protective equipment (PPE), including face shields, to prevent COVID-19 transmission; however, few studies have reported the impact of face shields on the quality of gastrointestinal (GI) endoscopy. We aimed to determine whether the use of PPE, including face shields, affected the quality of GI endoscopy during the COVID-19 pandemic.

Methods

The medical records of patients who had undergone screening or surveillance colonoscopy and gastric endoscopic submucosal dissection (ESD) at Dong-A University Hospital between June 2020 and March 2021 were retrospectively reviewed. Endoscopists wore isolation gowns, disposable gloves, and KF94 masks from June 2020 to October 2020. From November 2020, endoscopists also wore face shields. We compared GI endoscopy quality indicators between the first five months (no face shields) and the second five months (with face shields). In the non-face shield and face shield groups, we calculated the overall adenoma detection rates (ADRs), polyp detection rate (PDR), sessile serrated lesion detection rate (SSLDR), advanced neoplasia detection rate (ANDR), complete resection rate (CRR), number of polyps and/or adenomas per colonoscopy, and gastric ESD procedure time.

Results

In total, 1359 study patients had undergone screening or surveillance colonoscopy (face shield group, n = 679; non-face shield group, n = 680). No statistically significant between-group differences were observed (PDR, 49.04 vs. 52.50%, p = 0.202; ADR, 38.59 vs. 38.97%, p = 0.884; SSPDR, 1.91 vs. 1.32%, p = 0.388; ANDR, 3.98 vs. 3.97%, p = 0.991, respectively). No difference was found in colonoscopy quality indicators between patients examined by experienced and trainee endoscopists with and without face shields. Of 144 study patients who had undergone gastric ESD for gastric neoplasms, there were 72 patients in each group. No statistically significant differences were found in the CRR (94.44 vs 93.05%, p = 1.000) and procedure times (19.22 ± 9.33 vs. 19.03 ± 11.49, p = 0.911).

Conclusions

Wearing face shields during the COVID-19 pandemic did not affect the quality indicators for GI endoscopy.

Comparison of the impact of endoscopic retrograde cholangiopancreatography between pre-COVID-19 and current COVID-19 outbreaks in South Korea: Retrospective survey

BACKGROUND

The coronavirus disease 2019 (COVID-19) outbreak has markedly influenced the endoscopic patterns. Endoscopic retrograde cholangiopancreatography (ERCP) is an essential technique for pancreatobiliary disease but increases the risk of exposure to the virus-containing body fluid; however, the impact of COVID-19 on ERCP is unknown.

AIM

To compare the number of endoscopic activities and to analyze the clinical outcomes of ERCPs before and during the COVID-19 outbreak in Daegu, South Kore.

METHODS

This retrospective cohort study included patients aged ≥ 18 years who underwent ERCP between February 18 and March 28, 2020, at a tertiary hospital. ERCP indications and endoscopic details were compared with those from the same period in 2018 and 2019 as control groups.

RESULTS

Of the 269 ERCP procedures, 113 (42.0%) cases were performed as emergency procedures. The number of ERCP procedures in 2018 and 2019 decreased by 20.2% and 56.6%, respectively, compared with that in 2020 (P < 0.01); among the 113 emergency ERCPs, the observed numbers in 2018 (n = 42) and 2019 (n = 55) dramatically dropped by 61.9% and 70.9%, respectively, compared with that in 2020 (n = 16). Of the 16 cases in 2020, stone removal was performed in five, biliary stenting in five, sphincterotomy in five, and nasobiliary drainage in one. No case of ERCP-related infection in medical workers or other patients has been reported.

CONCLUSION

The COVID-19 outbreak significantly reduced the number of ERCPs; however, there is no difference in the indications and endoscopic interventions before and during the COVID-19 outbreak.

Current State and Future of Infection Prevention in Endoscopy

Gastrointestinal (GI) endoscopy units tend to be busy environments in which numerous categories of staff provide moderately complex procedural care to high volumes of patients. The prevention of infections of both patients and staff is a never-ending endeavor for both inpatient and outpatient environments. Necessary considerations must address patient-to-staff, staff-to-patient, environmental, and device-related transmission of infection. In addition to the typical environmental and interpersonal infection risks present in all medical environments, the major concern within the endoscopy suite relates to contamination and potential transmission via reusable devices and endoscopes. Our understanding of this ever-present issue has evolved over time and has become a major focus of scrutiny in the past 5 years. This significant problem has stimulated guidance and ingenuity by regulators, investigators, and industry. Most recently, the COVID-19 pandemic of 2020 to 21 has also added significant burdens to our infection control efforts in gastrointestinal endoscopy.

Perception of Gastrointestinal Endoscopy Personnel on Society Recommendations on Personal Protective Equipment, Case Selection, and Scope Cleaning During Covid-19 Pandemic: An International Survey Study

Background/Aims

The Thai Association for Gastrointestinal Endoscopy published recommendations on safe endoscopy during the coronavirus disease 2019 (COVID-19) pandemic. This study aimed to assess the practicality and applicability of the recommendations and the perceptions of endoscopy personnel on them.

Methods

A validated questionnaire was sent to 1290 endoscopy personnel globally. Of these, the data of all 330 responders (25.6%) from 15 countries, related to the current recommendations on proper personal protective equipment (PPE), case selection, scope cleaning, and safety perception, were analyzed. Ordinal logistic regression was used to determine the relationships between the variables.

Results

Despite an overwhelming agreement with the recommendations on PPE (94.5%) and case selection (95.5%), their practicality and applicability on PPE recommendations and case selection were significantly lower (p=0.001, p=0.047, p<0.001, and p=0.032, respectively). Factors that were associated with lower sense of safety in endoscopy units were younger age (p=0.004), less working experience (p=0.008), in-training status (p=0.04), and higher national prevalence of COVID-19 (p=0.003). High prevalent countries also had more difficulty implementing the guidelines (p<0.001) and they considered the PPE recommendations less practical and showed lower agreement with them (p<0.001 and p=0.008, respectively). A higher number of in-hospital COVID-19 patients was associated with less agreement with PPE recommendations (p=0.039).

Conclusions

Using appropriate PPE and case selection in endoscopic practice during a pandemic remains a challenge. Resource availability and local prevalence are critical factors influencing the adoption of the current guidelines.

Capsule Endoscopy in Crohn's Disease-From a Relative Contraindication to Habitual Monitoring Tool

Crohn’s disease (CD) is a chronic inflammatory disorder that may involve the gastrointestinal tract from the mouth to the anus. Habitual disease monitoring is highly important during disease management, aiming to identify and treat disease exacerbations, in order to avoid immediate and future complications. Currently, ilio-clonoscopy is the gold standard for mucosal assessment. However, the procedure is invasive, involves sedation and allows for visualization of the colon and only a small part of the terminal ileum, while most of the small bowel is not visualized. Since CD may involve the whole length of the small bowel, the disease extent might be underestimated. Capsule endoscopy (CE) provides a technology that can screen the entire bowel in a non-invasive procedure, with minimal side effects. In recent years, this technique has gained in popularity for CD evaluation and monitoring. When CE was first introduced, two decades ago, the fear of possible capsule retention in the narrowed inflamed bowel lumen limited its use in CD patients, and a known CD located at the small bowel was even regarded as a relative contraindication for capsule examination. However, at present, as experience using CE in CD patients has accumulated, this procedure has become one of the accepted tools for disease diagnosis and monitoring. In our current review, we summarize the historic change in the indications and contraindications for the usage of capsule endoscopy for the evaluation of CD, and discuss international recommendations regarding CE’s role in CD diagnosis and monitoring.

What gastroenterologists should know about SARS-CoV 2 vaccine: World Endoscopy Organization perspective

BACKGROUND

The novel Coronavirus (SARS-CoV-2) has caused almost 2 million deaths worldwide. Both Food and Drug Administration and European Medicines Agency have recently approved the first COVID-19 vaccines, and a few more are going to be approved soon.

METHODS

Several different approaches have been used to stimulate the immune system in mounting a humoral response. As more traditional approaches are under investigation (inactivated virus vaccines, protein subunit vaccines, recombinant virus vaccines), more recent and innovative strategies have been tried (non-replicating viral vector vaccines, RNA based vaccines, DNA based vaccines).

RESULTS

Since vaccinations campaigns started in December 2020 in both the US and Europe, gastroenterologists will be one of the main sources of information regarding SARS-CoV 2 vaccination for patients in their practice, including vulnerable patients such as those with Inflammatory Bowel Disease (IBD), patients with chronic liver disease, and GI cancer patients.

CONCLUSIONS

Thus, we must ourselves be well educated and updated in order to provide unambiguous counseling to these categories of vulnerable patients. In this commentary, we aim to provide a comprehensive review of both approved COVID-19 vaccines and the ones still under development, and explore potential risks, benefits and prioritization of vaccination.

Gastrointestinal and hepatic diseases during the COVID-19 pandemic: Manifestations, mechanism and management

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is considered the causative pathogen of coronavirus disease 2019 (COVID-19) and has become an international danger to human health. Although respiratory transmission and symptoms are still the essential manifestations of COVID-19, the digestive system could be an unconventional or supplementary route for COVID-19 to be transmitted and manifested, most likely due to the presence of angiotensin-converting enzyme 2 (ACE2) in the gastrointestinal tract. In addition, SARS-CoV-2 can trigger hepatic injury via direct binding to the ACE2 receptor in cholangiocytes, antibody-dependent enhancement of infection, systemic inflammatory response syndrome, inflammatory cytokine storms, ischemia/reperfusion injury, and adverse events of treatment drugs. Gastrointestinal symptoms, including anorexia, nausea, vomiting, and diarrhea, which are unusual in patients with COVID-19, and some digestive signs may occur without other respiratory symptoms. Furthermore, SARS-CoV-2 can be found in infected patients' stool, demonstrating the likelihood of transmission through the fecal-oral route. In addition, liver function should be monitored during COVID-19, particularly in more severe cases. This review summarizes the evidence for extra-pulmonary manifestations, mechanisms, and management of COVID-19, particularly those related to the gastrointestinal tract and liver.

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.

Acute physiologic effects of N95 respirator use on gastroenterologists performing simulated colonoscopy

BACKGROUND AND AIMS

During the severe acute respiratory syndrome coronavirus 2 pandemic, N95 filtering facepiece respirator (FFR) use was required while performing aerosol-generating procedures. We studied the physiologic effects of N95 FFR use in a cohort of gastroenterologists performing simulated colonoscopies.

METHODS

Data collection and comparisons included (1) symptoms and change in vital signs in 12 gastroenterologists performing simulated colonoscopy for 60 minutes while wearing a surgical mask (SM) and faceshield (FS); N95 FFR, SM, and FS; and powered air-purifying respirator (PAPR) and (2) respiratory belt plethysmography and continuous electrocardiographic frequency-based heart rate (HR) variability indices including very low frequency power (measures intracardiac sympathetic tone) and low frequency to high frequency ratios (intracardiac sympathetic to vagal ratio) in 11 gastroenterologists performing simulated colonoscopy while wearing an SM (15 minutes), N95 FFR and SM (60 minutes), and SM (15 minutes) in rapid sequence.

RESULTS

Ten of 12 gastroenterologists (83%) reported symptoms with N95 FFR use, most commonly breathing difficulty, frustration, fatigue, and headache. Nine of these gastroenterologists (75%) had associated significant HR elevation. Respiratory peak to trough measurement showed a significant increase (F(2) = 7.543, P = .004) during the N95 FFR stage, which resolved after removal of the N95 FFR. Although not statistically different, all gastroenterologists showed a decrease in sympathetic to vagal ratios and an increase in intracardiac sympathetic effects in the N95 FFR stage. PAPR use was better tolerated but was associated with headache and elevated HR in 4 gastroenterologists (33%).

CONCLUSIONS

N95 FFR use by gastroenterologists is associated with development of acute physiologic changes and symptoms.

Amount of contamination on the face shield of endoscopists during upper endoscopy between patients in two positions: A randomized study

BACKGROUND AND AIM

During the Coronavirus Disease 2019 pandemic, esophagogastroduodenoscopy (EGD) has been recognized as an aerosol-generating procedure. This study aimed to systematically compare the degree of face shield contamination between endoscopists who performed EGD on patients lying in the left lateral decubitus (LL) and prone positions.

METHODS

This is a randomized trial in patients scheduled for EGD between April and June 2020. Eligible 212 patients were randomized with 1:1 allocation. Rapid adenosine triphosphate test was used to determine contamination level using relative light units of greater than 200 as a cutoff value. All eligible patients were randomized to lie in either the LL or prone position during EGD. The primary outcome was the rate of contamination on the endoscopist's face shield.

RESULTS

The majority of patients were female (63%), with a mean age of 60 ± 13 years. Baseline characteristics were comparable between the two groups. There was no face shield contamination after EGD in either group. The number of coughs in the LL group was higher than the prone group (1.38 ± 1.8 vs 0.89 ± 1.4, P = 0.03). The mean differences in relative light units on the face shield before and after EGD in the LL and prone groups were 9.9 ± 20.9 and 4.1 ± 6 (P = 0.008), respectively.

CONCLUSION

As measured by the adenosine triphosphate test, performing diagnostic EGD does not lead to contamination on the face shield of the endoscopist. However, placing patients in the prone position may further mitigate the risk.

The use of pediatric flexible bronchoscopy in the COVID-19 pandemic era

On March 11, 2020, the World Health Organization (WHO) declared the pandemic because of a novel coronavirus, called severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). In January 2020, the first transmission to healthcare workers (HCWs) was described. SARS-CoV-2 is transmitted between people because of contact, droplets, and airborne. Airborne transmission is caused by aerosols that remain infectious when suspended in air over long distances and time. In the clinical setting, airborne transmission may occur during aerosol generating procedures like flexible bronchoscopy. To date, although the role of children in the transmission of SARS-CoV-2 is not clear the execution of bronchoscopy is associated with a considerably increased risk of SARS-CoV-2 transmission to HCWs. The aim of this overview is to summarize available recommendations and to apply them to pediatric bronchoscopy. We performed systematic literature searches using the MEDLINE (accessed via PubMed) and Scopus databases. We reviewed major recommendations and position statements published at the moment by the American Association for Bronchology and Interventional Pulmonology, WHO, European Center for Disease Prevention and Control and expert groups on the management of patients with COVID-19 to limit transmission among HCWs. To date there is a lack of recommendations for safe bronchoscopy during the pandemic period. The main indications concern adults and little has been said about children. We have summarized available recommendations and we have applied them to pediatric bronchoscopy.

Significant variations across European centres in implementing recommended guidelines for the paediatric gastroenterology endoscopy suite during the COVID-19 pandemic

Supplemental Digital Content is available in the text.

The European Society for Paediatric Gastroenterology, Hepatology and Nutrition (ESPGHAN) published recommendations regarding protection for the paediatric endoscopist during the coronavirus 2019 (COVID-19) pandemic.The aim of this survey was to investigate whether European paediatric gastroenterology centres applied the recommendations and how this extraordinary situation was handled by the different centres.

Endoscopy mitigation strategy with telemedicine and low-cost device use for COVID-19 prevention: A fourth-level Colombian center experience

BACKGROUND AND STUDY AIMS

The COVID-19 outbreak has reorganized surgical team conditions regarding endoscopy. The number of interventions has been reduced, the number of healthcare professionals must be limited, and both the patients and physicians are more protected than ever.

PATIENTS AND METHODS

In the highest peak of contagion in Colombia, endoscopy, colonoscopy, and esophagogastroduodenoscopy were performed using a low-cost disposable device. A total of 1388 procedures were performed. Every patient was assessed for symptoms via a telephone call, at the health center, and after the procedure, following specific attention routes.

RESULTS

After procedure follow-up, no positive cases of COVID-19 were noted.

CONCLUSION

The methodology reduced the risk of infection during the COVID-19 pandemic.

Gastrointestinal endoscopy infection control strategy during COVID-19 pandemic: Experience from a tertiary medical center in China

OBJECTIVES

Coronavirus disease 2019 (COVID-19) has spread globally and become a pandemic. The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) not only infects the gastrointestinal (GI) tract and causes GI symptoms, but also increases nosocomial transmission risk during endoscopic procedures for aerosol generation. We hereby share our infection control strategies aiming to minimize COVID-19 transmission in the endoscopy center.

METHODS

We established our infection control strategies based on the guidance of Chinese Society of Digestive Endoscopy and inputs from hospital infection control experts: admission control through the procedure and patient triage, environmental control to reduce possible virus exposure, proper usage of personal protective equipment (PPE), and scope disinfection and room decontamination. All endoscopic procedures accomplished during COVID-19 outbreak and progress of stepwise resumption of elective endoscopy procedures were retrospectively reviewed.

RESULTS

Only urgent or semi-urgent procedures were performed during COVID-19 outbreak. After no local new-onset COVID-19 case in Beijing for four weeks, we reopened the endoscopy center for elective procedures and monitored the outbreak continuously while maintaining a sustainable endoscopy service.

CONCLUSIONS

It is imperative that all endoscopy centers should establish standard infection control strategies in order to fight COVID-19 pandemic based on national guidance and academic society guidelines and tailor them to individual resources. These measures and setup can also be reserved for future pandemics.

Effect of COVID-19 pandemic on the workflow of endoscopy units: an international survey

INTRODUCTION

The coronavirus disease 2019 (COVID-19) pandemic poses a challenge to healthcare. Staff and patients are at increased risk during an examination or intervention, so certain restrictions ought to be introduced. Hence, we aimed to measure the effect of the pandemic on endoscopy units in real-life settings.

METHODS

This was an observational, cross-sectional, questionnaire-based study, carried out between 7 April and 15 June 2020. Responds came from many countries, and the participation was voluntary. The survey contained 40 questions, which evaluated the effect of the COVID-19 pandemic on the endoscopy units and assessed the infection control.

RESULTS

A total of 312 questionnaires were filled, 120 from Hungary, and 192 internationally, and 54 questionnaires (17.3%) were sent from high-risk countries; 84.9% of the gastroenterologists declared that they read the European Society of Gastrointestinal Endoscopy (ESGE) statement, while only 32.1% participated in any advanced training at their workplace. Overall, 92.1% of gastroenterologists realized risk stratification, and 72.1% claimed to have enough protective equipment. In 52.6% of the endoscopy units, at least one endoscopist had to discontinue the work due to any risk factor, while 40.6% reported that the reduced staff did not affect the workflow. Gastroenterologists considered that the five most important examinations both in low and high-risk patients are the following: lower/upper gastrointestinal (GI) bleeding with hemodynamic instability, endoscopic retrograde cholangiopancreatography (ERCP) in obstructive jaundice, foreign body in the esophagus, ERCP in acute biliary pancreatitis, and iron deficiency anemia with hemodynamic instability, which correlates well with the ESGE recommendation. Significant correlation was found in the usage of the necessary protective equipment in high-risk patients depending on the countries (p < 0.001).

CONCLUSIONS

The survey found weak correlation in preliminary training depending on countries; nevertheless, in Hungary during the examined period, endoscopists considered the recommendations more strictly than in other countries. Although many physicians left the endoscopy lab, the workflow was not affected, probably due to the reduced number of examinations.

Vinyl bag cover method to avoid droplet-containing aerosol escape from endoscopic forceps channel caps during COVID-19 pandemic (with Video 1 and Video 2)

Endoscopists are at high risk of allowing transmission of coronavirus disease 2019 (COVID-19) during gastrointestinal endoscopy (GIE) procedures under pandemic conditions. The main avenues of droplet-containing aerosol generated during GIE are the mouth, anus, and endoscopic forceps channel. Although the usefulness of personal protective equipment for preventing COVID-19 dissemination has been well reported, measures to address infected aerosol escaping during endoscopic forceps use have been neglected. Pathogen-contaminated aerosol from the endoscopic forceps channel, leading into the gastrointestinal lumen, has been confirmed and is a highly problematic source of infection. We developed a technique that entails covering the forceps entry/exit hole with a vinyl bag, thereby preventing contamination of the endoscopy room by the infected aerosol that escapes from this hole. The technique can be used in daily clinical endoscopic practice. Furthermore, this shielding technique is useful for all patients who undergo GIE, regardless of the purpose of the procedure such as for making a diagnosis, administering therapy, or in an urgent situation. In this letter, we introduce our novel, easily performed, inexpensive method of infection prevention by disallowing infected aerosol to escape from a COVID-19-infected patient into the air during a procedure that requires the use of endoscopic forceps.

Minimizing endoscopist facial exposure to droplets: Optimal patient-endoscopist distance and use of a barrier device

BACKGROUND AND AIM

Minimizing endoscopist exposure to bodily fluids is important for reducing the risk of infection transmission. This study investigated the patient-endoscopist vertical distance necessary to minimize an endoscopist's facial exposure to a patient's visible droplets during upper gastrointestinal endoscopy and the ability of a new device to prevent droplets from reaching the endoscopist's face.

METHODS

A model was developed to simulate a patient experiencing a forceful cough during an upper gastrointestinal endoscopy with a model endoscopist. Fluorescent dye was expelled from the model patient's mouth towards the model endoscopist during simulated coughs; dye adhesion to the model endoscopist's face was evaluated using ultraviolet light. The simulation was repeated with the model patient positioned 70-100 cm above the floor, with and without a barrier to shield the patient's face. The accuracy of the cough simulation model and the relationship between patient-endoscopist vertical distance and endoscopist's facial exposure were evaluated.

RESULTS

The flow dynamics of the cough simulation model were similar to that of an actual human cough. There was a significant inverse correlation between the patient-endoscopist vertical distance and the model endoscopist's facial exposure, with positive exposures decreasing from 87% at 70 cm to 0% at 100 cm (P < 0.001). The barrier device prevented facial exposure to droplets at all distances.

CONCLUSIONS

We found that positioning the patient at least 100 cm below the top of the endoscopist's head or using a barrier device minimized the endoscopist's facial exposure to visible droplets during upper gastrointestinal endoscopy.

Management of gastrointestinal endoscopy unit during post covid-19 endemic outbreak: A report from Wuhan epicenter

The COVID-19 pandemic is caused by severe acute respiratory syndrome coronavirus 2 and causing a global public health emergency. During the outbreak, Wuhan was the first reported and hardest-hit city. With the dramatic drop in number of confirmed cases and subsequent ending of Wuhan lock down, asymptomatic carriers and patients in their recovery period still pose an increased risk. Strict and effective infection control protocols should be established and followed.

Intraluminal gas escape from biopsy valves and endoscopic devices during endoscopy: caution advised during the COVID-19 era

Background and study aims  The risk of aerosolization of body fluids during endoscopic procedures should be evaluated during the COVID-19 era, as this may contribute to serious disease transmission. Here, we aimed to investigate if use of endoscopic tools during flexible endoscopy may permit gas leakage from the scope or tools. Material and methods  Using a fresh 35-cm porcine rectal segment, a colonoscope tip, and manometer were placed intraluminally at opposite ends of the segment. The colonoscope handle, including the biopsy valve, was submerged in a water bath. Sequentially, various endoscopic devices (forceps, clips, snares, endoscopic submucosal dissection (ESD) knives) were inserted into the biopsy valve, simultaneously submerging the device handle in a water bath. The bowel was slowly inflated up to 74.7 mmHg (40 inH ₂ O) and presence of gas leakage, leak pressure, and gas leakage volume were measured. Results  Gas leakage was observed from the biopsy valve upon insertion and removal of all endoscopic device tips with jaws, even at 0 mmHg (60/60 trials). The insertion angle of the tool affected extent of gas leakage. In addition, gas leakage was observed from the device handles (8 of 10 devices) with continuous gas leakage at low pressures, especially two snares at 0 mmHg, and an injectable ESD knife at 0.7 ± 0.8 mmHg). Conclusions  Gas leakage from the biopsy valve and device handles commonly occur during endoscopic procedures. We recommend protective measures be considered during use of any tools during endoscopy.

Guidelines for Robotic Flexible Endoscopy at the Time of COVID-19

Flexible endoscopy involves the insertion of a long narrow flexible tube into the body for diagnostic and therapeutic procedures. In the gastrointestinal (GI) tract, flexible endoscopy plays a major role in cancer screening, surveillance, and treatment programs. As a result of gas insufflation during the procedure, both upper and lower GI endoscopy procedures have been classified as aerosol generating by the guidelines issued by the respective societies during the COVID-19 pandemic-although no quantifiable data on aerosol generation currently exists. Due to the risk of COVID-19 transmission to healthcare workers, most societies halted non-emergency and diagnostic procedures during the lockdown. The long-term implications of stoppage in cancer diagnoses and treatment is predicted to lead to a large increase in preventable deaths. Robotics may play a major role in this field by allowing healthcare operators to control the flexible endoscope from a safe distance and pave a path for protecting healthcare workers through minimizing the risk of virus transmission without reducing diagnostic and therapeutic capacities. This review focuses on the needs and challenges associated with the design of robotic flexible endoscopes for use during a pandemic. The authors propose that a few minor changes to existing platforms or considerations for platforms in development could lead to significant benefits for use during infection control scenarios.

International Observational Survey of the Effectiveness of Personal Protective Equipment during Endoscopic Procedures Performed in Patients with COVID-19

INTRODUCTION AND AIMS

This international survey was performed to evaluate the cumulative incidence of nosocomial novel coronavirus disease 2019 (COVID-19) among healthcare professionals during endoscopic procedures.

METHODS

We performed an international web-based self-reported questionnaire survey. Participants completed the questionnaires every week for 12 weeks. The questionnaire elicited responses regarding the development of COVID-19 and details of the personal protective equipment (PPE) used.

RESULTS

All 483 participants were included in the analysis. Participants had a mean age of 42.3 years and comprised 68.3% males. The geographic distribution of the study population was Asia (89.2%), Europe (2.9%), North and South America (4.8%), Oceania (0.6%), and Africa (1.5%). The most common endoscopy-related role of the participants was endoscopist (78.7%), and 74.5% had >10 years of experience. Fourteen participants had performed 83 endoscopic procedures in patients positive for COVID-19. During the mean follow-up period of 4.95 weeks, there were no cases of COVID-19 when treating COVID-19 positive patients. The most common PPE used by participants treating patients with COVID-19 was a surgical mask plus N95 mask plus face shield, goggles, cap, long-sleeved isolation gown, and single pair of gloves. The most common PPE used by participants treating patients without COVID-19 was a surgical mask, no face shield but goggles, cap, long-sleeved isolation gown, and single pair of gloves during all endoscopic procedures.

CONCLUSIONS

The risk of COVID-19 transmission during any endoscopic procedure was low in clinical practice.

COVID-19 prevalence among health-care workers of Gastroenterology department: An audit from a tertiary-care hospital in India

BACKGROUND AND AIM

In the present coronavirus disease-19 (COVID-19) era, health-care workers (HCWs) warrant special attention because of their higher risk and potential to transmit the disease. Gastroenterology services include emergency and critical care along with the endoscopy procedures, which have aerosol-generating potential. This study was aimed at auditing the COVID-19 impact on HCWs working in the Gastroenterology department of our hospital.

METHODS

The COVID-19 status of 117 HCWs was collected using either polymerase chain reaction (PCR) or Immunoglobulin G (IgG) seroassay. COVID-19 positivity was correlated with demographic characteristics, job profile, area of work, and medical history.

RESULTS

Thirty-eight HCWs (32.48%) showed evidence of COVID-19 using PCR (23.93%) or only IgG assay (8.55%). Endoscopy technicians (68.75%) exhibited significantly higher (P = 0.003) COVID-19 incidence compared to doctors (20.69%). Those working in the critical care units exhibited a trend toward higher COVID-19 incidence (42.86%). None of the six HCWs who received adequate hydroxychloroquine prophylaxis developed evidence of COVID-19. All the HCWs with COVID-19 disease recovered. However, there was a considerable loss of "man-days."

CONCLUSIONS

In our setting, we observed a high COVID-19 risk for HCWs working in the Gastroenterology department, with the highest risk among the endoscopy technicians. A more stringent triaging and pretesting of patients, as well as HCWs, might decrease the risk of COVID-19. Further multicenter studies are needed to evaluate the risk and related parameters.

Recent Advances in Endoscope Disinfection: Where Do We Stand in the COVID era?

Over 16 million cases worldwide, severe acute respiratory syndrome coronavirus 2 has profoundly affected healthcare as we know it. Given reports of gastrointestinal involvement and viral shedding in the stool, it is unsurprising there are concerns that endoscopic equipment may be a potential vector of viral transmission. Here, we provide an overview of existing practices for endoscope reprocessing, recent developments in the field, and challenges in the COVID-19 environment. Current multi-society guidelines do not advise any change to endoscope disinfection protocols but emphasize strict adherence to recommended practices. However, endoscopy reprocessing staff may benefit from supplemental personal protective equipment measures, especially in high risk situations. Because thorough endoscope reprocessing is highly operator dependent, adequate training of personnel is critical for proper manual cleaning and disinfection of endoscopes that have potential to harbor virus. Bacterial contamination of duodenoscopes has caused outbreaks of infection from multidrug-resistant organisms, highlighting vulnerable areas. The emphasis of current studies is on optimization of disinfection and drying, minimization of simethicone use, and on quality control of endoscope reprocessing with sampling and microbiological culturing. Recent advances include novel approaches to endoscope sterilization, infection barrier methods, and design of partially or fully disposable duodenoscopes. Overall, the available data indicate that, when correctly executed, current reprocessing practices are sufficient in preventing SARS-COV-2 transmission.

How Risky are Elective Endoscopic Procedures during the COVID-19 Normalization Process?

Objective In this study, we aimed to investigate the incidence of COVID-19 after endoscopic procedures were performed with elective indications during the normalization process of the COVID-19 pandemic. We also aimed to investigate safety of these procedures.

Materials and Methods The study included 351 patients who underwent an endoscopic procedure for elective indications in the endoscopy unit of the gastroenterology department of the İstanbul Kanuni Sultan Süleyman Training and Research Hospital and whose risk assessment for COVID-19 was low before the procedure. All patients were followed-up within 14 days after the procedure in terms of getting a COVID-19 PCR test and its results and also assessing development of any symptoms such as fever, cough, and shortness of breath associated with COVID-19.

Results A total of 351 patients were included in the study. A total of 445 procedures were performed: upper gastrointestinal (GI) system endoscopy in 180 patients, colonoscopy in 74 patients, double procedure (upper GI endoscopy + colonoscopy) in 94 patients, and percutaneous endoscopic gastrostomy (PEG) in three patients. It was found that at least one of the symptoms including cough, shortness of breath, and fever developed in 33 (9.4%) of these 351 patients within 14 days. It was observed that 20(5.6‰)of these 33 patients were tested for COVID-19 and the test results were reported as positive in two(5.6‰)patients.

Conclusion In the normalization process of COVID-19, elective endoscopic procedures can be performed in patients, who are shown to be low risk, by paying attention to the consummate use of the personal protective equipment (PPE).

A novel perspective approach to explore pros and cons of face mask in prevention the spread of SARS-CoV-2 and other pathogens

Corona virus disease 2019 (COVID-19) outbreak has become a severe community health threat across the world. Covid-19 is a major illness, presently there is no as such any medicine and vaccine those can claim for complete treatment. It is spreading particularly in a feeble immune people and casualties are expanding abruptly and put the health system under strain. Among the strategic measures face mask is one of the most used measures to prevent spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Wearing a face mask possibly create a false sense of security lead to decline others measures. Face mask could be risk for the people of under lying medical conditions, old age group, outdoor exercise, acute and chronic respiratory disorders and feeble innate immune. Restrictive airflow due to face mask is the main cause of retention of CO2 called hypercapnia that can lead to respiratory failure with symptoms of tachycardia, flushed skin, dizziness, papilledema, seizure and depression. According to latest updates face shield and social distancing could be better substitute of face mask.

Coronavirus Disease (COVID-19) Caused by (SARS-CoV-2) Infections: A Real Challenge for Human Gut Microbiota

The current COVID-19 pandemic is a great challenge for worldwide researchers in the human microbiota area because the mechanisms and long-term effects of the infection at the GI level are not yet deeply understood. In the current review, scientific literature including original research articles, clinical studies, epidemiological reports, and review-type articles concerning human intestinal infection with SARS-CoV-2 and the possible consequences on the microbiota were reviewed. Moreover, the following aspects pertaining to COVID-19 have also been discussed: transmission, resistance in the human body, the impact of nutritional status in relation to the intestinal microbiota, and the impact of comorbid metabolic disorders such as inflammatory bowel disease (IBS), obesity, and type two diabetes (T2D). The articles investigated show that health, age, and nutritional status are associated with specific communities of bacterial species in the gut, which could influence the clinical course of COVID-19 infection. Fecal microbiota alterations were associated with fecal concentrations of SARS-CoV-2 and COVID-19 severity. Patients suffering from metabolic and gastrointestinal (GI) disorders are thought to be at a moderate-to-high risk of infection with SARS-CoV-2, indicating the direct implication of gut dysbiosis in COVID-19 severity. However, additional efforts are required to identify the initial GI symptoms of COVID-19 for possible early intervention.

Current and future implications of COVID-19 on gastroenterology training and clinical practice

The novel coronavirus disease 2019 (COVID-19) pandemic has affected almost every country on the globe, affecting 185 countries with more than 2.6 million cases and 182,000 deaths as of April 22, 2020. The United States (US) has seen an exponential surge in the COVID-19 patients and has become the epicentre with more than 845,000 confirmed cases and 46,000 deaths. The governments and healthcare providers all over the world are racing with time to reduce the rate of increase in active cases by social distancing to flatten the curve of this pandemic. Practicing gastroenterologists are facing multiple challenges in the safe practice of medicine because of patient's inability to visit physicians' offices, endoscopy centers and the threat of potential virus spread through gastrointestinal secretions by endoscopies in emergent cases. The gastroenterological associations from Europe and North America have made position statements to guide gastroenterologists to navigate through the clinical practice during the COVID-19 pandemic. Gastroenterology fellows are on the frontlines during the COVID-19 pandemic, experiencing personal, physical and economic stresses. They had to balance the programmatic changes to meet the demands of the patient care with the additional pressure to meet training requirements. Given the imperatives for social and physical distancing, training programmes have to implement innovative educational methods to substitute traditional teaching. Healthcare organisations must synchronise institutional workforce needs with trainee safety, education and well-being. In this perspective, we have discussed the challenges that can be anticipated and implementing strategies to support fellows during the times of the COVID-19 pandemic.

Coronavirus disease 2019 and the pancreas

Coronavirus disease 2019 (COVID-19) caused by Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) has led to a world-wide pandemic since its onset in December of 2019. Although, a primary respiratory pathogen, over the ensuing period, its extra-pulmonary effects have come to the forefront. The virus, having multi-organ tropism, has been shown to affect a host of other organs beyond the lung, including the pancreas. The data on pancreatic involvement by COVID-19, however, have been limited. Moreover, whether the effects on the pancreas are due to the direct effects of the virus or is just an epi-phenomenon is debatable. The prevalence of pancreatic injury and degree of injury are the other issues that need to be addressed. Pancreatic cancer has a dismal prognosis and the management of the same in the COVID era needs to be tailored assessing the risk-benefit ratio for the same. Additionally, pancreatic surgery increases not only the morbidity of the patient, but also the risk of the operator and burden on the health care system. Hence, the decision for such major procedures needs to be rationalized for optimum benefit during this pandemic. Similarly, for the endoscopist, pancreatic endoscopy needs to be carefully regulated to reduce risk to both the patient and the physician and yet deliver optimum patient care. This review gives a concise summary of various aspects of pancreatic involvement and pancreatic disease management during this pandemic.

Gastrointestinal Endoscopy in the Era of COVID-19

Coronavirus disease 2019 (COVID-19) is caused by severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2), which led to a worldwide pandemic that started in early 2020. Healthcare systems across the world encountered an unprecedented surge of COVID-19 patients resulting in more than half a million deaths globally. COVID-19 has affected multiple sub-specialties and procedure-related fields, including gastroenterology. Gastrointestinal (GI) endoscopy centers are specialized units where thousands of endoscopies are performed annually. A significant proportion of these procedures are affected due to the national and regional lockdowns across the globe. To adapt to this rapidly evolving situation, endoscopy centers have undergone significant changes and have taken unprecedented precautions to avoid the transmission of the virus. However, endoscopy centers are going through financial strain due to a reduction in the number of procedures from lockdowns and fear of virus transmission. Theoretically, endoscopies could add to the disease transmission as SARS-CoV-2 has shown to be present in the GI secretions. Multiple precautions such as mandatory use of face masks, safe distancing, use of barriers between the endoscopists and patients, negative pressure rooms, extended use of personal protective equipment, and volume reduction have been taken to decrease the risk of disease transmission by these centers. Moreover, pre-endoscopy COVID-19 testing has now become the norm. In this review, we highlight the significant changes assumed by the endoscopy center. Furthermore, we discuss cost-related concerns of pre-endoscopy COVID-19 testing, the downtime and delays related to the procedures, and effects of rescheduling. As the pandemic progresses through multiple phases, endoscopy centers should use a dynamic approach to adapt and strive to provide the best patient care.

Changes in Policy and Endoscopic Procedures during the 2019 Coronavirus Disease Outbreak: A Single Center Experience

Background/Aims

The coronavirus disease-19 (COVID-19) pandemic forced endoscopy units to enact major changes on daily practice and policy. The Chaim Sheba Medical Center is a tertiary referral center located in the center of Israel, and serves cities with high infection rates. Our aim was to review the policies enacted during this outbreak and study their influence on the performance of endoscopic procedures.

Methods

Following the revision of work protocols, personnel were divided into two permanent and physically separate working groups and screening procedures were rescheduled. Relevant data including the number of endoscopic examinations, type of procedure performed, and patient referrals and indications were taken from a computerized database and evaluated. The study included data for January–March 2018–2020, and a comparison among the data from each year was performed.

Results

As of March 2020, the total number of endoscopic examinations performed reduced by 44% (p<0.0001) as compared to previous years, gastroscopy examinations reduced by 39% (p=0.02), and lower endoscopy procedures reduced by 57% (p<0.0001). Meanwhile, the number of advanced endoscopic procedures performed remained consistent with previous years. The indications for performance of gastroscopy and lower endoscopy were different in March 2020, while these remained unchanged for advanced endoscopic procedures.

Conclusions

The current policy appears to serve both our initial goals: protecting personnel and patients’ safety and minimizing potential damage from delayed endoscopic procedures. A longer term follow-up study is needed in order to fully analyze our results.