The BSG has produced recommendations(1,2) based on the best available evidence from China(3), Italy(4) and the USA(5) that show:
- The virus causing COVID-19 is potentially present in all GI secretions.
- That all endoscopic procedures, but particularly upper GI endoscopy, are aerosol-generating procedures. (AGP) This is acknowledged in Public Health England. COVID-19: Guidance for infection prevention and control in healthcare settings.
- That viral transmission can occur at the time of endoscopy.
We have received reports that some centres are continuing to run elective endoscopy lists, requiring patients:
- To travel.
- To enter hospitals already treating significant numbers of COVID-19 patients.
- To wait in areas that do not meet any of the Government’s social isolating directives.
For these reasons, the BSG has recommended that all but emergency and essential procedures should stop immediately. The list of procedures to continue/be deferred/be considered case-by-case has been updated here.
- The main issues of contention remain whether Urgent 2 Week Wait (2WW) / Urgent Suspected Cancer (USC) patients, and patients already diagnosed as FIT positive under Bowel Cancer Screening Programs (BCSP), should be “paused” during the current crisis.
- How any potential harm from delayed diagnosis or treatment can be mitigated.
2WW/USC, and BCSP referrals: Relative Diagnostic Yield
The Risks of Pausing.
- 2WW/USC referrals – yield of cancer = 3%
- Bowel cancer screening programmes (BCSP) (FIT+) – yield of cancer = 8-10%
- Another, small percentage of patients will have advanced disease at the time of referral and the delay will not alter their prognosis, which unfortunately will already be very poor.
- For this group, a delay of 6 weeks is unlikely to materially alter the risk of an adverse outcome.
- Some of those who do not have established malignancy will have benign lesions such as polyps.
- In the majority of these cases, progression to malignancy, if it occurs, may take years.
Conclusion: Very few patients are likely to come to harm from a PAUSE
We suggest an immediate pause of 6 weeks for symptomatic referrals including 2WW /USC referrals and case by case triage (see below)
The devolved administrations in Wales, Scotland and Northern Ireland have formally paused bowel screening. A decision regarding bowel screening in England is still awaited. We recommend that all screening is PAUSED pending further guidance on the recommencement of screening services nationally
Risks of continuing 2WW/USC, BCSP and urgent referrals.
- Removing polyps, particularly those over 1 cm, carries risks of haemorrhage and perforation often requiring admission to hospital.
- During the COVID-19 crisis, ICU beds are unlikely to be available and even urgent surgical procedures will be restricted.
- The risks of death from polypectomy usually quoted, are based on entry into a hospital operating under normal conditions, but not during a COVID-19 epidemic, where the risks of death will be significantly higher.
- Patients who are diagnosed with cancer may not be offered surgery at the height of the epidemic. Their anxiety is likely to be equal to or even greater, than those with a positive FIT test whose colonoscopy is paused. Peri-operative COVID-19 infection in patients undergoing major cancer surgery may be associated with higher mortality.
- All patients attending for a non-emergency endoscopy now enter a high-risk environment.
- The benefit of endoscopy may be offset by the risk of COVID-19 infection to themselves.
- The majority will be older than 60 years with higher mortality from COVID-19 if they become infected.
- They become a potential risk to their families and contacts.
- Patients with asymptomatic COVID-19 infection pose a significant risk to staff. By definition, their infection will not be detected before having a procedure.
- The aerosol or droplets take up to an hour disperse, so they remain a risk to staff and other patients after they leave the room.
- Endoscopic procedures generate aerosols, so staff will require PPE at an appropriate level, at a time when it will be in short supply. (See PPE recommendations from the BSG pending further Government recommendations.)
- There is little evidence that a PAUSE of 6 weeks will pose a significant risk to the great majority of 2WW/USC or BCSP patients, although it is accepted that a small number of patients may have a delay in their diagnosis.
- On the other hand, a much larger number of patients and staff will be put at significant risk of COVID-19 if the 2WW/USC and BCSP is continued even at a scaled-down level.
Conclusions and Actions
- Stop all non-emergency, non-essential endoscopy immediately.
- Triage plan to identify patients who fall into the emergency/continue category. The evidence base for this is laid out in previous BSG documents (1) and follows experience from China(3), Italy(4) and the USA(5).
- 2WW/USC referrals should be triaged individually by consultants and risk assessed. Patients should be involved in decisions regarding investigation or deferral; decisions should be documented and patients kept on tracking lists. Full NHSE advice can be found here (9).
- List all patients on to a separate Urgent Deferred Waiting List to prioritise their proactive follow-up and investigation when services resume.
- Experienced medical and nursing staff with emergency admin support will need to be allocated to provide service to these at risk patients groups
- For patients needing immediate investigation, Units should develop local pathways for this. The British Society of Gastrointestinal and Abdominal Radiology (BSGAR) have issued pragmatic guidance for the Investigation of patients with lower GI symptoms during the COVID-19 epidemic.
Conclusion: The BSG/JAG guidance on prioritisation should be followed by all units using a 6 weeks pause to re-organise and redeploy resources against these criteria.
We believe that this pause is the least damaging strategy to patients at a time where choice is limited.
Looking to the future
Hospitals should ONLY resume endoscopy for 2WW/USC, BCSP patients when:
- National circumstance permit. Further guidance will be issued.
- Sufficient PPE, appropriate for the current risk level, is available for staff.
- Rapid COVID -19 testing for all staff is made available
- Patient flow is safely adjusted through units to minimise risk.
NB 2WW/USC patients may need to be reassessed to determine if their cancer risk has changed by phone triage.
- PAUSE (for 6 weeks)
Ian Penman, BSG VP Endoscopy
Cathryn Edwards, BSG President
Mark Coleman, Chair JAG Endoscopy
Alastair McKinlay, BSG President Elect
(1) British Society of Gastroenterology (BSG). Endoscopy activity and COVID-19: BSG and JAG guidance – update 22.03.20. 2020; Available at: https://www.bsg.org.uk/covid-19-advice/endoscopy-activity-and-covid-19-bsg-and-jag-guidance/. Accessed 03/26, 2020.
(2) British Society of Gastroenterology (BSG). BSG/JAG Statement on bowel screening & endoscopy service provision. 2020; Available at: https://www.bsg.org.uk/covid-19-advice/bsg-jag-statement-on-bowel-screening-endoscopy-service-provision/. Accessed 3/26, 2020.
(3) Zhang Y, Zhang X, Liu L, Wang H, Zhao Q. Suggestions of Infection Prevention and Control in Digestive Endoscopy During Current 2019-nCoV Pneumonia Outbreak in Wuhan, Hubei Province, China. February 2020. 2020; Available at: http://www.worldendo.org/wp-content/uploads/2020/02/Suggestions-of-Infection-Prevention-and-Control-in-Digestive-Endoscopy-During-Current-2019-nCoV-Pneumonia-Outbreak-in-Wuhan-Hubei-Province-China.pdf Accessed 03/22, 2020.
(4) Repici A, Maselli R, Comobo M, et al. Coronavirus (COVID-19) outbreak: what the department of endoscopy should know. 2020; Available at: https://doi.org/10.1016/j.gie.2020.03.019. Accessed 03/22, 2020.
(5) Soetikno R, Teoh AY, Kaltenbach T, et al. Considerations in performing endoscopy during the COVID-19 pandemic. 2020; Available at: https://els-jbs-prod-cdn.literatumonline.com/pb/assets/raw/Health%20Advance/journals/ymge/GIE-D-20-00499%20_Roy-1584643794760.pdf
(6) American Society for Gastrointestinal Endoscopy. Covid-19-asge-updates-for-members. 2020; Available at: https://www.asge.org/home/advanced-education-training/covid-19-asge-updates-for-members/. Accessed 03/20, 2020.
(7) European Society for Gastrointestinal Endoscopy. ESGE-and-ESGENA-position-statement-on-gastrointestinal-endoscopy-and-the-covid-19-pandemic. 2020; Available at: https://www.esge.com/esge-and-esgena-position-statement-on-gastrointestinal-endoscopy-and-the-covid-19-pandemic/. Accessed 03/22, 2020.
(8) World Endoscopy Organisation (WEO). WEO recommendations on digestive endoscopy and the COVID-19 pandemic. 2020; Available at: http://www.worldendo.org/2020/03/24/weo-advice-on-digestive-endoscopy-and-the-covid-19-pandemic/. Accessed 03/26, 2020.
(9) NHS England and Improvement. Advice on maintaining cancer treatment during the COVID-19 response. Publications approval reference: 001559.