key: cord-0043000-zjdxz9vq
authors: Yip, Hon Chi; Chiu, Philip; Hassan, Cesare; Antonelli, Giulio; Sharma, Prateek
title: ISDE guidance statement: management of upper gastrointestinal endoscopy and surgery in COVID-19 outbreak
date: 2020-04-28
journal: Dis Esophagus
DOI: 10.1093/dote/doaa029
sha: 25ad61c44c1d61b9e69201cd10b107f55b93788a
doc_id: 43000
cord_uid: zjdxz9vq

This is an official guidance statement of The International Society of the Diseases of the Esophagus (ISDE) to address all the operators involved in management of patients affected by upper gastrointestinal diseases during COVID-19 pandemic. This guidance is based on the best available evidence to date and will be updated as new evidence becomes available.

Hospital-based transmission of COVID-19 unexpectedly plays a major role in the spreading of the disease in the Western countries, generating an enormous pressure on health care personnel (HCP), patients, and community. 1 One third of COVID-19 patients in Spain were HCPs, and up to two in every 10 HCPs in the red-area in North Italy was infected. 2, 3 The magnitude of HCPs involvement represents a key difference in the COVID-19 spreading between Western countries and China as only 3% of the Chinese HCPs was actually infected by the virus. 4 Such difference may be explained by a different attitude between Western and Asian HCPs in adopting the necessary preventive measures. For instance, the use of a standard surgical mask-that was current standard in Asian countries even before COVID-19 outbreak-encounters some reluctance in Europe and United States. 1, 5 The same applies to the need of physical or social distance between HCPs and patients or among HCPs themselves. 6 This is dramatically shown by the unexpected clustering of COVID-19 HCPs in the Western outbreak as compared with the Chinese experience.

Not all the procedures are at the same risk of COVID-19 transmission. 7 Despite the dominant route of transmission remains through airborne droplets or surface contact, aerosol generation is considered to be an additional risk factor as it was for influenza spreading. Gastrointestinal (GI) endoscopy and surgery represents potentially aerosol generation procedures, putting additional risks on the HCPs. 8 Long-lasting and difficult procedures are likely to further increase the professional risk of getting infected.

HCP protection is well effective in preventing COVID-19 transmission. 9 Respiratory droplets can be disrupted by a simple mask, while a surface contact by meticulous cleaning and disinfection. Aerosol generation, mainly to be attributed to coughing or exposure of the respiratory mucosa, may be antagonized by appropriate respirators, such as N95 or equivalents. 9,10 Of note, these were the same precautions widely used against Influenza transmission, before the population-based vaccination campaign marginalized its usefulness. On the other hand, protective measures tend to be jeopardized in Western countries by the lack of resources due to the unprecedented brisk surging of this outbreak that found unprepared most of the health systems in these countries. 11 In addition to direct preventive measures, indirect strategies aiming to reduce the chances of contacts between HCPs and patients have been advocated. 12 Postponing elective procedures in low-risk patients, especially if at high risk of COVID-19 death, triaging any patient for clinical/epidemiological riskfactors for COVID-19, and isolation and separation of all infected or high-risk cases are all effective strategies in the containment of the COVID-19 spreading. 8, 12 Aim of this position statement is the need of ISDE to address simultaneously all the operators involved in both GI endoscopy and surgery in order to define a common pathway that may be applied to those departments with special interest in upper GI diseases and their management. Operations may need to be canceled if the stock of these equipment runs low.

A list of proposed elective upper GI surgical procedures to be postponed is provided in a. Operations should be avoided as much as possible when the patient is still test positive for the virus, unless the surgery is deemed lifesaving and needs to be performed immediately.

b. CO 2 insufflation should be avoided during transthoracic esophagectomy in COVID-19 cases. c. Operations should be performed in an operating theater with negative pressure airflow, and all staff should be equipped with N95 or equivalent and goggles/facial shield throughout the procedure. d. Cleaning and disinfection of the operating theater should be performed after COVID-19 cases according to Center for Disease Control (CDC) standards 15, 16 : routine cleaning and disinfection procedures using an Environmental Protection Agency (EPA)-registered, hospital-grade disinfectant from List N are appropriate for SARS-CoV-2 in healthcare settings. Upon patient leaving the room, entry should be delayed until sufficient time has elapsed for enough air changes to remove aerosolized infectious particles.

COVID-19: protecting health-care workers

COVID-19 and Italy: what next?

COVID-19: Spain reports 462 more deaths in one day

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Mass masking in the COVID-19 epidemic: people need guidance

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