key: cord-0749348-1sds5n37
authors: Jurado, José Roberto; Nieto, Jorge Hernán Santos; Gaitán, Jairo Ospina; Bonilla, Constanza Garzón; Villarreal, Ricardo; Acevedo, David; Cabrera, Laura; Cabrera, Luis Felipe; Pedraza, Mauricio
title: Endoscopy mitigation strategy with telemedicine and low-cost device use for COVID-19 prevention: a fourth-level colombian center experience
date: 2021-05-06
journal: Arab J Gastroenterol
DOI: 10.1016/j.ajg.2021.05.004
sha: 9409eb429c903a951695e17d7fdbccf907df56ec
doc_id: 749348
cord_uid: 1sds5n37

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.

At the end of 2019, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged for the first time in the Chinese region of Hubei, the SARS-CoV-2 virus appeared for the first time, and spread worldwide in a few months, causing; this infection causes mainly respiratory conditions, ranging from mild symptoms such as rhinitis, fever, cough, anosmia, and dysgeusia, to pneumonia and acute respiratory distress syndrome (ARDS).. (1) Virus transmission The SARS-CoV-2 virus is mainly transmitted by droplets of saliva when speaking or coughing, however. However, the fecal--oral transmission is not excluded, which makes. Thus, gastrointestinal endoscopic procedures ofhave a high risk of contagion asbecause they require airway manipulation of the airway and direct contact with respiratory droplets or gastrointestinal secretions. In addition, they'reThey are also considered aerosolgenerating procedures. (1, 2) Previous reports in the literature ofon other outbreaks showshowed that gastrointestinal endoscopy can also be a vector of transmission for some viruses, such as hepatitis B and C. (3) Currently, there are around approximately 23 million cases and 800,000 deaths have been reported cases worldwide and approximately 800 thousand deaths. . In Colombia has reported, over 1.5 million cases and over 40.,000 deaths. This article presents have been recorded. Hence, this study aimed to describe our clinical experience and, the results of using a low-cost device for endoscopy, and an approach to the methodology used in theour hospital center for thepatient admission and departure of patients in orderdischarge to reduce theinfection risk of infection when performing an endoscopy.

We conducted a retrospective study ofretrospectively investigated patients who required an endoscopic procedure during the peak of the COVID-19 pandemic infections at our center in Bogotá, Colombia, between mayMay and julyJuly of 2020.

The database from our center was reviewed to collect and analyze patientsPatient data and characteristics. collected from the center's database were analyzed. These data included the number of calls answered, calls, the symptoms, and type ofthe procedure. type. The IRB number: was 353130. According to our epidemiological moment, it is necessary to establishreports, establishing a strategy for the prevention ofpreventing COVID-19 contagion of COVID-19is crucial.

Two days before the intervention, patients received a were called via a telephone call where the questionnaire was applied to inquire about respiratory or systemic symptoms. using a questionnaire. If the patient was asymptomatic and isolated, the attention routes were explained. AnWe sent an email was sent with instructions with the following information wherewherein the patient and itshis/her partner wereshould be assigned a letter (as A) for the patient and (B) for the partner, respectively.

At procedure day, 4 groups of patients were assigned:grouped into four, namely, the first groupgroups (A1B1) and (A2B2) in the first time slot for procedures and the second groupgroups (A3B3) and (A4B4), all according to our proposed organizational scheme.

Every patient All patients followed the required biosecurity and hygiene elements, maintaining the 2 metersm physical distance in the waiting room. They were divided into 4four groups to access by turns to the endoscopy room. At the end of the procedure, the patient and his/her companion were reunited and discharged through an alternative exit route. (Figure (Figures 1 and Figure 2) ).

Endoscopies were performed with the application ofusing a disposable low-cost method (conventional , that is, disposable mask wearing with modification of ana modified incision of 1 to -1.5 cm) ( Figure 3A ) in order), to reduce the risk of contagion for both the patient and the healthcare professionals in the operating room. The use of this device did not alter the development of any of the endoscopic procedures, and the protective benefits of the protection provided by this device were clearly explained to the patient. ColonoscopiesMeanwhile, colonoscopies had a lesser risk of contagion, however,but the physician and the patient still used the PPE recommended for each case.

The staff consisted of 4 gastroenterologists, 5 nurses, 2 receptionists, and one1 counselor. The gastroenterologistgastroenterologists and assistants used all the protection elements to limit the contagion by droplets of the virus,droplet transmission and always keepingmaintained the correspondingappropriate distance. Such protection consisted of gloves, medical masks, goggles or a face shield, gowns, and aprons. (4) ( Figure 3B ). (4) All staff members will bewere tested periodically for COVID-19. In the event thatIf a staff member of staff presents suggestiveexhibited possible COVID-19 symptoms, or iswas exposed to a positive case, local safety protocols must be followed while staying off work.

After the procedure, all patients were followed up byvia a telephone call on 3three separate occasions (7, 14, and 21 days, respectively) in order) to assess the presence offor de novo symptoms followingaccording to the recommendations of the New York Society of Gastrointestinal Endoscopy and the American Society of Gastrointestinal Endoscopy. In American English, a comma (called serial or Oxford comma) is inserted before "and" in a series of three or more items.

We suggest changing this term to "new" for clarity.

The study protocol was approved by our Our institution's ethics committee. approved our study protocol. The protocol was implemented in accordance withconformed to the provisionsprinciples of the Declaration of Helsinki and Good Clinical Practice guidelines.

A total ofDuring the study duration (May 2020 to July 2020), 1388 procedures were performed during the duration of the study, in which ranged from May, 2020 to July, 2020, where 80 (5.76%) were in hospitalized patientsinpatients and 1308 (94.24%) were outpatients. Of the total ofAmong the procedures, 3three were diagnostic (Endoscopyendoscopy, colonoscopy, and esophagogastroduodenoscopy)), and 16 were therapeutic. Among the procedures performed are (resection of large intestine injury, endoscopic extraction of foreign bodies, dilation of anastomosis, ERCP, and insertion of stent for the esophagus.). Subsequent follow-up was achieved at least once in 93.4% of the patients. Patients who presentedmanifested symptoms after the procedure underwent aan RT-PCR test for the SARS-Cov -2 virus and were suggested to undergo preventive isolation was suggested, however. However, of all the symptomatic patients, none were positive in the following test. All the staff members in charge of the procedure were also screened by the same RT-PCR for COVID 19, giving atest and were found to be negative result as of the date of the study.

COVID-19 is a disease caused by the pathogen officially called severe acute respiratory syndrome coronavirus 2 (SARSas SARS-CoV-2),, which is an RNA betacoronavirus, which that is quite similar to anotherthe known coronavirus, such as SARS, described discovered in 2003. The mechanism of action of theseThese coronaviruses is the use ofutilize the angiotensin-converting enzyme 2 (ACE-2) to access the cell and begin its replication. (4) (5) (6) Respiratory symptoms are the most common manifestation related to COVID-19, however. However, a recent meta-analysis of 60 studies with 4243 patients from Asia, Europe, and the United States showed a prevalence of gastrointestinal symptoms of 17.6%. Anorexia was theThe most commonly reported symptom was anorexia (26.8%), followed by diarrhea (12.5%), nausea and vomiting (10.2%), and abdominal pain or discomfort with (9.2%.

However,%). Nonetheless, in most patients presentcases, these symptoms on entry but decrease or disappear over the course of the disease. (5) (6) Gastrointestinal manifestations of the virus seem to be more involved every time. AIn a multicenter retrospective study conducted in China demonstrated that, almost half of the patients with SARS-Cov-2 infection reportedCOVID-19 mainly complained of at least one gastrointestinal symptom as their main complaint.. The variety in the symptomatology leads to confusion in some patients due tobecause of the characteristic mildness. (7) An aerosol-generating procedure is defined as any medical procedure that can induce the production of aerosols of any size, including droplet nuclei. (8) Endoscopy services worldwide, being an aerosol-generating procedure, have hadneed to adaptmodify their protocols to deal with this pandemic. In a study by Filho et al, recommendations and practices were reviewed by. reported that various international gastroenterology societies. They reviewed endoscopy recommendations and practices. These societies all agreed to recommend the mandatory use of PPE during the examination as a mandatory subject,examinations and also, to postpone non-urgent procedures. However,, but only 86% recommendrecommended stratifying the patients'patients' risk for COVID-19. (9) TheBy conducting a systematic review, the Canadian Agency for Drugs and Technologies in Health did a systematic review to identify theidentified procedures that showed a significant increase in SARS infection induring the SARS outbreak in 2002--2003. ThoseThese procedures included endotracheal intubation, noninvasive intubation (CPAP, and BiPAP), tracheostomy intubation, and manual ventilation before intubation. (2) A general recommendation is to reduce the number of endoscopy personnel, beingwho should be highly trained in order to reduce the duration of the procedure time and the risk of exposure, as well as the use of suitable PPE for both the personnel and the patient. Staff members who are in close contact with thea patient with COVID-19 have an increased risk of infection due tobecause of the potential for transmission induring upper digestive endoscopy and the increasing evidence of fecal--oral transmission, by inhalation or contact of conjunctival spatter or direct contact with feces during colonoscopy. (6) Zhang et al,. created a flowchart to explain the conditions under whichon who should receive endoscopies should be made and which oneswho should be postponed. IfThose who were in need of the procedure was necessary a pre-screening was performedwere prescreened, and only thethose with negative teststest results were appointed for endoscopy. The temperature was also checked, and every patient had a follow-was followed up for 14 days later. The patients signed an additional informed consent form, approving a digestive endoscopy during the coronavirus outbreak. (10) (11) The endoscopic intervention's priority is to improve a patient's survival in an emergency situation, such as critical oncological patientsevents, life -threatening gastrointestinal bleedings andbleeding, or foreign body ingestion. Otherwise, the procedure can be postponed after the resolution of Covidthe COVID-19 pandemic. However, the decision is mainly based on the criteria of the physician, taking into account possible contagion risks depending on the patient's clinical status of the patient. (7) The majorityMost of those infected the individuals with the SARS-Cov 2 virusCOVID-19 are asymptomatic patients or withhave mild symptoms. This can make these asymptomatic patients, making them go unnoticed, for that reason it is necessary an; hence, increased vigilance and careful screening of individuals who are at risk are needed, and deferring theirelective, non-urgent procedures should be deferred until this pandemic is over, especially if they are elective non-urgent in nature. (3) Another important recommendation in confirmed COVID-19 cases or high-risk patients is mandatory double disinfection of the equipment used for the procedure. The incidence of infection linked to theassociated with endoscope use is one case per 1.8 million procedures. It is important to recognize the difficulty in estimatingEstimating the causal relationship between the endoscope use and the pathogen. However is challenging. Nevertheless, the disinfection process of the endoscope should include: pre-be the following: precleaning, cleaning, cleaning, rinserinsing, high-level disinfection, rinserinsing, drying (air/alcohol)), and storage. (6) (7) (8) (9) (10) (11) (12) (13) (14) To conclude, there is still much to understand about SARS-Cov-2the COVID-19 pandemic and the real risk for healthcare personnel. need further elucidation. Other viral epidemics have shown practically nilno risk of transmission of viral diseases in endoscopic and laparoscopic procedures, and we can extrapolate thosethe results. (15) The use orThough no studies have expressed recommendation ofon using a similar low -cost device was not found in the literature regardingfor endoscopy, however, the use of this device helped contributed to the safety of both the staff and patients during the duration of the study period.

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