key: cord-0820006-9nw0xv4g authors: Abdelrahim, Mohamed; Hossain, Ejaz; Subramaniam, Sharmila; Bhandari, Pradeep title: Essentials of donning, doffing, and changes in endoscopy practice to reduce the risk of spreading COVID-19 during endoscopy date: 2020-06-29 journal: VideoGIE DOI: 10.1016/j.vgie.2020.04.013 sha: d3d7df6894fab94d458845fef58b5a7e9e3c6552 doc_id: 820006 cord_uid: 9nw0xv4g nan The COVID-19 pandemic has resulted in a significant disruption to normal endoscopy practice in the United Kingdom and around the world. 1 Clinical manifestations of this infection are broad spectrum and can be very subtle; thus, a high degree of clinical suspicion and risk stratification are essential. 2 Endoscopy is an aerosol-generating procedure. 3 Aerosol generated during upper GI endoscopy is likely to be more infective than that generated during colonoscopy. Transmission in the endoscopy setting can also occur through inhalation of droplets and direct contact with contaminated body secretions. 4 During the pandemic, it is best to restrict endoscopy to emergency and selective urgent indications. 1 Several national and local guidelines are in place and should be followed. The spread of COVID-19 during endoscopy can be minimized by adopting correct personal protective equipment (PPE) measures (Figs. 1 and 2). 5 PPE can only be effective if worn correctly. 5, 6 The process of putting on the PPE is called "donning" and consists of 4 steps, as illustrated in Figure 6 and demonstrated in Video 1 (available online at www.VideoGIE.org). The process of taking off the PPE is called "doffing" and consists of 5 steps, as illustrated in Figure 6 and demonstrated in Video 1. A lot of thought has to go into the placement of donning and doffing areas in relation to the endoscopy suite to avoid cross-contamination (Figs. 4 and 5). The endoscopy suites have to be completely stripped down, and only the most essential equipment required for that particular procedure should be kept inside (Fig. 3) . We demonstrate the principles of this in our video. The way endoscopes are held during the procedure can also be altered to minimize accidental splashing of fluid and release of air from the endoscope. The ports of the en-doscopes can be covered by a plastic sleeve to contain any accidental leakage. Finally, aerosol is generated during endoscopy for a variety of reasons, but a major contributing factor is air/Co 2 insufflation during endoscopy. This leads to a buildup of Abdelrahim et al positive pressure in the gut, resulting in intermittent release of aerosol. We have adapted our technique and replaced air/Co 2 insufflation with water to minimize risk of aerosol generation. Underwater colonoscopy is widely practiced, so most clinicians can acquire these skills. 7 Special precautions need to be taken when doing underwater gastroscopy because of the risk of aspiration, and endotracheal intubation should be considered. We acknowledge that the exact measures adopted by each unit will depend on a range of factors, including availability of PPE, logistics, and local protocols. However, our video should provide broad principles that can be adapted to suit local circumstances. All authors disclosed no financial relationships. Abbreviation: PPE, personal protective equipment. Endoscopy activity and COVID-19: BSG and JAG guidance -update 22 Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China From containment to mitigation of COVID-19 in the US COVID-19: gastrointestinal manifestations and potential fecal-oral transmission Public Health England guidance on COVID-19 personal protective equipment (PPE) for aerosol generating procedures European Centre for Disease Prevention and Control. Guidance for wearing and removing personal protective equipment in healthcare settings for the care of patients with suspected or confirmed COVID-19 Water exchange colonoscopy increases adenoma detection rate: a systematic review with network meta-analysis of randomized controlled studies Copyright ยช 2020 American Society for Gastrointestinal Endoscopy