key: cord-0882653-qnaztrmh
authors: Papparella, Luigi Giovanni; Barbaro, Federico; Larghi, Alberto; Boskoski, Ivo; Costamagna, Guido
title: Safe endoscopy during the COVID-19 pandemic: Can we do more?
date: 2021-07-13
journal: Gastrointest Endosc
DOI: 10.1016/j.gie.2021.03.009
sha: b5a12bef60566b9e9cb9659cd322dcefb551bfc7
doc_id: 882653
cord_uid: qnaztrmh

nan

We thank Dr Lee 1 for commenting on our article 2 and highlighting the significance of difficult cannulation for the development of post-ERCP pancreatitis (PEP). Difficult cannulation has been defined in many ways by different researchers. It has been described on the basis of duration (>5-20 min) required for cannulation, attempts (>15 attempts) at cannulation, and also by more than 3 inadvertent pancreatic duct (PD) cannulations. [3] [4] [5] [6] In our study, the development of PEP (5.2% vs 0.67%; P Z .04) and bile duct cannulation time in minutes was shorter (13.8 AE 2.2 vs 7.2AE1.7; P Z .001) in the primary precut group than in the very early precut group. 7 Prolonged cannulation time in the very early precut group indirectly reflects prolonged manipulation of the ampulla during cannulation attempts. Thus, prolonged manipulation of the ampulla even without entering the PD may cause pancreatitis by traumatizing the pancreatic orifice. In our study, inadvertent PD entry was observed in 58.5% of patients in the very early precut group compared with none in the primary precut group, which clearly reflects that multiple cannulations increase the chances of inadvertent PD cannulation. In another study, difficult cannulation and precut were noted to be significant factors for PEP. 3 In previous studies, precut was contemplated for patients with difficult cannulation, in whom condition for pancreatitis had already developed by frequent manipulation of the ampulla for a time span varying from 5 to 20 minutes. [3] [4] [5] Precut sphincterotomy in this circumstance appears to be unnecessarily responsible for PEP. In our study, the primary precut was compared with very early precut because we wanted to re-move the impact of ampullary manipulation in the causation of PEP, given that it has been clearly observed that the incidence of PEP increases as the number of attempts of cannulation increases. [3] [4] Another study has also revealed that the risk of PEP increases greatly after 7 to 8 attempts at, or failure of, cannulation. 8 Safe endoscopy during the COVID-19 pandemic: Can we do more?

To the Editor:

We read with interest the article by Repici et al, 1 describing all measures to adopt to minimize the dissemination of SARS-CoV-2 infection during endoscopic procedures. By using such processes, another Italian endoscopic unit reported no cases of transmission up to May 1, 2020. 2 Subsequently, to guarantee patients and healthcare workers (HCWs) additional protection, serologic screening of the HCWs was also implemented. No cases of infection occurred, thus suggesting that all recommendations were efficient in preventing SARS-CoV-2 infection.

We report our experience from a referral center in Rome that was fully involved in SARS-CoV-2 patient care. At least up to August 2020, SARS-CoV-2 infection was limited in comparison with the north of Italy. However, HCWs wore personal protective equipment and observed proper hand hygiene. To improve safety in the outpatient setting, screening with rapid serologic testing (IgG/IgM rapid test) was used between August and October 2020, even for asymptomatic outpatients. From November to December 2020, because of an increase in the overall SARS-CoV-2 cases in Italy, screening of both outpatients and HCWs was established with use of the antigenic nasopharyngeal swab.

We describe the risk of SARS-CoV-2 infection among HCWs divided into 3 time interval periods, during which different screening procedures were used as described above (Table 1 ). In all, 6936 outpatient procedures were performed. During the first and second phases, no cases of infection among HCWs were recorded. Conversely, in the last period, 10 out of 40 (25%) HCWs had positive test results with the antigenic nasopharyngeal swab, confirmed with the molecular test. Most of them were asymptomatic, with only 3 individuals reporting mild symptoms without the need for hospitalization.

In our experience, screening with the antigenic nasopharyngeal swab should be implemented in both outpatients and HCWs to provide a more effective method to detect asymptomatic infected individuals and to prevent spreading of SARS-CoV-2 infection.

Cannulation attempts and the development of post-ERCP pancreatitis

Early precut versus primary precut sphincterotomy to reduce post-ERCP pancreatitis: randomized controlled trial (with videos)

Complications of biliary sphincterotomy

Risk factor for complications after performance of ERCP

Precut papillotomy versus persistence in difficult biliary cannulation: a prospective randomized trial

Timing of precut procedure does not influence success rate and complications of ERCP procedure: a prospective randomized comparative study

Early precut versus primary precut sphincterotomy to reduce post ERCP pancreatitis: randomized controlled trial (with videos)

Needle knife sphincterotomy does not increase the risk of pancreatitis in patients with difficult biliary cannulation

COVID-19) outbreak: what the department of endoscopy should know

Safe endoscopy during the COVID-19 pandemic

Is EUS-guided fine-needle biopsy the end of contrast-enhanced EUS guidance for tissue sampling?

Both authors disclosed no financial relationships. 

We read the study by Cho et al 1 with interest. The authors investigated the usefulness of contrast-enhanced EUS (CEH-EUS) as guidance for EUS tissue sampling of solid pancreatic lesions. They found that CEH-EUS did not improve the diagnostic accuracy of EUS tissue sampling compared with conventional B-mode (88.3% and 85.8%, respectively). Their results are somewhat in disagreement with those of our recent meta-analysis, 2 reporting that the diagnostic sensitivity of CEH-EUSguided FNA was significantly superior to conventional EUS-FNA (84.6% and 75.3%, respectively; P < .001).We believe that this discrepancy may be explained by the different needle choices between the 2 studies. Although Cho et al 1 used fine-needle biopsy (FNB) needles in >80% of cases, the studies included in our meta-analysis 2 used 22-gauge EUS-FNA needles in almost all cases. Comparing the 2 studies, it seems that CEH-EUS improved the diagnostic sensitivity of EUS-FNA but failed to provide a significant impact on EUS-FNB. Nevertheless, it should be noted that the authors used ProCore needles, which failed to prove superior to standard FNA in several meta-analyses. 3 In this regard, a specific subgroup analysis according to the needle used (EUS-FNB vs EUS-FNA) would have been useful to clarify this issue. On the other hand, even if the diagnostic sensitivity of EUS-FNA seems improved by CEH-EUS, it remains generally inferior to that of the new Franseen-tip and fork-tip needles, which was reported to be 95%. 4, 5 If CEH-EUS fails to improve the sensitivity of EUS tissue sampling with the use of FNB needles, it may follow