Rationing endoscopy during the COVID-19 lockdown was safe: The experience of an Australian hospital

ABSTRACT

Background and Aim: Coronavirus disease 2019 (COVID-19) is now a worldwide pandemic. Gastrointestinal endoscopy is considered an aerosol-generating procedure (AGP) for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) transmission. On 25 March 2020, the Prime Minister of Australia announced a nationwide suspension of all non-urgent endoscopy. There are limited data to provide insight into creating a safe model for rationing gastrointestinal endoscopy that does not compromise patient care. Our hospital mobilized a model of care, deferring all non-urgent category 2 and all category 3 cases, and created specific clinics with experienced endoscopists to re-triage outstanding cases. We aimed to conduct a retrospective study to evaluate this single-center experience. Methods: We collected data on patients who had an emergency (performed within 48 h of emergency admission) or elective gastroscopy or colonoscopy during the 5-week lockdown period (26 March to 1 May 2020). For comparison, the same analysis was performed on all those who underwent an endoscopic procedure during the same period 12 months earlier. Our primary objective was to compare the rate of highly significant abnormalities detected during these two periods. Highly significant abnormalities were defined as upper or lower gastrointestinal malignancy, adenomatous polyps larger than 2 cm, or a new diagnosis of inflammatory bowel disease. Furthermore, we evaluated all gastrointestinal malignancy diagnoses over the past 2 years, identifying the triage category, indication, endoscopic and histological findings, and the rate of malignancy diagnosis. Results: During the COVID-19 era, 66% fewer procedures were performed than in the previous year's corresponding period (141 procedures [79% category 1, 21% category 2] vs 410 procedures [45% category 1, 45% category 2, 10% category 3];P < 0.001). The numbers of emergency endoscopies were similar (16 in COVID-19 era vs 18 pre-COVID-19). A comparable number of highly significant abnormalities were found (Table 1). The six new malignancy diagnoses in the COVID-19 era were in keeping with our median monthly cancer rate of 5.5 (IQR, 3-6.3) over the past 2 years. Of the 4621 gastroscopies and 4573 colonoscopies performed in the past 2 years, 94% of the newly diagnosed upper and lower gastrointestinal cancers were triaged as category 1, 6% as category 2, and none as category 3. Conclusion: Our findings suggest that significant and time-critical abnormalities are unlikely to be missed by a model of care prioritizing category 1 and urgent category 2 upper and lower endoscopies, as we did during the COVID-19 shutdown. These reassuring findings may help guide the approach to endoscopy management if another shutdown occurs here or overseas, especially given the recent spike in COVID-19 cases in Victoria.