Triaging GI Endoscopic Procedures During COVID-19: Expert Recommendations

A national panel of expert gastroenterologists has developed consensus recommendations for triaging endoscopic procedures during the coronavirus disease 2019 (COVID-19) pandemic, as published in Techniques and Innovations in Gastrointestinal Endoscopy.

The panel of 14 gastroenterologists created the recommendations regarding common indications for general endoscopy, critical patient-important outcomes for endoscopy, defining time-sensitive intervals, and assigning time-sensitive intervals to procedure indications.

“As the COVID-19 pandemic moves into the post-peak period, the focus has now shifted to resuming endoscopy services to meet the needs of patients who were deferred,” stated the panel members. “By using a modified Delphi process, we sought to develop a structured framework to provide guidance regarding procedure indications and procedure time intervals.”

The panelists selected are from diverse backgrounds in geography, practice location, and practice type. The members include 5 advanced endoscopists and 9 general gastroenterologists; 8 panelists work in academic, teaching, or Veterans Administration hospital settings, and 6 work in private or community practices.

The panel identified 62 common general endoscopy indications: 33 for esophagogastroduodenoscopy (EGD), 21 for colonoscopy, and 8 for sigmoidoscopy. The panel members reached consensus on patient-important outcomes for each procedure indication and for 74% of indications regarding timing of the procedure.

“We placed patient priorities at the center of this decision-making process by asking experts to prioritize patient-important outcomes,” the panel commented. “Using this approach, we were able to achieve consensus regarding procedural timing in three-fourths of the indications. We also provide a decision-making framework by which endoscopists can consider timing for those endoscopic procedures that are not included in this [consensus].”

Medical decision making is often criticized for prioritizing what is “clinically relevant” over what is “patient important,” according to the panel. “To avoid this pitfall, we asked the panelists to vote regarding timing of each procedure while strongly prioritizing the critical patient-important outcome,” the group stated.

The panel categorized patient-important outcomes into the following classes: avoidance of death/prolongation of life; avoidance of cancer/avoidance of cancer progression; avoidance of major surgery and/or hospitalization; improvement, diagnosis, or palliation of symptoms; and other.

The time intervals were categorized as follows:

·       Time-sensitive emergent = scheduled within 1 week

·       Time-sensitive urgent = scheduled within 1 to 8 weeks

·       Non–time-sensitive = defer to more than 8 weeks, and reassess timing then

Regarding EGD, the panel did not achieve consensus for 6 indications: percutaneous endoscopic gastrostomy tube placement, acute iron deficiency anemia needing hospitalization or transfusions, chronic anemia/iron deficiency anemia, esophageal narrowing/stenosis needing treatment, Barrett esophagus with high-grade dysplasia, and stent placement for esophageal cancer. The panel achieved consensus for 79% of EGD indications.

For colonoscopy, the panel did not achieve consensus for 7 indications: lower gastrointestinal bleeding, abnormal imaging suggestive of malignancy, change in bowel habits, colon stricture dilation, endoscopic mucosal resection of colon polyp, positive fecal immunohistochemical testing, and weight loss. The panel achieve consensus in 67% of colonoscopy indications.

For flexible sigmoidoscopy, there were 3 indications in which the panel did not achieve final consensus: colonic pseudo-obstruction, pouchitis, and rectal bleeding. The panel achieved consensus in 63% of flexible sigmoidoscopy indications.

Table 1 provides a summary of all procedural indications with recommended time intervals.

The panel recognized that the majority of the indications that occur within the 1-week category will likely be performed sooner than 7 days.

“Having a second category of ‘time-sensitive urgent’ procedures allows for the gastroenterologists to triage procedures depending on availability of [personal protective equipment (PPE)], resources, staff, and the timing of the peak and surge of COVID-19 cases in the region during the pandemic,” the panel stated.

“Categorizing some procedures as needing to be done within 1 to 8 weeks can allow the gastroenterologist to schedule patients for this time interval and/or to keep a list of patients that potentially would need to be done within these 8 weeks and can be re-assessed at short intervals based on patient symptomatology and the evolving pandemic,” the panelists noted.

The panel achieved consensus on 2 critical points when considering re-opening endoscopy suites: the availability of adequate PPE and adequate training of staff to screen for COVID-19 and manage patients with suspected COVID-19 patients.

“These consensus recommendations provide some general guidance regarding the key considerations for resuming normal endoscopic practice in the post-pandemic era,” the panel commented. “However, final recommendations on this are beyond the scope of this panel’s goals since this is an ongoing and rapidly evolving situation, with significant lack of clarity regarding the availability, feasibility, and accuracy of various testing approaches for COVID-19.

“While each patient’s symptoms must be interpreted in a case-by-case context, this [consensus] will provide valuable guidance to practicing gastroenterologists who are triaging procedures in the setting of the ongoing pandemic, as the COVID-19 cases resurge,” the panel concluded.

Disclosures: Some of the authors reported affiliations with medical device companies. Please see the original reference for a full list of disclosures.

Reference

Feuerstein JD, Bilal M, Berzin TM, et al. Triage of general gastrointestinal endoscopic procedures during the COVID-19 pandemic: results from a National Delphi Consensus Panel. Tech Innov Gastrointest Endosc. Published online December 26, 2020. doi:10.1016/j.tige.2020.12.005

Table 1. Best Practices Recommendations for Time Intervals for Various Procedural Indications

	EGD Indications	Colonoscopy Indications	Flexible Sigmoidoscopy Indications
Time-sensitive emergent (within 1 week)	Duodenal stenting for duodenal/pancreatic cancer	Obstruction/needing colon stent	Colonic pseudo-obstruction*
	Esophageal food impaction	Pseudo-obstruction
	Foreign body removal	Sigmoid volvulus
	GI bleeding/hematemesis/melena
	Esophageal cancer stent placement*
Time-sensitive urgent (within 8 weeks)	Acute iron deficiency anemia needing hospitalizations of transfusions*	Abnormal imaging suggestive of malignancy*	Abnormal CT scan/imaging concerning for malignancy
	Early satiety	Bloody diarrhea/bright red blood per rectum	Colitis flare
	Esophageal narrowing/stenosis needing treatment*	Colon stricture dilation*	Rectal bleeding*
	Nausea and vomiting (daily/persistent)	Iron deficiency anemia/symptomatic anemia	Pouchitis*
	Unexplained weight loss	Lower gastrointestinal bleeding*
	Barrett esophagus withhigh-grade dysplasia*
	Duodenal adenoma withhigh-grade dysplasia ofintramucosal cancer
	Esophageal varices for secondary prophylaxis
	Percutaneous endoscopic gastrostomy tube placement*
Can defer to >8 weeks (not time-sensitive)	Bravo pH probe placement	Abdominal pain	Anorectal symptoms
	Chest pain	Change in bowel habits*	Diarrhea
	Chronic anemia/iron deficiency anemia*	Constipation	Rectal cuff surveillance
	Diarrhea	Diarrhea (chronic)
	Dyspepsia/epigastric pain	Endoscopic mucosal resection of colon polyp*
	Gastric polyp	Follow-up of diverticulitis
	Gastroesophageal reflux disease	Heme-positive stool
	Nausea and vomiting (intermittent)	Colitis/IBD surveillance
	Barrett esophagus surveillance (nondysplastic)	Colorectal cancer screening
	Barrett esophagus withlow-grade dysplasia	Colorectal cancer surveillance, history of colon polyps, and postendoscopic mucosal resection surveillance
	Celiac disease	Fecal immunohisto-chemical testing/positive Cologuard*
	Duodenal adenoma without high-grade dysplasia	Unexplainedweight loss*
	Eosinophilic esophagitis surveillance
	Esophageal varices(primary prophylaxis)
	Follow-up of gastric ulcer
	Gastric intestinal metaplasia
	Helicobacter pylori

*Procedural indications in which final consensus was not achieved.