Timing of Elective Endoscopic Procedures in patients with recent Covid-19 Infection

SARS-CoV-2 is currently widely prevalent in the Australian community. Rapid antigen tests (RATs) are being routinely used in several facilities in Australia for point-of-care testing of patients presenting for endoscopic procedures. Consequently, asymptomatic, or mildly symptomatic patients are being diagnosed with COVID-19 on the day of their scheduled procedure. Active COVID-19 infection has been associated with increased risk of post-operative morbidity and mortality in patients undergoing major surgery.1-3 This has led to local and international guidelines recommending delaying elective surgical procedures in patients with active COVID-19 infection where possible.4-6 Questions as to whether elective endoscopic procedures should be delayed, and the duration of delay, are therefore of contemporaneous importance. We reviewed the published current evidence to develop this guidance statement regarding timing of elective endoscopic procedures in patients with recent COVID-19 illness.

The appropriateness of point of care rapid antigen tests (RATs) on the day of endoscopic procedures is not reviewed in this document. We acknowledge that there is lack of evidence supporting routine use of COVID-19 screening tests prior to outpatient endoscopy procedures in asymptomatic individuals. However, as this is an evolving situation, and depends on various factors such as local prevalence and community transmission rate, the use of RATs is left to the discretion of individual endoscopic / hospital facilities and health department jurisdictions.

There have been several large cohort studies that have assessed post-operative outcomes in patients with COVID-19. In a prospective cohort study from the Unites States involving patients undergoing elective major surgery, patients with recent SARS-CoV-2 infection (< 4 weeks before surgery) were found to be at increased risk of developing post-operative pneumonia and respiratory failure.1 In an international collaborative study by COVIDSURG group, patients with COVID-19 infection undergoing any surgery were found to have significantly increased risk of 30-day mortality up to 6 weeks after infection compared to COVID-19 negative patients.2 A previous COVIDSURG study assessing risk of COVID-19 infection on post-operative morbidity and mortality early in the pandemic reached a similar conclusion.3 Following an evaluation of the literature, Kovoor et al recommended that minor surgery be delayed for 4 weeks and major surgery 8-12 weeks following laboratory confirmation of symptomatic SARS-CoV-2 infection7.

While these studies have been instrumental in risk-stratifying patients and informing timing of elective surgeries in patients with COVID-19, extrapolation of these data to endoscopy practice requires caution. Patients undergoing endoscopic procedures were excluded in all these cohort studies. Furthermore, there are no data directly assessing risk of post-procedure outcomes in patients with COVID-19 undergoing endoscopy procedures. Given that major surgeries require general anaesthesia, and involve a measurable inflammatory insult, these are not comparable to endoscopic procedures performed under intravenous sedation, where patients routinely return to their normal activity level within 12-24 hours after the procedure. Significantly, all large cohort studies examined outcomes in unvaccinated patients. Since the highly effective vaccines became available in Australia in early 2021, over 93% of Australia’s population age 16 and over have now received at least two doses of vaccine.8

In summary, high quality evidence informing endoscopy practice in the 2022 phase of the COVID-19 pandemic is lacking. The implications for patient health outcomes as a result of further delays in endoscopic management, need to be assessed in the context of potential waiting list pressures due to legislated elective surgery restrictions. The recommendations below must be individualised and do not obviate the need for appropriate clinical judgement regarding risks and benefits for a given patient. The recommendations are intended to advise planning elective endoscopy procedures only. Any patient requiring an urgent endoscopic procedure should proceed based on the clinical indication with attention to local infection prevention and control policies.

Contributers
Dr Mehul Lamba, Royal Brisbane and Women’s Hospital
Dr Neha Tiwari, Royal Brisbane and Women’s Hospital
Dr Steven Bollipo, Director of Gastroenterology, John Hunter Hospital, Newcastle
A/Professor Britt Christensen, Chair, IBD Faculty GESA
A/Professor Jake Begun, Director, GESA
Dr Matthew Remedios, Chair, Endoscopy Faculty GESA
Professor Benedict Devereaux, President, GESA

Disclaimer
The Gastroenterological Society of Australia (GESA) provides the above advice to guide gastroenterologists and hepatologists who provide care for patients with chronic liver diseases, transplant recipients and IBD during the COVID-19 pandemic. This advice should be modified to fit the context of individual medical practice based on the local policies of the relevant health facilities. Given the rapidly evolving situation, this advice is subject to change, and we will make efforts to update them as needed. Please check the Australian Government website for the latest information on COVID-19 vaccines.

References
1. Deng JZ, Chan JS, Potter AL, et al. The Risk of Postoperative Complications After Major Elective Surgery in Active or Resolved COVID-19 in the United States. Ann Surg. 2022;275(2):242-6. Epub 2021/11/19.
2. Collaborative CO, GlobalSurg C. Timing of surgery following SARS-CoV-2 infection: an international prospective cohort study. Anaesthesia. 2021;76(6):748-58. Epub 2021/03/11.
3. Collaborative CO. Mortality and pulmonary complications in patients undergoing surgery with perioperative SARS-CoV-2 infection: an international cohort study. Lancet. 2020;396(10243):27-38. Epub 2020/06/02.
4. A multidisciplinary consensus statement on behalf of the Association of Anaesthetists C, for Perioperative Care FoSSA, Royal College of, Anaesthetists RCoSoE. SARS-CoV-2 infection, COVID-19 and timing of elective surgery. 2021.
5. Surgeons RACo. Guidance on delay to elective surgery post recovery from SARS-COV 2 infection. 2020.
6. Anaesthesiologists ASo. ASA and APSF Joint Statement on Elective Surgery and Anesthesia for Patients after COVID-19 Infection=. 2021.
7. Kovoor JG, Scott NA, Tivey DR, et al. Proposed delay for safe surgery after COVID-19. ANZ J Surg 2021;91:495-506
8. Australian Government DoH. COVID-19 vaccination daily rollout update. 2022.