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During the COVID-19 crisis, most endoscopy procedures have been cancelled or deferred. However, endoscopic retrograde cholangiopancreatography (ERCP) is unique in that almost none of these procedures are elective. Patients with obstructive jaundice, pancreaticobiliary malignancies, bile leaks, and other indications cannot wait to undergo procedures after the pandemic has receded. In a recent paper, endoscopists in Wuhan, China, described performing ERCP in that global hotspot for COVID-19.
Between February 1 and March 31, 2020, 31 ERCPs were performed. Indications were common bile duct gallstones, acute biliary pancreatitis, and pancreaticobiliary malignancies. Appropriate personal protective equipment (PPE) was used. Two thirds of patients underwent COVID-19 testing prior to ERCP; the remainder did so afterwards. One asymptomatic patient was found to be COVID-19-positive immediately before undergoing ERCP and was later confirmed infected. All procedures were performed under conscious sedation. All patients were treated as potentially having COVID-19, but in 10 acutely ill patients, it was not possible to complete screening before performing the ERCP. As of April 6, no new cases had been identified among these patients or the facility's healthcare staff.
An P et al. ERCP during the pandemic of COVID-19 in Wuhan, China. Gastrointest Endosc 2020 Apr 16; [e-pub]. (https://doi.org/10.1016/j.gie.2020.04.022)
Comment
I laud the authors for providing care to ill patients in these high-risk, high-stress conditions. Recently I have found myself performing ERCPs in similar circumstances, albeit in a part of the world (Salt Lake City, Utah) with far fewer COVID-19 patients. It is unclear to me why these procedures were performed with conscious sedation and not general anesthesia; perhaps this resource was not available. ERCPs are, in general, more complex and time consuming than other upper endoscopic procedures and thus have a greater potential for aerosolization of any virus particles. General anesthesia greatly reduces the rate of aerosolization during ERCP and, in my opinion, is preferable in this setting.