EUS-guided gallbladder drainage during a pandemic crisis - How the COVID-19 outbreak could impact interventional endoscopy.

Dear Editor,

We have read with great interest the recent ESGE and ESGENA Position Statement on gastrointestinal endoscopy and the Covid-19 pandemic [1], describing how endoscopic units should manage infection prevention during the current outbreak of SARS-CoV-2 and the spread of COVID-19 disease [1]. Authors of the Position Statement stratified the risk of infection according to patients’ history and symptoms. We believe that the type of endoscopic procedure should also be taken into account, since exposure longer than 15 min is considered to present a significant high risk [2]. In this scenario, therapeutic endoscopy is clearly considered more risky than diagnostic endoscopy. On the other hand, the current situation has caused dramatic changes in the way we provide health care in northern Italy. In particular, significant limitations to intensive care units (ICU) and operating rooms for the management and treatment of COVID-19-free patients have been introduced to guarantee adequate assistance for COVID-19 patients [3,4]. In this respect, endoscopic treatment that is minimally invasive should be preferred over surgery.

It has been demonstrated that lap-cholecystectomy for acute cholecystitis is a high-risk procedure in elderly patients with comorbidities. Endoscopic ultrasound-guided gallbladder drainage (EUS-GBD), which is already considered an effective alternative to surgery, may now see its indications expanded if intensive care resources and operating rooms are overwhelmed [5], [6], [7], [8]. During the COVID-19 crisis in Italy, our multidisciplinary team has started favoring EUS-GBD over percutaneous drainage in order to obtain a definitive treatment that potentially allows rapid patient discharge. Indeed, our group previously reported that EUS-GBD could be performed without general anesthesia in up to 90% of cases, leading to very low anesthesiological complications and ICU admissions [9,10].

EUS-GBD is recommended in high-risk surgical patients with acute cholecystitis, either as a bridge to surgery or as a definitive therapy. As an indirect consequence of the COVID-19 crisis, the management of treatable conditions should be adapted not only to local expertise but also to the temporary availability of hospital beds, operating rooms or ICU admissions. Up to a few weeks ago, we were evaluating these issues in terms of resource-sparing (i.e. length of stay, costs), but now, at the height of the COVID-19 crisis, we have to assess whether interventional endoscopy is the only option left to take care of and treat these patients. We hypothesize that in the short-term, we may see indications and applications of minimally invasive interventions, such as EUS-GBD, expanded even further.

Conflict of interest

The Authors received no support or funding for this study. Andrea Lisotti: no financial association or conflict of interest relevant to this letter to declare. Pietro Fusaroli: Speaker for Olympus Company. No financial association or conflict of interest relevant to this letter to declare.