EUS-guided drainage of pancreatic fluid collections during COVID-19 pandemic.

Dear Editor,

We read with interest the study by Zhao et al. regarding their experience of performing EUS-guided fine needle aspiration during COVID-19 outbreak.[1] We congratulate the authors for sharing their EUS workflow and safety measures put in place to prevent transmission of COVID-19 infection both to the staff and to the patients. Endoscopists access gastrointestinal lumen from close distance to the patient, thereby being exposed to large amount of respiratory, oropharyngeal, and gastrointestinal secretions. Hence, endoscopy is considered a high-risk procedure for transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection.[2] Moreover, gastrointestinal endoscopy is a procedure that can generate aerosols because of coughing and retching. The risk of transmission may be much higher with therapeutic EUS procedures as these are complex procedures, which require short physical distance between endoscopist and patient for longer period of time, involve presence of increased number of assisting staff in endoscopy suite, involve use of complex endoscopes that are difficult to clean/sterilize, and require exchange of several accessories that may increase risk of spreading potentially infective body fluids.[3]

During this pandemic period, international endoscopic societies have recommended performing urgent EUS procedures.[4] EUS-guided drainage of symptomatic/infected pancreatic fluid collections (PFCs) is considered as an emergency procedure that needs to be performed with necessary precautions during this COVID-19 outbreak.[4] EUS-guided drainage of PFC is a complex procedure with potentially high risk of transmission of SARS-CoV-2 and therefore it is very important to follow the stepwise protocol of proper triage workflow as suggested by the authors.[1] India is currently in the midst of COVID-19 pandemic and there is a significant reduction in the number of diagnostic as well as therapeutic endoscopic procedures being performed at various centers including ours. We have been currently performing only urgent therapeutic procedures, and EUS-guided drainage of PFCs is one of the procedures being performed following stepwise protocol of proper triage workflow. Along with the stepwise protocol, we have also been using a protective transparent enclosure around the patient and this probably is an additional layer of protection in endoscopy suites.

PFCs can be drained using endoscopic, percutaneous, or surgical drainage. Percutaneous drainage is a commonly utilized minimally invasive intervention in the management of symptomatic PFC, especially in critically ill patients. However, percutaneous drainage is associated with an increased risk of development of external pancreatic fistula in setting of disconnected pancreatic duct syndrome (DPDS).[5] Therefore, before embarking upon drainage of PFC, we are assessing pancreatic ductal (PD) anatomy by magnetic resonance cholangiopancreatography. In order to minimize risk of endoscopy-related transmission of COVID-19, patients with PFC and normal PD or partial duct disruption are treated with percutaneous drainage, whereas patients with DPDS or unclear PD anatomy are being drained internally under EUS guidance. In conclusion, using a combination of triage and procedural strategies, it may be possible to mitigate the risk of COVID-19 transmission during therapeutic EUS procedures.

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Conflicts of interest

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