Protective enclosure for performing gastrointestinal endoscopy.

We read with interest the article by Mcleod et al 1 describing the use of a specially designed novel acrylic box (endoscopy box; EBOX) for performing endoscopic retrograde cholangiopancreatography (ERCP) as well as endoscopic ultrasound (EUS) in the current era of COVID-19 pandemic.1 We congratulate the authors for designing this enclosure that has potential of mitigating risk of transmission of infections via air droplets during endoscopy. Endoscopy can generate aerosols because of coughing or retching and it has demonstrated that COVID-19 virus can remain viable in aerosols for hours.2 An experimental study using transparent aerosol box for endotracheal intubation demonstrated that simulated cough caused contamination of only inner surface of box and operator’s gloves and gowned forearms whereas without aerosol box simulated cough resulted in widespread contamination.3 Using similar analogy, EBOX designed by authors also resulted in limited contamination during endoscopy especially of key areas such as exposed neck of the endoscopist. This protective box will be especially useful for longer duration procedures like ERCP/EUS as has been demonstrated by the authors.

However, it is important to understand the limitations of such protective enclosures. The experimental study by Canelli et al generated more droplets as compared with aerosols and their method of detection could not identify small quantities of infectious material.3 Therefore, these protective enclosures are not a replacement for standard protective precautions but an adjunct to standard protective equipment and practices.4 Also, ERCP is an advanced procedure that involves lot of dexterity and unrestricted movements of duodenoscope. Therefore, ease of performing ERCP using this enclosure, where movements of duodenoscope could be restricted, needs to be assessed in large sample size studies with operators of varying experiences. It is important to emphasise that operator’s performance is already compromised with heavy personal protection equipment, face shield, goggles and lead apron. Despite these concerns, designed EBOX seems to be an added layer of protection in endoscopy suites. In current testing times of COVID-19 pandemic it is important that we keep thinking and innovating to make endoscopy more safer.