IFSO Endoscopy Committee has published a Position Statement on the best practise of bariatric endoscopy in response to the CVOID-19 pandemic. The statement offers guidance on navigating bariatric endoscopic procedures in patients with obesity during the COVID-19 pandemic, in the hope of mitigating the risk of SARS-CoV-2 transmission to vulnerable patients and healthcare workers. The statement acknowledges that the recommendations may evolve as the pandemic progresses. The paper, ‘IFSO Endoscopy Committee Position Statement on the Practice of Bariatric Endoscopy During the COVID-19 Pandemic’, written on behalf of the IFSO Endoscopy Committee, was published in Obesity Surgery.
The statement notes that the “practice of endoscopy poses special challenges and risks of SARS-CoV-2 transmission to patients and providers, given the evolving role of the gastrointestinal tract in viral transmission and aerosol generation during endoscopic procedures.” The following specific recommendations for bariatric endoscopy were empirically formulated based on expert opinion and extrapolated from the Asian Pacific Society for Digestive Endoscopy (APSDE-COVID statements) and the American Gastroenterological Association (AGA) guidelines:
Elective bariatric endoscopy procedures that should be delayed >8 weeks are as follows:
- Primary bariatric intervention (implantable gastric and small intestinal devices, gastric remodelling techniques, aspiration therapy, duodenal resurfacing procedures).
- Revisional bariatric intervention (transoral outlet reduction (TORe), restorative obesity surgery endoscopic (ROSE), endoscopic sleeve gastroplasty revision of laparoscopic sleeve gastrectomy (R-ESG)).
- Elective removal or adjustment of an implanted gastric or small intestinal device within the approved dwelling time of the device.
- Elective removal of Orbera, Orbera 360,or Spatz 3 intragastric balloon in asymptomatic patients in the period between six to 12 months after implantation.
- Elective upward adjustment of the Spatz3 intragastric balloon for enhancing weight loss.
- Preoperative endoscopic examinations prior to bariatric surgery.
- Follow-up endoscopic examinations for non-malignant conditions in asymptomatic patients such as nondysplastic Barrett’s oesophagus, esophagitis, gastritis, bile reflux, marginal ulceration, fistula, and gastrointestinal strictures.
- Post-bariatric surgery endoscopic work-up of common complaints such as abdominal pain, gastroesophageal reflux, nausea, vomiting without clinical red flags, or documentation of pathology on radiographic imaging.
- Elective removal or change of double pig-tail plastic stents that were previously placed for management of a chronic post-bariatric surgery leak and are in a suitable position without associated symptoms.
However, the paper states that semi-urgent bariatric endoscopy procedures that can be considered in 48 hours to ≤8 weeks, for:
- Scheduled removal of any implantable gastric or small intestinal bariatric device at the manufacturer’s recommended removal interval other than the Orbera IGB
- Removal of any implantable gastric or small intestinal bariatric device for refractory symptoms.
- Removal of an implantable gastric or small intestinal device during pregnancy. This should be a multidisciplinary team decision, coordinated and approved by obstetrics and or maternal foetal medicine.
- Downward volume adjustment of the Spatz3 IGB to manage medically refractory symptoms.
- TORe or ROSE procedure for treatment of early or late severe dumping syndrome refractory to medical management.
- Endoscopic surveillance and management of preneoplastic or neoplastic conditions with significant risk of progression such as Barrett’s oesophagus with highgrade dysplasia or intramucosal cancer.
- Removal or exchange of sponges for vacuum therapy of endoluminal bariatric leaks.
- Removal or exchange of indwelling self-expanding or lumen-opposing metal stents to manage complications post-bariatric endoscopy or surgery, such as strictures and leaks.
- Endoscopic management of symptomatic patients with documented anatomical post-bariatric surgery pathology by non-invasive imaging that can be addressed endoscopically, such as strictures.
- Replacement of non-functioning or leaking A-tube for aspiration therapy.
Urgent bariatric endoscopy procedures that should be considered within 48 hours, to treat a condition that threatens the patient’s life or results in permanent dysfunction of an organ, such as:
- Removal of any intragastric device for symptoms of refractory gastric outlet obstruction symptoms, especially with presence of gastric dilation on non-invasive imaging.
- Removal of migrated prosthesis or migrated/deflated gastric or small intestinal bariatric device within the reach of upper endoscopy.
- Endoscopic management of gastrointestinal bleeding, perforation, acute leaks, and severe stenosis.
- Endoscopic management of a buried A-tube bumper during aspiration therapy.
In addition, the paper recommends that all endoscopic procedures should be considered aerosol generating and high risk, and it is of critical importance that physical distancing, personnel protective equipment (PPE) and hygiene measures need to be practiced diligently. Staffing of endoscopy rooms should be reduced to the minimum number of individuals necessary to conserve PPE and other resources.
Finally, the statement recommends that standard operating procedures must be established with regular meetings of endoscopy leadership to review relevant information, with frequent scheduled updates provided to faculty and staff.
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