Increased mortality in patients waiting for biliary stent replacement during the COVID-19 pandemic

We read with great interest the recent European Society of Gastrointestinal Endoscopy (ESGE) and European Society of Gastroenterology Nurses and Associates (ESGENA) Position Statement on gastrointestinal (GI) endoscopy and the COVID-19 pandemic [1]. The aim of the statement was to provide guidance in order to assure the highest level of protection against COVID-19 for both patients and healthcare personnel.

One important topic that was discussed was the timing of the procedures and which GI endoscopy procedures should always go ahead and which should be postponed. The authors wrote that GI endoscopy units should strongly consider temporarily postponing elective, nonurgent endoscopy procedures, based upon availability of local human resources and local policies that may depend on regional/national pandemic rules/regulations. According to the proposed guidance, patients with obstructive jaundice and/or ascending cholangitis should not be postponed and endoscopic retrograde cholangiopancreatography (ERCP) should always be performed. Conversely, patients who are scheduled for elective replacement of biliary stents were not included in this group; instead, these patients were listed in the high-priority endoscopy procedures group (either to be performed immediately or postponed within 12 weeks). We think that these patient procedures should not be postponed and should be listed in the “Perform always” section.

During the current COVID-19 outbreak, between 15 March and 30 April, 27 patients were scheduled for ERCP and biliary stent replacement in our unit (Department of Gastroenterology, Rambam Health Care Campus, Haifa, Israel). The patients were rescheduled within 12 weeks. During the first 4 weeks, eight patients were admitted urgently due to ascending cholangitis and underwent emergency ERCP with stent replacement. Two patients died during hospitalization.

Subsequently, we started to recall other patients for on-time stent replacement. We found that three more patients had died at home from unknown causes.

The COVID-19 pandemic is having a disruptive effect on the workflow and safety of GI endoscopy units worldwide. Indeed, most endoscopy procedures have been canceled or deferred. However, ERCP is unique in that almost none of these procedures are elective.

We think that ERCP procedures, including elective stent replacement procedures, should be performed without delay.

Publication History

Article published online:
28 July 2020

• Reference

• 1 Gralnek IM, Hassan C, Beilenhoff U. et al. ESGE and ESGENA Position Statement on gastrointestinal endoscopy and the COVID-19 pandemic. Endoscopy 2020; DOI: 10.1055/a-1155-6229. [Epub ahead of print]