We hope that this edition of the Banding Bulletin finds you and yours well! We are receiving many inquiries regarding the necessary precautions surrounding the performance of anoscopy and band ligation using the CRH O’Regan System. I must include a disclaimer that new information is popping up continually, which may impact currently posted guidelines, so I will try to provide the most up to date information that we have available.
This is an enormous topic which is beyond the scope of this Bulletin, so let me refer you to some excellent work done by the ACG and ASGE in regard to this. The ACG hosted a recent webinar entitled “COVID-19: A Roadmap to Safely Resuming Endoscopy”, and it can still be accessed by way of the “ACG Universe”, where you can access the webinar and apply for free CME as well. You can also view the webinar slides here. The ASGE recently published their “Guidance for Resuming Endoscopy and Practice Operations After the COVID-19 Pandemic” as well. Both resources provide excellent information to guide us as we start to “re-open” practices around the country.
As we begin to provide more non-emergent and then routine care for our patients, we obviously want to do this as safely as possible, protecting our patients, our staff, and ourselves. The ACG and ASGE have done a wonderful job summarizing some of the general guidelines that we should follow, but the intent here is to apply the same principles when caring for your patients with hemorrhoids and other anorectal complaints. When determining the appropriate types of PPE to utilize in these interactions, it seems most reasonable to take 2 main factors into consideration…whether or not there is an aerosol-related risk associated with these procedures, and the potential transmissibility of the virus from bodily fluids.
Generally speaking, procedures involving the respiratory system and upper GI tract have been classified as AGP’s. COVID-19’s primary means of spread seems to be by way of sputum and microdroplets that are caused by coughing, etc. Anything that causes aerosolization of this material is a prime risk for spread of the disease. The NIH guidelines describe AGP’s as follows:
“Aerosol-generating procedures include endotracheal intubation and extubation; bronchoscopy; open suctioning; high-flow nasal cannula (HFNC) or face mask; nebulizer treatment; manual ventilation; physical proning of the patient; disconnecting a patient from a ventilator; mini-bronchoalveolar lavage; noninvasive positive pressure ventilation (NIPPV); tracheostomy; or cardiopulmonary resuscitation.”1
Another source referenced things like transsphenoidal surgery, nasogastric or nasojejunal tube placement2, and we’re all aware of the risks involved in upper endoscopy for many of the same reasons.
Based on the above and the facts that neither anoscopy nor band ligation involve the generation of positive pressure or any analogies of the procedures above, it seems reasonable to assume that these are not AGP’s, and so would not warrant the additional PPE’s and precautions that are required for AGP’s.
SARS-CoV-2 is obviously very transmissible by way of the respiratory tract and is found in the sputum of infected patients. New reports regarding the infectivity of virus from other bodily fluids seems to be coming to light every day. Gastrointestinal manifestations of COVID-19, the presence of viral RNA in the stool, and even evidence of intact virus in the stool has been well documented, and in fact, has been shown to persist in the stool longer than it does in the sputum of some patients.3, 4, 5 Because of the presence of this material, there initially was great concern as to whether or not this viral material was transmissible.
More recent information has raised significant doubts regarding the infectivity of the stool. On April 16th, the Korean CDC published results of culture testing of 24 samples from which viral genetic material was found, and was unable to culture virus from serum, urine or stool. Their conclusion was that it was “highly unlikely that COVID-19 could be transmitted through a path other than the respiratory system”6. This seems to be supported by the findings of Wolfel’s group, who found infectious virus in isolates from the throat and lung, but not from the stool “in spite of high concentrations of virus RNA”7.
The US CDC updated their information on April 23rd in regard to the potential infectivity of fecal material:
“There has not been any confirmed report of the virus spreading from feces to a person. Scientists also do not know how much risk there is that the virus could be spread from the feces of an infected person to another person. However, they think this risk is low based on data from previous outbreaks of diseases caused by related coronaviruses, such as severe acute respiratory syndrome (SARS) and Middle East respiratory syndrome (MERS).”8
With the understanding that the procedures involved are not AGP’s and given the KCDC’s assertion that it is “highly unlikely” that COVID-19 can be transmitted via stool, it seems reasonable that the precautions necessary for anoscopy and RBL would be the same as they are for any routine office encounter. For that, we will return to the CDC guidelines.
CDC guidelines can be very difficult to wade through (demonstrated by the 20 minutes it took me to find the page I had originally downloaded some material from for the bulletin the other day)! I’m going to try to condense these recommendations down to a few simple points, if you want more information – you can find that here.
It seems to boil down to the following. Patients can be infectious prior to the time that they become symptomatic, we must assume that every patient we see has COVID-19, despite the screening that is done prior to having that patient in your exam room. Looking at the page cited, there are 2 tables describing the relative risks of seeing patients depending upon what sort of PPE you are wearing and whether or not the patient is wearing at least a cloth face covering. IF the patient is wearing a cloth face covering and you are wearing at least a mask, then your risk of contracting the virus is low, so if you later find out that a patient was positive for COVID, you would NOT need to resort to actively monitoring yourself nor restrict yourself from work. The risk profile changes if the patient was not wearing that face covering, and, if under those circumstances you were not wearing a mask and eye protection, you would need to enter active monitoring and restrict yourself from work for 14 days.
This is a good place to note that there may be state or local regulations that might impact the recommendations made. For example, Texas just updated their “minimum standards of safe practice”. These include having both the patient and provider wear masks if they will be within 6 feet of one another, that they follow whatever policies that their practice adopts regarding testing and screening, that every patient is screened for symptoms of COVID, and if an AGP is performed, that the provider wear a face shield and an N95 mask or some equivalent protection. A link to those regulations is HERE. 9
So, for anoscopy and RBL, it seems as if the prudent way to go would be for your patient to wear a face covering, and for you to wear a mask and gloves. I’ll plan on wearing eye protection as well, to add that little extra bit of safety. Again, I’ll refer you to the above CDC document for more detail.
We have developed a number of suggestions and tools in order to help improve your efficiency, avoid missed or unproductive visits, help your staff, and to provide additional training and support. We are available to help virtually right now, and as your area transitions into “Phase I” of re-opening, and your governing medical authorities lift the restrictions on non-emergent care, we’ll be available to visit with you on-site. We will be having weekly webinars where much of the above will be discussed, and you’ll have the ability to ask questions and share best practices. We are anxious to get back “out there” and to help you and your practice as we emerge from this crisis. Please feel free to contact ME with any questions, as we’re looking forward to working with you.