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We are writing in relation to the study by Rutter et al with interest.1 The COVID-19 pandemic has resulted in major changes to healthcare delivery in many clinical areas including endoscopic services.1–3 The British Society of Gastroenterology (BSG) and Joint Advisory Group for Gastrointestinal Endoscopy (JAG) issued guidance for endoscopic services on 23 March 2020 recommending activities prioritising emergencies or essential procedures and postponement of non-emergency cases, bowel cancer screening and surveillance.4
The study by Rutter et al reported a substantial reduction to as low as 5% of normal endoscopic activity in the UK earlier on in the pandemic with only a 20% increase of pre-COVID-19 levels 10 weeks later. Endoscopic cancer detection rate reduced by 58% overall, with a worrying 72% reduction for colorectal cancer during the study period.1 A national survey of UK endoscopy leads in May 2020 showed a substantial number of endoscopy services stopped performing endoscopy with an anticipated slow recovery and trebling of current workload.5
We have significant concerns regarding these findings and would like to express that major efforts should be taken to restore endoscopic capacity.
Although strategies for resuming diagnostic endoscopy services has been proposed, there has been very little guidance and published data on prioritisation of elective therapeutic endoscopy work such as resection of complex colonic lesions.6 7
Locally, endoscopic activities continued earlier on in the pandemic but with prioritisation of emergencies and reduction of elective work as outlined by the BSG–JAG guidance. A ‘case-by-case consultant-led discussion’ strategy was adopted but despite this, delays were expected. To scale the impact of this further, we conducted a retrospective review of 111 patients with complex colonic lesions defined as size, morphology, site, access (SMSA)≥10 in two large National Health Service hospitals within our trust. We evaluated timing of lower gastrointestinal (LGI) endoscopies (assessing time interval between index (diagnostic) and follow-up (therapeutic) procedures), polyp size, characteristics and patient outcomes following the revised service arrangement. All lesions had the index and follow-up procedures in their respective resecting centres. Therapeutic endoscopic resections (ER) performed 6 months from 23 March 2020 were defined as cases affected by the COVID-19 outbreak (group A (n=35)) and ER performed within 1 year prior to this were chosen as control for comparison (group B (n=76)). All patients had LGI endoscopies as their index procedure except one in group A who had an MRI describing a non-invasive rectosigmoid polyp. All follow-up procedures were performed with therapeutic intent.
The median time interval between procedures were prolonged in group A compared with group B (16 weeks (IQR 12–20) vs 8 weeks (IQR 5–13) respectively; p=0.001). There was a larger increase in median polyp size between interval procedures and higher ER abandoned rates in group A compared with group B. There was also higher percentage of patients with an increase in polyp size (≥1 cm growth) in group A but statistical analysis showed no significant difference between the two groups (table 1). Subgroup analysis was performed to assess for reasons for abandoning ER in group A and summarised in table 2. Overall, 80% (n=4) of abandoned procedure in group A required surgery with histology confirming high-grade dysplasia or malignant changes.
Our data support the negative impact on patients due to delays in ER of complex colonic lesions. Although mobilising a safe model for rationing GI endoscopy should be taken, it is crucial that efforts are also made to protect elective therapeutic endoscopy work such as resection of complex colonic lesions. This is vital in conjunction, to prevent a future cancer healthcare crisis.
Contributors SS contributed to planning, data collection, analysis, reporting of work and wrote the letter (responsible for overall content). NM contributed to planning, data collection, analysis and made adjustments to letter. MD contributed to data collection. DNN contributed to statistical analysis. SK contributed to data, planning, data analysis and made adjustments to letter. JG contributed to data, planning, data analysis and made adjustments to letter. MI contributed to data, data analysis and made adjustments to letter. MM contributed to data and data analysis. VG (overall supervisor) supervised and contributed to data, project planning, data analysis, made adjustments and help finalise the letter.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.
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