PMC7500472_01
Patient management and risk assessment and detailed workflow during ERCP procedure. To minimize human-to-human transmission and to best protect HCW, our hospital, which used to be the part of the coronavirus epicenter, has cut its ambulatory endoscopy practice and developed a screening system to only allow urgent endoscopy being performed during the COVID-19 outbreak. (a) Pre-assessment for COVID-19 is mandatory and conducted in the out-patient department, and it includes inquiries into potential contact history (whether contacted with a suspected or laboratory-confirmed COVID-19 patient in the last 2 weeks), a patient symptom check (body temperature >=37.3 C, coughing or shortness of breath and/or other symptoms of acute respiratory symptom are highly suspected), laboratory test (a nasopharyngeal swab specimen for COVID-19 RNA test and serological tests for COVID-19 antibody), and a chest computed tomography (CT) scan (a typical "ground glass opacity" image is highly suspected). If the patient meets one of these criteria, they will be categorized as being at high risk of infection, and they will be administered at a separated unit for all patients with respiratory symptoms. The negative-pressure room will be requested for undergoing therapeutic procedure. (b) At the ERCP unit, patients are further assessed for suitability for conscious sedation. Those who have cardio-pulmonary disease, difficult airway, morbid obesity, and significant GERD are not eligible for conscious sedation.
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F1
Before admission, she went through the mandatory pre-screening assessment (Figure 1), which has been implemented at our hospital through the COVID-19 outbreak, including inquiry of potential contact history (whether contacted with a suspected or laboratory-confirmed COVID-19 patient in the last 2 weeks); patient's symptom check (body temperature >=37.3 C, coughing or shortness of breath and/or other symptoms of acute respiratory symptom are highly suspected); laboratory test (a nasopharyngeal swab specimen for COVID-19 RNA test and serological tests for COVID-19 antibody); and a chest computed tomography (CT) scan (a typical "ground glass opacity" image is highly suspected), respectively.
Performing ERCP on a 73-year-old female patient presented with acute pancreatitis secondary to JPDD related CBD stone. (A) CT scan shows the inflammation and swelling of the pancreas and a mildly enlarged gallbladder. A diverticular pouch was present at the junction of second and third portions of the duodenum (yellow arrows). (B) MRCP coronal haste thin slice image confirmed shows the presence of periampullary diverticulum, which causes extrinsic compression upon the CBD (yellow arrow). Note the possible CBD stone associated with dilation of the distal end of CBD. (C) ERCP confirm the CBD stone and divericulum exerting compression upon the CBD outlet. (D) The stone was successfully removed though the ERCP procedure.
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F2
An abdominal CT scan indicated inflammation and swelling of the pancreas, a mildly enlarged gallbladder, as well as a slightly dilated common biliary duct (CBD) (Figure 2A). MR cholangiopancreaticography (MRCP) examination. MRCP coronal haste thin slice image confirmed the presence of duodenal diverticular partially compressing the distal end of CBD and resulting in dilation of its proximal part (Figure 2B). ERCP, JPDD was observed, and a duodenoscopy identified the papilla located on the edge of diverticular fundus (Figure 2C). ERCP was performed in the usual fashion with selective biliary cannulation and injection of contrast material into common bile. To remove the stone, the endoscopist performed a small sphincterotomy in conjunction with balloon dilation, and subsequent removal of the stone was achieved with balloon extraction (Figure 2D).
(A-C) HCWs adhere to Level 2 biosafety requirement during the procedure. ERCP Endoscopy personnel precautions and dress code as follows: prior to ERCP procedure, the patient's status of COVID-19 was verified among the ERCP team. HCW wore PPE in the following order: respirator (N95, NK95, or the equivalent); impermeable gown; a first pair of gloves (over the impermeable gown that cover the wrist); lead aprons, thyroid shields, and dosimeters; boot covers; goggles and face shield; disposable isolation gown; and a second pair of gloves (over the isolation gown which cover the wrist). Washing hands with soap and water or alcohol-based hand rub were mandatory before and after patient interaction, contact with potentially infectious sources, and before putting on and upon removal of PPE.
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F3
The step-by-step approach for wearing PPE is as follows (Figures 3A-C): wear a respirator [either N95, the US standards for respirator masks, or NK95, the Chinese standards for respirator masks, or the equivalent, which are rated to capture 95% of tiny particles (0.3 micron particles, to be exact)]; wear an impermeable gown; wear the first pair of gloves so they cover the impermeable gown, which cover the wrist; wear lead aprons, thyroid shields, and dosimeters; wear boot covers; wear goggles and a face shield; wear a disposable isolation gown; wear a second pair of gloves over the isolation gown so they cover the wrist.