Response to Almalki et al.: Resuming endoscopy services during the COVID-19 pandemic

We thank Almalki et al.[1] for their insightful comments on the current situation of endoscopy services in the country, and we clearly share their concerns. The repercussions of the pandemic have been echoed not only in the original position statement from the Saudi Gastroenterology Association (SGA)[2] but also by numerous other societies. The pandemic has resulted in significant restrictions to patient care in the form of hospital visits, which adds insult to injury since challenges to access specialized care existed even before the pandemic.[3] The pandemic has also been a source of anxiety for patients and healthcare providers alike as depicted in a series of papers in the Journal in the last few months.[4567] To be clear, the overall aim of the SGA statement was to facilitate performing procedures during the critical phase of the pandemic and to provide care to the most needy in the face of a looming shutdown of services. The statement was never intended to curtail the provision of services, but rather to ensure the safety and welfare of healthcare workers. It was also in-line with the recommendations of various other societies around the world like the American Gastroenterological Association (AGA),[8] Asian Pacific Society for Digestive Endoscopy (APSDE),[9] the chapter of gastroenterologists in Singapore,[10] as well as others.[11] To the contrary, we had hoped that this statement would increase the procedures that would be performed in the country during this period rather than the counterfactual cancellation of all procedures. Also, the statement was published in a time of great uncertainty, with constraints on personal protective equipment (PPE) as well as disruption of supply chains. It was drafted by a group of local experts from various regions of the country and from different healthcare sectors with the aim of incorporating the various challenges that were being experienced at the time, and to our knowledge, was widely accepted and welcomed. Moreover, this could also be a potential silver lining in this pandemic, to use our resources in a more cost-efficient, beneficial manner, as there is a definite increase in demand and more limited supply due to infection control constraints. This should lead to strategies that improve aspects focusing on procedures with an anticipated higher yield, as well as focusing on improving bowel preparation quality[1213] and avoiding cancelling procedures and possibly shifting, even momentarily, from open-access systems to more controlled scheduling of patients after meticulous screening of requests. We have clearly demonstrated in the past that a significant proportion of those referrals in an open-access system were inappropriate.[14] Saudi Arabia has recently witnessed a diminishing number of active and critical COVID-19 infected individuals. In this context, as a nudge towards re-instating endoscopy services, we delineated the current adapted practice at our center in Riyadh.[15] We have also participated in the development of a more detailed guideline with international representation on the management of endoscopic services.[16] This document has the value of bringing in experts from different areas that have been affected to variable degrees by the pandemic, and gives a balanced practical view while covering topics of point-of-care testing, and recommendations for services before, during, and after an encounter in endoscopy units. Additionally, the position statement of APSDE addresses a practical phased re-instatement of endoscopy services based on the resource availability in each institution as well as the burden of the disease in the community.[9] Ultimately, the decision of re-instating endoscopy services will depend on each institution's situation in terms of the availability of PPE, testing capacity and turn-around time, local case loads, the case-mix of the patient-population served, logistical matters, and numerous other factors that would be an oversimplification to have a document describe. Nonetheless, we believe that the proposal that Azzam et al.[15] had presented is a good backbone to adapt when planning on scaling-up endoscopy services from the status existing during the pandemic. Furthermore, it is only natural that we learn as we go forward, and try to make the best out of our current situation. The pandemic had created immense debate around how to best tackle problems, and there have been numerous proposals from various “experts”, but when the dust settles, it usually ends along the lines that Sir Arthur Conan Doyle describes as being “easy to be wise after the event.” Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

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