Observational Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Endosc. Sep 16, 2021; 13(9): 416-425
Published online Sep 16, 2021. doi: 10.4253/wjge.v13.i9.416
COVID-19 in the endoscopy unit: How likely is transmission of infection? Results from an international, multicenter study
Ioannis S Papanikolaou, Georgios Tziatzios, Alexandros Chatzidakis, Antonio Facciorusso, Stefano Francesco Crinò, Paraskevas Gkolfakis, Gjorgi Deriban, Mario Tadic, Goran Hauser, Antonios Vezakis, Ivan Jovanovic, Nicola Muscatiello, Anna Meneghetti, Konstantinos Miltiadou, Kalina Stardelova, Alojzije Lacković, Maria-Zoi Bourou, Srdjan Djuranovic, Konstantinos Triantafyllou
Ioannis S Papanikolaou, Georgios Tziatzios, Alexandros Chatzidakis, Konstantinos Miltiadou, Konstantinos Triantafyllou, Hepatogastroenterology Unit, 2nd Department of Internal Medicine-Propaedeutic, National and Kapodistrian University of Athens, "Attikon" University General Hospital, Athens 12462, Greece
Antonio Facciorusso, Nicola Muscatiello, Gastroenterology Unit, Department of Surgical and Medical Sciences, University of Foggia AOU, Foggia 1245, Italy
Stefano Francesco Crinò, Anna Meneghetti, Gastroenterology and Digestive Endoscopy Unit, The Pancreas Institute, University of Verona, Verona 37138, Italy
Paraskevas Gkolfakis, Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Brussels 1070, Belgium
Paraskevas Gkolfakis, Department of Medical Oncology, Institut Jules Bordet, Brussels 1000, Belgium
Gjorgi Deriban, Kalina Stardelova, University Clinic of Gastroenterohepatology, Medical Faculty, University "Ss. Cyril and Methodius" Skopje, Skopje 12345, Republic of North Macedonia
Mario Tadic, Department of Gastroenterology, Dubrava University Hospital Zagreb, Zagreb 10040, Croatia
Goran Hauser, Alojzije Lacković, Clinical Hospital Center Rijeka, Faculty of Medicine, University of Rijeka, Rijeka 51000, Croatia
Antonios Vezakis, Maria-Zoi Bourou, 2nd Department of Surgery, Aretaieio Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens 11528, Greece
Ivan Jovanovic, Srdjan Djuranovic, Clinical Center of Serbia, Clinic for Gastroenterology and Hepatology, University of Belgrade Faculty of Medicine, Beograd 12345, Serbia
Author contributions: Papanikolaou IS designed the study, was involved with data collection, and drafted the manuscript; Tziatzios G, Chatzidakis A, Facciorusso A, Francesco Crinò S, Gkolfakis P, Deriban G, Tadic M, Hauser G, Vezakis A, Jovanovic I, Muscatiello N, Meneghetti A, Miltiadou K, Stardelova K, Lacković A, Bourou MZ, Djuranovic S were involved with data collection, and drafted the manuscript; Triantafyllou K participated in design of the study, and drafted the manuscript; All authors read and approved the final manuscript.
Institutional review board statement: The protocol of this study was reviewed and approved by the local institutional review board (BΠΠΚ EBΔ 320/10-6-20). The study was conducted in accord with the ethical principles of the Declaration of Helsinki and in compliance with good clinical practice.
Informed consent statement: All study participants, or their legal guardian, provided informed written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no conflicting interests.
Data sharing statement: No additional data are available.
STROBE statement: The authors have read the STROBE statement, and the manuscript was prepared and revised according to the STROBE statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Paraskevas Gkolfakis, MD, Research Associate, Department of Gastroenterology, Hepatopancreatology and Digestive Oncology, Erasme University Hospital, Université Libre de Bruxelles, Rue de Lennik 808, Brussels 1070, Belgium. pgkolfakis@med.uoa.gr
Received: February 25, 2021
Peer-review started: February 25, 2021
First decision: April 18, 2021
Revised: April 27, 2021
Accepted: July 21, 2021
Article in press: July 21, 2021
Published online: September 16, 2021

Coronavirus disease 2019 (COVID-19) significantly affected endoscopy practice, as gastrointestinal endoscopy is considered a risky procedure for transmission of infection to patients and personnel of endoscopy units (PEU).


To assess the impact of COVID-19 on endoscopy during the first European lockdown (March-May 2020).


Patients undergoing endoscopy in nine endoscopy units across six European countries during the period of the first European lockdown for COVID-19 (March-May 2020) were included. Prior to the endoscopy procedure, participants were stratified as low- or high- risk for potential COVID-19 infection according to the European Society of Gastrointestinal Endoscopy (ESGE) and the European Society of Gastroenterology and Endoscopy Nurses and Associates (ESGENA) joint statement, and contacted 7-14 d later to assess COVID-19 infection status. PEU were questioned regarding COVID-19 symptoms and/or infection via questionnaire, while information regarding hospitalizations, intensive care unit-admissions and COVID-19-related deaths were collected. The number of weekly endoscopies at each center during the lockdown period was also recorded.


A total of 1267 endoscopies were performed in 1222 individuals across nine European endoscopy departments in six countries. Eighty-seven (7%) were excluded because of initial positive testing. Of the 1135 pre-endoscopy low risk or polymerase chain reaction negative for COVID-19, 254 (22.4%) were tested post endoscopy and 8 were eventually found positive, resulting in an infection rate of 0.7% [(95%CI: 0.2-0.12]. The majority (6 of the 8 patients, 75%) had undergone esophagogastroduodenoscopy. Of the 163 PEU, 5 [3%; (95%CI: 0.4-5.7)] tested positive during the study period. A decrease of 68.7% (95%CI: 64.8-72.7) in the number of weekly endoscopies was recorded in all centers after March 2020. All centers implemented appropriate personal protective measures (PPM) from the initial phases of the lockdown.


COVID-19 transmission in endoscopy units is highly unlikely in a lockdown setting, provided endoscopies are restricted to emergency cases and PPM are implemented.

Keywords: COVID-19, SARS-CoV-2, Gastrointestinal endoscopy, Personal protection measures, Transmission, Lockdown

Core Tip: The Coronavirus disease 2019 (COVID-19) pandemic outbreak caused an unprecedented disruption in everyday endoscopy practice worldwide, with recent guidelines advocating suspension of nonemergency endoscopies, implementation of strict personal protection measures (PPM) and post-endoscopy evaluation of patient COVID-19 status. This was an international multicenter study seeking to evaluate the impact of COVID-19 on endoscopy during the first European lockdown (March-May 2020). COVID-19 transmission across endoscopic units proved to be highly unlikely in lockdown circumstances as long as endoscopy performance was restricted to emergency cases and sufficient PPM are available.