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Ali O, Kesar V, Alizadeh M, Kalachi K, Twery B, Wellnitz N, Kim RE, Goldberg E, Uradomo LT, Darwin PE. Low-dose pulsed vs standard pulsed fluoroscopy during ERCP to reduce radiation without change in image quality: Prospective randomized study. Endosc Int Open 2024; 12:E554-E560. [PMID: 38628393 PMCID: PMC11018389 DOI: 10.1055/a-2284-8656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Accepted: 03/06/2024] [Indexed: 04/19/2024] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of radiation exposure (RE) to patients and staff and increases the risk of adverse biological effects such as cataracts, sterility, and cancer. Newer fluoroscopy equipment (C-Arm) provides options to limit radiation in the form of lower radiation dose and frame rate or time-limited "pulsed" settings. However, the impact of lower settings on image quality has not been assessed, and no standard protocol exists for fluoroscopy settings used during ERCP. Patients and methods This was a single-center, double-blind, prospective randomized study of consecutive adult patients undergoing standard-of-care ERCP at a tertiary academic medical center. Patients were randomized into two groups: 1) standard-dose pulsed and 2) low-dose pulsed. Pulsed mode (8 fps) was defined as x-ray exposure either in the manufacturer standard-dose or low-dose settings limited to 3 seconds each time the foot-operated switch was depressed. Results Seventy-eight patients undergoing ERCP were enrolled and randomized. No difference in age, gender, or body mass index was found between the two groups. No significant difference in image quality was found between standard-dose and low-dose fluoroscopy P = 0.925). The low-dose group was exposed to significantly less radiation when compared with standard-dose P < 0.05). Fluoroscopy time (minutes) was similar in both groups (2.0 vs 1.9), further suggesting that group assignment had no impact on image quality or procedure time. Conclusions Low-dose pulsed fluoroscopy is a reliable method that substantially reduces radiation without compromising image quality or affecting procedure or fluoroscopy times. This underscores the need for standardization in ERCP fluoroscopy settings to limit radiation exposure.
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Affiliation(s)
- Osman Ali
- Gastroenterology, University of Maryland School of Medicine, Baltimore, United States
| | - Varun Kesar
- Gastroenterology and Hepatology, Carilion Clinic, Roanoke, United States
| | - Madeline Alizadeh
- IGS, University of Maryland Institute for Genome Sciences, Silver Spring, United States
| | - Kourosh Kalachi
- Gastroenterology, University of Maryland School of Medicine, Baltimore, United States
| | - Benjamin Twery
- Gastroenterology, University of Maryland School of Medicine, Baltimore, United States
| | - Nicholas Wellnitz
- A&F Environmental Health & Safety, University of Maryland Baltimore, Baltimore, United States
| | - Raymond Eunho Kim
- Gastroenterology and Hepatology, University of Maryland Baltimore, Baltimore, United States
| | - Eric Goldberg
- Gastroenterology, University of Maryland School of Medicine, Baltimore, United States
| | - Lance T Uradomo
- Gastroeneterology, City of Hope Comprehensive Cancer Center, Duarte, United States
| | - Peter E Darwin
- Gastroenterology, University of Maryland School of Medicine, Baltimore, United States
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Oh CH, Son BK. Minimizing radiation exposure in endoscopic retrograde cholangiopancreatography: a review for medical personnel. Korean J Intern Med 2022; 37:1111-1119. [PMID: 36217814 PMCID: PMC9666259 DOI: 10.3904/kjim.2022.093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2022] [Accepted: 07/21/2022] [Indexed: 11/27/2022] Open
Abstract
Fluoroscopy is used frequently during endoscopic procedures, such as endoscopic retrograde cholangiopancreatography (ERCP). However, exposure to radiation is an important health concern, primarily because of the potential increase in the lifetime risk of malignancy. This consideration is important for patients and staff exposed to radiation during ERCP. Thus, an understanding of how radiation doses are measured during ERCP and the potential risks of this radiation is important. Additionally, staff must be educated about methods used to minimize the radiation dose, such as the use of different imaging techniques, the general principles of fluoroscopy, and advances in hardware and software. The use of personal protective equipment is also essential to minimize occupational exposure. However, no comprehensive ERCP guideline on the use of X-ray systems in clinical settings or on radiation protection for operators has been established. This review focuses on the properties of fluoroscopy systems and methods of radiation protection for physicians and assistants participating in ERCP.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University Hospital, Kyung Hee University College of Medicine, Seoul,
Korea
| | - Byoung Kwan Son
- Department of Internal Medicine, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu,
Korea
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Kim B, Park J, Ahn J, Jung K, Jung JH, Lee JC, Hwang JH, Kim J. Prediction model using clinical factors for radiation exposure during endoscopic retrograde cholangiopancreatography. J Gastroenterol Hepatol 2022; 37:1342-1348. [PMID: 35362155 DOI: 10.1111/jgh.15844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 03/24/2022] [Accepted: 03/27/2022] [Indexed: 12/09/2022]
Abstract
BACKGROUND AND AIM Endoscopic retrograde cholangiopancreatography (ERCP) requires radiation. This study aimed to assess the clinical factors influencing radiation exposure and devise a scoring model for predicting high-dose radiation exposure. METHODS Endoscopic retrograde cholangiopancreatography cases recorded between 2016 and 2019 in a single tertiary teaching hospital were retrospectively reviewed. A scoring model was created by bootstrap method in a derivation cohort (2016-2018) and was assessed in a validation cohort (2019). RESULTS Out of 4223 ERCPs, 2983 and 1240 cases were included in the derivation and validation cohorts, respectively. In the derivation cohort, 746 cases (top 25%) comprised the high-dose exposure group, and 2237 cases (bottom 75%) comprised the low-dose exposure group. Nine clinical parameters associated with high-dose exposure were male, pancreatic sphincterotomy, balloon dilatation, biliary or pancreatic drainage, procedures with contrast dye, endoscopist, in-hospital ERCP, and spot image. Stone removal was included by bootstrap analysis. As presented in a nomogram, the weight score of each variable was as follows: male, 1; pancreatic sphincterotomy, 3; balloon dilatation, 7; stone removal, 3; biliary or pancreatic drainage, 5; procedures with contrast dye, 1; endoscopist B, 4; endoscopist C, 5; in-hospital procedure, 3; and spot image, 3. A total score ≥ 15 suggested a high-dose radiation exposure. The sensitivity and specificity of the model for high-dose exposure were 0.562 and 0.813, respectively. In the validation cohort, the model showed reasonable predictability. CONCLUSIONS Various factors were associated with radiation exposure. The simple scoring system in this study could guide endoscopists in predicting the risk of high-dose radiation exposure.
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Affiliation(s)
- Bomi Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jaewoo Park
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jinwoo Ahn
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Kwangrok Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jae Hyup Jung
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jong-Chan Lee
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jin-Hyeok Hwang
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Jaihwan Kim
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
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Takenaka M, Hosono M, Hayashi S, Nishida T, Kudo M. How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology? Dig Endosc 2022; 34:890-900. [PMID: 34850457 PMCID: PMC9543255 DOI: 10.1111/den.14208] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/08/2021] [Accepted: 11/29/2021] [Indexed: 02/08/2023]
Abstract
Fluoroscopy-guided endoscopic procedures (FGEPs) are rapidly gaining popularity in the field of gastroenterology. Radiation is a well-known health hazard. Gastroenterologists who perform FGEPs are required to protect themselves, patients, as well as nurses and radiologists engaged in examinations from radiation exposure. To achieve this, all gastroenterologists must first understand and adhere to the International Commission on Radiological Protection Publication. In particular, it is necessary to understand the three principles of radiation protection (Justification, Optimization, and Dose Limits), the As Low As Reasonably Achievable principle, and the Diagnostic Reference Levels (DRLs) according to them. This review will mainly explain the three principles of radiation exposure protection, DRLs, and occupational radiological protection in interventional procedures while introducing related findings. Gastroenterologists must gain knowledge of radiation exposure protection and keep it updated.
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Affiliation(s)
- Mamoru Takenaka
- Departments of Gastroenterology and HepatologyKindaiOsakaJapan
| | - Makoto Hosono
- Department of RadiologyKindai University Faculty of MedicineOsakaJapan
| | - Shiro Hayashi
- Department of Gastroenterology and Internal MedicineHayashi ClinicOsakaJapan
| | - Tsutomu Nishida
- Department of GastroenterologyToyonaka Municipal HospitalOsakaJapan
| | - Masatoshi Kudo
- Departments of Gastroenterology and HepatologyKindaiOsakaJapan
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Zeng W, Hu J, Pan Y, Zhang M, Xu L. Nonradiation-to-endoscopist ERCP is non-inferior to standard ERCP. Surg Endosc 2021; 36:4795-4801. [PMID: 34698935 PMCID: PMC9160145 DOI: 10.1007/s00464-021-08822-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 10/17/2021] [Indexed: 12/04/2022]
Abstract
Background Radiation exposure is inherently involved in endoscopic retrograde cholangiopancreatography (ERCP), which could cause radiation-induced injury to endoscopists with long-term exposure. Nonradiation ERCP has been applied to pregnant patients. Conceivably, the same techniques could be used to benefit endoscopists. This study was designed to evaluate the effectiveness and safety of nonradiation-to-endoscopist (NRE) ERCP, compared with standard ERCP. Methods A retrospective, single-center study was conducted from August 2010 to December 2015. Patients aged 18–90 years and with choledocholithiasis (< 15 mm) or distal biliary stricture were eligible. Pre-ERCP evaluation with magnetic resonance cholangiopancreatography was mandatory. To overcome selection bias, we performed 1:2 match using propensity score matching (PSM) between NRE and standard groups. The primary endpoint was overall ERCP success rate. Secondary endpoints were cannulation success rate, stone clearance rate, complication rate, and duration of hospitalization. Results A total of 329 patients met inclusion criteria. After PSM, 73 patients were included in the NRE group and 146 in the standard group. The ERCP overall success rate for NRE and standard groups was equivalent (94.5% vs. 93.2%, P = 0.70). There was no difference in cannulation success rates between the two groups (95.6% vs. 97.8%, P = 0.39). A total of 88.3% of patients in the NRE group and 93.9% of patients in the standard group had stones cleared at initial ERCP (P = 0.57). No difference in overall stone clearance rate between the two groups (95.0% vs. 93.9%, P = 0.77) was found after second ERCP. The complication rate (1.4% vs. 1.4%, P = 1.00) and hospital duration (8.3 ± 5.1 vs. 10.2 ± 8.8 days, P = 0.07) were not different between the two groups. Conclusion Although technically demanding, NRE-ERCP is both safe and feasible in selected patients compared with standard ERCP.
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Affiliation(s)
- Wei Zeng
- Department of Gastroenterology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 2000 Xiang'an East Road, Xiamen, 361102, Fujian, China
| | - Jie Hu
- Department of Medical Engineering, The 305 Hospital of PLA, Beijing, China
| | - Yanglin Pan
- State Key Laboratory of Cancer Biology and National Clinical Research Center for Digestive Diseases, Xijing Hospital of Digestive Diseases, Air Force Medical University, Xi'an, 710032, Shaanxi, China
| | - Mingqing Zhang
- Department of Gastroenterology, 909 Hospital of PLA, Affiliated Southeast Hospital of Xiamen University, 269 zhanghua middle road, Zhangzhou, 363000, Fujian, China.
| | - Li Xu
- Department of Gastroenterology, Xiang'an Hospital of Xiamen University, School of Medicine, Xiamen University, 2000 Xiang'an East Road, Xiamen, 361102, Fujian, China.
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Takenaka M, Hosono M, Hayashi S, Nishida T, Kudo M. The radiation doses and radiation protection on the endoscopic retrograde cholangiopancreatography procedures. Br J Radiol 2021; 94:20210399. [PMID: 34379457 PMCID: PMC9328071 DOI: 10.1259/bjr.20210399] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 07/07/2021] [Accepted: 07/20/2021] [Indexed: 12/12/2022] Open
Abstract
Although many interventions involving radiation exposure have been replaced to endoscopic procedure in the gastrointestinal and hepatobiliary fields, there remains no alternative for enteroscopy and endoscopic retrograde cholangiopancreatography (ERCP), which requires the use of radiation. In this review, we discuss the radiation doses and protective measures of endoscopic procedures, especially for ERCP. For the patient radiation dose, the average dose area product for diagnostic ERCP was 14-26 Gy.cm², while it increased to as high as 67-89 Gy.cm² for therapeutic ERCP. The corresponding entrance skin doses for diagnostic and therapeutic ERCP were 90 and 250 mGy, respectively. The mean effective doses were 3- 6 mSv for diagnostic ERCP and 12-20 mSv for therapeutic ERCP. For the occupational radiation dose, the typical doses were 94 μGy and 75 μGy for the eye and neck, respectively. However, with an over-couch-type X-ray unit, the eye and neck doses reached as high as 550 and 450 μGy, with maximal doses of up to 2.8 and 2.4 mGy/procedure, respectively.A protective lead shield was effective for an over couch X-ray tube unit. It lowered scattered radiation by up to 89.1% in a phantom study. In actual measurements, the radiation exposure of the endoscopist closest to the unit was reduced to approximately 12%. In conclusion, there is a clear need for raising awareness among medical personnel involved endoscopic procedures to minimise radiation risks to both the patients and staff.
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Affiliation(s)
- Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Makoto Hosono
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | | | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
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Kwok K, Hasan N, Duloy A, Murad F, Nieto J, Day LW. American Society for Gastrointestinal Endoscopy radiation and fluoroscopy safety in GI endoscopy. Gastrointest Endosc 2021; 94:685-697.e4. [PMID: 34399965 DOI: 10.1016/j.gie.2021.05.042] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Karl Kwok
- Department of Medicine, Division of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California, USA
| | - Nazia Hasan
- Department of Medicine, Division of Gastroenterology, NorthBay Healthcare, Fairfield, California, USA
| | - Anna Duloy
- Department of Medicine, Division of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Faris Murad
- Department of Gastroenterology, FHN Memorial Hospital, Freeport, Illinois, USA
| | - Jose Nieto
- Department of Gastroenterology, Borland Groover Clinic, Jacksonville, Florida, USA
| | - Lukejohn W Day
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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Kakodkar S, Haider A, Hoff RT, Zamfirova I, Chi K. Reduced Fluoroscopy Time With Physician-Controlled Fluoroscopy During Endoscopic Retrograde Cholangiopancreatography: A Community Hospital Experience. Cureus 2021; 13:e13771. [PMID: 33842147 PMCID: PMC8026404 DOI: 10.7759/cureus.13771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and objective Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure and related health risks. Either the physician or the radiology technologist can activate fluoroscopy during ERCP. The aim of this study was to determine if physician-controlled fluoroscopy is associated with decreased fluoroscopy time, which may correspond to less radiation exposure to patients and staff. Methods We conducted a single-center, retrospective study; data were collected on ERCP performed using physician-controlled and technologist-controlled fluoroscopy. Fluoroscopy time, procedure complexity level, and Stanford Fluoroscopy Score were compared between the two groups. Results The median fluoroscopy time significantly differed between the two groups with 108 seconds for physician-controlled and 146 seconds for technologist-controlled procedures (p=0.004). The ratio of median fluoroscopy time to procedure complexity level was significantly lower in the physician-controlled group at 73.0 seconds compared to 97.0 seconds in the technologist-controlled group (p=0.002). The ratio of median fluoroscopy time to Stanford Fluoroscopy Score was 25.5 seconds in the physician-controlled group compared to 39.3 seconds in the technologist-controlled group, which was also statistically significant (p<0.001). A subgroup analysis of physicians with advanced training in ERCP also showed a significantly reduced median fluoroscopy time to Stanford Fluoroscopy Complexity Score ratio: 25.5 seconds for physician-controlled versus 35.0 seconds for technologist-controlled (p=0.001). Conclusion The ERCP technique with physician-controlled fluoroscopy may be associated with shorter fluoroscopy time. This may correspond to decreased radiation exposure to patients compared to radiology technologist-controlled fluoroscopy. Further investigations with larger, prospective studies are warranted.
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Affiliation(s)
- Samir Kakodkar
- Department of Medicine, Division of Gastroenterology, Advocate Lutheran General Hospital, Park Ridge, USA
| | - Ali Haider
- Department of Medicine, Division of Gastroenterology, Advocate Lutheran General Hospital, Park Ridge, USA
| | - Ryan T Hoff
- Department of Medicine, Division of Gastroenterology, Advocate Lutheran General Hospital, Park Ridge, USA
| | - Ina Zamfirova
- Russell Research Institute, Advocate Lutheran General Hospital, Park Ridge, USA
| | - Kenneth Chi
- Department of Medicine, Division of Gastroenterology, Advocate Lutheran General Hospital, Park Ridge, USA
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Sulieman A, Tamam N, Khandaker MU, Bradley D, Padovani R. Radiation exposure management techniques during endoscopic retrograde cholangio-pancreatography procedures. Radiat Phys Chem Oxf Engl 1993 2021. [DOI: 10.1016/j.radphyschem.2020.108991] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Use of Artificial Intelligence to Reduce Radiation Exposure at Fluoroscopy-Guided Endoscopic Procedures. Am J Gastroenterol 2020; 115:555-561. [PMID: 32195731 DOI: 10.14309/ajg.0000000000000565] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Exposure to ionizing radiation remains a hazard for patients and healthcare providers. We evaluated the utility of an artificial intelligence (AI)-enabled fluoroscopy system to minimize radiation exposure during image-guided endoscopic procedures. METHODS We conducted a prospective study of 100 consecutive patients who underwent fluoroscopy-guided endoscopic procedures. Patients underwent interventions using either conventional or AI-equipped fluoroscopy system that uses ultrafast collimation to limit radiation exposure to the region of interest. The main outcome measure was to compare radiation exposure with patients, which was measured by dose area product. Secondary outcome was radiation scatter to endoscopy personnel measured using dosimeter. RESULTS Of 100 patients who underwent procedures using traditional (n = 50) or AI-enabled (n = 50) fluoroscopy systems, there was no significant difference in demographics, body mass index, procedural type, and procedural or fluoroscopy time between the conventional and the AI-enabled fluoroscopy systems. Radiation exposure to patients was lower (median dose area product 2,178 vs 5,708 mGym, P = 0.001) and scatter effect to endoscopy personnel was less (total deep dose equivalent 0.28 vs 0.69 mSv; difference of 59.4%) for AI-enabled fluoroscopy as compared to conventional system. On multivariate linear regression analysis, after adjusting for patient characteristics, procedural/fluoroscopy duration, and type of fluoroscopy system, only AI-equipped fluoroscopy system (coefficient 3,331.9 [95% confidence interval: 1,926.8-4,737.1, P < 0.001) and fluoroscopy duration (coefficient 813.2 [95% confidence interval: 640.5-985.9], P < 0.001) were associated with radiation exposure. DISCUSSION The AI-enabled fluoroscopy system significantly reduces radiation exposure to patients and scatter effect to endoscopy personnel (see Graphical abstract, Supplementary Digital Content, http://links.lww.com/AJG/B461).
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Menon S, Mathew R, Kumar M. Ocular radiation exposure during endoscopic retrograde cholangiopancreatography: a meta-analysis of studies. Eur J Gastroenterol Hepatol 2019; 31:463-470. [PMID: 30830881 DOI: 10.1097/meg.0000000000001341] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND The increasing complexity involved in procedures requiring fluoroscopy such as endoscopic retrograde cholangiopancreatography (ERCP) results in heightened screening times with attendant radiation exposure during these procedures. There is increasing awareness of tissue-reactions to the lens of the eye due to radiation exposure, with evidence suggesting that threshold doses may be lower than previously considered. MATERIALS AND METHODS A literature search was performed to identify studies involving ERCP in which radiation exposure was reported. Demographic data and data on fluoroscopy time and ocular exposure were extracted. Fixed and random-effects meta-analyses were conducted. RESULTS Twenty-six studies (8016 procedures) were identified, of which 10 studies (818 procedures) contained data on ocular exposure. The mean screening time per procedure was 3.9 min with a mean of three images captured per procedure. On fixed effects meta-analysis, the point estimate for the effective ocular exposure dose per procedure was 0.018 (95% confidence interval: 0.017-0.019) mSv. On random-effects meta-analysis, the effective ocular exposure dose was 0.139 (0.118-0.160) mSv (Q=2590.78, I=99.5, P<0.001). On comparing these point estimates to the ocular dose limit of 20 mSv/year, 1111 ERCPs (using fixed effects data) and 144 ERCPs (using random-effects data), with a mean of 627 ERCPs/individual/year, could deliver an ocular radiation dose equivalent to this dose limit. CONCLUSION Ocular radiation exposures in high-volume ERCP operators (>200 procedures/year) and operators performing complex ERCPs involving prolonged fluoroscopy, need to exercise caution in relation to ocular exposure. Shielding using lead-lined glasses may be reasonable in this group.
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Affiliation(s)
- Shyam Menon
- The Royal Wolverhampton NHS Trust, Wolverhampton
| | - Ray Mathew
- The Royal Wolverhampton NHS Trust, Wolverhampton
| | - Mayur Kumar
- Kings College Hospital NHS Foundation Trust, London, UK
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12
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Zeng HZ, Liu Q, Chen HL, Liu W, Zeng QS, Wu CC, Hu B. A pilot single-center prospective randomized trial to assess the short-term effect of a flashing warning light on reducing fluoroscopy time and radiation exposure during ERCP. Gastrointest Endosc 2018; 88:261-266. [PMID: 29559225 DOI: 10.1016/j.gie.2018.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS ERCP has the risk of exposure to ionizing radiation. Performers may unconsciously increase fluoroscopy time (FT) because of a lack of radiation protection awareness. This study investigates whether a flashing warning light adopted as a behavioral intervention for performers reduces FT and radiation exposure during ERCP. METHODS We conducted a prospective randomized trial of 200 therapeutic ERCPs. A flashing warning light was placed on top of the endoscopy monitor. Cases were consecutively enrolled and randomly assigned to 2 groups in a 1:1 ratio. In the warning light group, the light was on when the fluoroscopy foot pedal was depressed; in the control group, the light was off. Fluoroscopy and procedure-related data were recorded. RESULTS The median FT and dose-area product (DAP) for the warning light group versus the control group were 142.5 seconds versus 175.0 seconds (P = .045) and 856.8 μGy∙m2 versus 1054.4 μGy∙m2 (P = .043). In a multivariable analysis, the use of the warning light was found to reduce FT by 15.4% (-27.0 seconds; P = .042). DAP reduction because of the decreased FT was 15.2% (160.3 μGy∙m2). The reduction in patient effective dose per case was .42 mSv, equivalent to 21 chest radiographs. No adverse events or interference with the procedures because of the warning light were noted. CONCLUSIONS The use of a flashing warning light is a feasible way to reduce FT and radiation exposure during ERCP. (Clinical trial registration number: ChiCTR-IPR-14005349.).
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Affiliation(s)
- Hong-Ze Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qin Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hong-Lin Chen
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi-Shan Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chun-Cheng Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Ofori E, Ramai D, John F, Reddy M, Ghevariya V. Occupation-associated health hazards for the gastroenterologist/endoscopist. Ann Gastroenterol 2018; 31:448-455. [PMID: 29991889 PMCID: PMC6033760 DOI: 10.20524/aog.2018.0265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/11/2018] [Indexed: 12/13/2022] Open
Abstract
Advances in the field of endoscopy have allowed gastroenterologists to obtain detailed imaging of anatomical structures and to treat gastrointestinal diseases with endoscopic therapies. However, these technological developments have exposed endoscopists and staff to hazards such as musculoskeletal injuries, exposure to infectious agents, and ionizing radiation. We aimed to review the occupational hazards for the gastroenterologist and endoscopist. Using PubMed, Medline, Medscape, and Google Scholar, we identified peer-reviewed articles with the keywords “occupational hazards,” “health hazards,” “occupational health hazards,” “endoscopy,” “gastroenterologist,” “infectious agents,” “musculoskeletal injuries,” and “radiation.” Strategies for reducing exposure to infectious agents, radiation, and the risk of musculoskeletal injuries related to gastroenterology include compliance with established standard measures, the use of thyroid shields and radioprotective eyewear, and ergonomic practices. We conclude that educating endoscopic personnel and trainees in these practices, in addition to further research in these areas, will likely lead to the development of more efficient and user-friendly workspaces that are safer for patients and personnel.
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Affiliation(s)
- Emmanuel Ofori
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy)
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy).,St George's University School of Medicine, True Blue, Grenada, W.I. (Daryl Ramai)
| | - Febin John
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy)
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy)
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Saukko E, Grönroos JM, Salminen P, Henner A, Nieminen MT. Patient radiation dose and fluoroscopy time during ERCP: a single-center, retrospective study of influencing factors. Scand J Gastroenterol 2018; 53:495-504. [PMID: 29489436 DOI: 10.1080/00365521.2018.1445774] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Recently, both the number and the complexity with associated increased technical difficulty of therapeutic ERCP procedures have significantly increased resulting in longer procedural and fluoroscopy times. During ERCP, the patient is exposed to ionizing radiation and the consequent radiation dose depends on multiple factors. The aim of this study was to identify factors affecting fluoroscopy time and radiation dose in patients undergoing ERCP. MATERIALS AND METHODS Data related to patient demographics, procedural characteristics and radiation exposure in ERCP procedures (n = 638) performed between August 2013 and August 2015 was retrospectively reviewed and analyzed. Statistically significant factors identified by univariate analyses were included in multivariate analysis with fluoroscopy time (FT) and dose area product (DAP) as dependent variables. Effective dose (ED) was estimated from DAP measurements using conversion coefficient. RESULTS The factors independently associated with increased DAP during ERCP were age, gender, radiographer, complexity level of ERCP, cannulation difficulty grade, bile duct injury and biliary stent placement. In multivariate analysis the endoscopist, the complexity level of ERCP, cannulation difficulty grade, pancreatic duct leakage, bile duct dilatation and brushing were identified as predictors for a longer FT. The mean DAP, FT, number of acquired images and ED for all ERCP procedures were 2.33 Gy·cm2, 1.84 min, 3 and 0.61 mSv, respectively. CONCLUSIONS Multiple factors had an effect on DAP and FT in ERCP. The awareness of these factors may help to predict possible prolonged procedures causing a higher radiation dose to the patient and thus facilitate the use of appropriate precautions.
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Affiliation(s)
- Ekaterina Saukko
- a The Medical Imaging Centre of Southwest Finland, Turku University Hospital , Turku , Finland
| | - Juha M Grönroos
- b Division of Digestive Surgery and Urology , Turku University Hospital , Turku , Finland.,c Department of Surgery , University of Turku , Turku , Finland
| | - Paulina Salminen
- b Division of Digestive Surgery and Urology , Turku University Hospital , Turku , Finland.,c Department of Surgery , University of Turku , Turku , Finland
| | - Anja Henner
- d School of Health and Social Care , Oulu University of Applied Sciences , Oulu , Finland
| | - Miika T Nieminen
- e Research Unit of Medical Imaging, Physics and Technology, University of Oulu , Oulu , Finland.,f Department of Diagnostic Radiology , Oulu University Hospital , Oulu , Finland.,g Medical Research Center Oulu, University of Oulu and Oulu University Hospital , Oulu , Finland
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Hadjiconstanti AC, Messaris GAT, Thomopoulos KC, Panayiotakis GS. Patient Radiation Doses in Therapeutic Endoscopic Retrograde Cholangiopancreatography in Patras and the Key Role of the Operator. RADIATION PROTECTION DOSIMETRY 2017; 177:243-249. [PMID: 28419374 DOI: 10.1093/rpd/ncx037] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2016] [Accepted: 03/14/2017] [Indexed: 06/07/2023]
Abstract
The patient radiation doses, in conjunction with the operator experience, in therapeutic endoscopic retrograde cholangiopancreatography (ERCP) procedures, performed in our hospital, were obtained. Ninety-six patients participated in the study and were divided into 3 groups, based on the operator experience. The dosemetric indices, fluoroscopy time (FT), cumulative dose (Ka,r) and air kerma-area product (PKA), were collected. For the total and weight banding group the third quartile values of the distribution of FT, Ka,r and PKA were 2.90 and 2.92 min, 6.89 and 6.93 mGy and 1.84 and 1.85 Gycm2, respectively, and were comparative or significantly lower than the corresponding values previously reported. Taking as a criterion the operator, the differences in the patient radiation doses were statistically significant, with the highest dose recorded for the operator of the lowest experience degree. The values obtained could contribute in establishing local and national diagnostic reference levels and in optimising ERCP procedure.
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Affiliation(s)
| | - Gerasimos A T Messaris
- Department of Medical Physics, School of Medicine, University of Patras, 265 04 Patras, Greece
| | | | - George S Panayiotakis
- Department of Medical Physics, School of Medicine, University of Patras, 265 04 Patras, Greece
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Jowhari F, Hopman WM, Hookey L. A simple ergonomic measure reduces fluoroscopy time during ERCP: A multivariate analysis. Endosc Int Open 2017; 5:E172-E178. [PMID: 28299352 PMCID: PMC5348293 DOI: 10.1055/s-0043-102934] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background and study aims Endoscopic retrograde cholangiopancreatgraphy (ERCP) carries a radiation risk to patients undergoing the procedure and the team performing it. Fluoroscopy time (FT) has been shown to have a linear relationship with radiation exposure during ERCP. Recent modifications to our ERCP suite design were felt to impact fluoroscopy time and ergonomics. This multivariate analysis was therefore undertaken to investigate these effects, and to identify and validate various clinical, procedural and ergonomic factors influencing the total fluoroscopy time during ERCP. This would better assist clinicians with predicting prolonged fluoroscopic durations and to undertake relevant precautions accordingly. Patients and methods A retrospective analysis of 299 ERCPs performed by 4 endoscopists over an 18-month period, at a single tertiary care center was conducted. All inpatients/outpatients (121 males, 178 females) undergoing ERCP for any clinical indication from January 2012 to June 2013 in the chosen ERCP suite were included in the study. Various predetermined clinical, procedural and ergonomic factors were obtained via chart review. Univariate analyses identified factors to be included in the multivariate regression model with FT as the dependent variable. Results Bringing the endoscopy and fluoroscopy screens next to each other was associated with a significantly lesser FT than when the screens were separated further (-1.4 min, P = 0.026). Other significant factors associated with a prolonged FT included having a prior ERCP (+ 1.4 min, P = 0.031), and more difficult procedures (+ 4.2 min for each level of difficulty, P < 0.001). ERCPs performed by high-volume endoscopists used lesser FT vs. low-volume endoscopists (-1.82, P = 0.015). Conclusions Our study has identified and validated various factors that affect the total fluoroscopy time during ERCP. This is the first study to show that decreasing the distance between the endoscopy and fluoroscopy screens in the ERCP suite significantly reduces the total fluoroscopy time, and therefore radiation exposure to patients and staff involved in the procedure.
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Affiliation(s)
- Fahd Jowhari
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada
| | - Wilma M. Hopman
- Clinical Research Centre, Kingston General Hospital, and Department of Public Health Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Lawrence Hookey
- Gastrointestinal Diseases Research Unit, Kingston General Hospital, Queen’s University, Kingston, Ontario, Canada,Corresponding author Lawrence Hookey, MD, FRCPC Division of GastroenterologyHotel Dieu Hospital166 Brock StreetKingston, ON K7L 5G2
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No reduction of radiation dose following the introduction of dose-area product measurement in endoscopic retrograde cholangiopancreatography. Eur J Gastroenterol Hepatol 2015; 27:1454-8. [PMID: 24849767 DOI: 10.1097/meg.0000000000000128] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND During radiological examinations such as endoscopic retrograde cholangiopancreatography (ERCP), it is recommended to record the dose-area product (DAP) to reduce the patient's and the physician's exposure to ionizing radiation. However, the effect of DAP measurement on the total radiation dose in ERCP procedures has never been assessed. OBJECTIVES This study evaluated radiation dose use in ERCP procedures following the introduction of DAP measurement in the endoscopy unit. Also, patient-related, endoscopist-related and procedure-related factors associated with high DAP values were assessed. MATERIALS AND METHODS All consecutive ERCPs from January 2008 to March 2011 were retrospectively reviewed. The DAP values and demographic-specific and disease-specific parameters were obtained from patient files and ERCP reports. RESULTS A total of 279 ERCPs was analysed. The median DAP was 1907 cGy cm (range 316-7981). There was no significant decrease in the total radiation dose used in ERCPs following the installation of the DAP-meter in the endoscopy unit. Variables associated with significantly higher DAP values were precut papillotomy [odds ratio (OR) 2.44], hydrostatic balloon dilation (OR 3.56), stone extraction with a basket (OR 5.27) and procedures performed at the weekend (OR 6.43). CONCLUSION The introduction of DAP measurement during ERCP did not result in a significant decrease in the total radiation dose. Several risk factors associated with a high radiation dose during ERCP procedures were identified, of which precut papillotomy and procedures performed during the weekend have not been described before in the literature. These factors enable endoscopists to more accurately identify patients at an increased risk of high radiation exposure.
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Mu H, Gao J, Kong Q, Jiang K, Wang C, Wang A, Zeng X, Li Y. Prognostic Factors and Postoperative Recurrence of Calculus Following Small-Incision Sphincterotomy with Papillary Balloon Dilation for the Treatment of Intractable Choledocholithiasis: A 72-Month Follow-Up Study. Dig Dis Sci 2015; 60:2144-9. [PMID: 25875753 DOI: 10.1007/s10620-015-3559-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2014] [Accepted: 01/22/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To evaluate the recurrence of common bile duct stones and risk factors for recurrence following routine endoscopic sphincterotomy (EST) versus small-incision endoscopic sphincterotomy plus endoscopic papillary balloon dilation (EST-EPBD). METHODS Three hundred patients who were hospitalized between June 2007 and June 2008 with common bile duct stones >10 mm in diameter were randomly assigned to the EST or EST-EPBD group. We compared the short-term (≤3 years) and long-term (>3 years) recurrence of ductal stones in the two groups over a 72-month follow-up period. Potential risk factors were evaluated using a logistic regression analysis. RESULTS A total of 291 patients completed the study. The short-term recurrence rate in the EST group was not significantly higher than that in the EST-EPBD group (P > 0.05). The long-term recurrence rate for the EST group was significantly higher than that for the EST-EPBD group (P < 0.05). The serum level of cholesterol, body mass index, gallstones, maximum stone diameter, number of stones, and mechanical lithotripsy were risk factors for the recurrence of ductal stones. Minimal size of the duodenal papilla incision was a protective factor with regard to the recurrence of ductal stones. Cholecystectomy, sex, and age were not associated with the recurrence of ductal stones. CONCLUSIONS Small-incision EST-EPBD has a similar overall success rate and a significantly lower rate of the recurrence of ductal stones, compared with those of EST alone. Thus, the curative effect of EST-EPBD is better than that of EST alone. Minimal size of the duodenal papilla incision protects against the recurrence of ductal stones.
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Affiliation(s)
- Hailian Mu
- Department of Gastroentorology, Qilu Hospital, Shandong University, 44#, Wenhua Xi Road, Jinan, 250000, P. R. China
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Kai K, Hamada T, Yuge A, Kiyosue H, Nishida Y, Nasu K, Narahara H. Estimating the Radiation Dose to the Fetus in Prophylactic Internal Iliac Artery Balloon Occlusion: Three Cases. Case Rep Obstet Gynecol 2015; 2015:170343. [PMID: 26180648 PMCID: PMC4477202 DOI: 10.1155/2015/170343] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2015] [Revised: 05/27/2015] [Accepted: 05/28/2015] [Indexed: 11/29/2022] Open
Abstract
Background. Although radiation exposure is of great concern to expecting patients, little information is available on the fetal radiation dose associated with prophylactic internal iliac artery balloon occlusion (IIABO). Here we estimated the fetal radiation dose associated with prophylactic IIABO in Caesarean section (CS). Cases. We report our experience with the IIABO procedure in three consecutive patients with suspected placenta previa/accreta. Fetal radiation dose measurements were conducted prior to each CS by using an anthropomorphic phantom. Based on the simulated value, we calculated the fetal radiation dose as the absorbed dose. We found that the fetal radiation doses ranged from 12.88 to 31.6 mGy. The fetal radiation dose during the prophylactic IIABOs did not exceed 50 mGy. Conclusion. The IIABO procedure could result in a very small increase in the risk of harmful effects to the fetus.
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Affiliation(s)
- Kentaro Kai
- Department of Obstetrics and Gynecology, Oita University Faculty of Medicine, Oita 879-5593, Japan
| | - Tomohiro Hamada
- Department of Radiology, Oita University Faculty of Medicine, Oita 879-5593, Japan
| | - Akitoshi Yuge
- Department of Obstetrics and Gynecology, Oita University Faculty of Medicine, Oita 879-5593, Japan
| | - Hiro Kiyosue
- Department of Radiology, Oita University Faculty of Medicine, Oita 879-5593, Japan
| | - Yoshihiro Nishida
- Department of Obstetrics and Gynecology, Oita University Faculty of Medicine, Oita 879-5593, Japan
| | - Kaei Nasu
- Department of Obstetrics and Gynecology, Oita University Faculty of Medicine, Oita 879-5593, Japan
| | - Hisashi Narahara
- Department of Obstetrics and Gynecology, Oita University Faculty of Medicine, Oita 879-5593, Japan
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Mori H. Action research regarding the optimisation of radiological protection for nurses during vascular interventional radiology. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2015; 35:457-466. [PMID: 26052718 DOI: 10.1088/0952-4746/35/2/457] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The optimisation and decision-making processes for radiological protection have been broadened by the introduction of re-examination or feedback after introducing protective measures. In this study, action research was used to reduce the occupational exposure of vascular interventional radiology (IR) nurses. Four radiological protection improvement measures were continuously performed in cooperation with the researchers, nurses and stakeholders, and the nurses' annual effective doses were compared before and after the improvements. First, the dosimetry equipment was changed from one electronic personal dosimeter (EPD) to two silver-activated phosphate glass dosimeters (PGDs). Second, the nurses were educated regarding maintaining a safe distance from the sources of scattered and leakage radiation. Third, portable radiation shielding screens were placed in the IR rooms. Fourth, the x-ray units' pulse rates were reduced by half. On changing the dosimetry method, the two PGDs recorded a 4.4 fold greater dose than the single EPD. Educating nurses regarding radiological protection and reducing the pulse rates by half decreased their effective doses to one-third and two-fifths of the baseline dose, respectively. No significant difference in their doses was detected after the placement of the shielding screens. Therefore, the action research effectively decreased the occupational doses of the vascular IR nurses.
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Affiliation(s)
- Hiroshige Mori
- Department of Radiology, Japan Community Healthcare Organization Hokkaido Hospital, 1-8-3-18 Nakanoshima, Toyohira, Sapporo, Hokkaido 062-8618, Japan
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Alkhatib AA, Abdel Jalil AA, Faigel DO, Pannala R, Crowell M, Harrison ME. Anatomical Location of Pathology Is Predictive of Prolonged Fluoroscopy Time During ERCP: A Multicenter American Study. Dig Dis Sci 2015; 60:1787-92. [PMID: 25648640 DOI: 10.1007/s10620-014-3508-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 12/23/2014] [Indexed: 12/29/2022]
Abstract
BACKGROUND Different factors have been associated with prolonged fluoroscopy time (FT) during endoscopic retrograde cholangiopancreatography (ERCP). AIM We hypothesize that FT depends on both the anatomical location of the pathology managed during ERCP and the complexity of the ERCP. METHODS Three centers participated in a retrospective multi-center cohort study. Data on patient demographics, ERCP complexity, and the location of pathology were collected. The relationships between FT and the location of pathology, ERCP complexity, patient demographics, and ERCP maneuvers, respectively, were analyzed. Prolonged FT was defined as a FT > 10 min. RESULTS A total of 442 cases underwent ERCP in three different centers (301 cases, 76 cases, and 65 cases in centers A, B, and C, respectively) by six endoscopists. The median FT for all cases was 282 (range 8-3,516) s. Mean FT increased progressively according to anatomical location in the order extrahepatic cases {n = 298; mean FT 292 [95 % confidence interval (CI) 263-322] s}, pancreatic cases [n = 27; mean FT 359 (95 % CI 200-517) s], and intrahepatic cases [n = 117; mean FT 736 s (95 % CI 635-836) s]. Mean FT increased progressively with the complexity scale, with mean FT for Grade I, 218 (95 % CI 138-299) s; Grade II, 295 (95 % 261-329) s; Grade III, 586 (95 % CI 508-663) s; Grade IV, 636 (95 % CI 437-834) s. Multivariable analysis confirmed that prolonged FT was independently associated with anatomical location of the targeted pathology during ERCP-but not with ERCP complexity and endoscopy center. CONCLUSION Prolonged FT during ERCP is associated most strongly with intrahepatic cases. FT can be used most effectively as a quality measure if it is stratified according to presence or absence of intrahepatic cases.
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Affiliation(s)
- Amer A Alkhatib
- Division of Gastroenterology, Cancer Treatment Centers of America, 10109 E 79th St, Tulsa, OK, 74133, USA,
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Muniraj T, Aslanian HR, Laine L, Farrell J, Ciarleglio MM, Deng Y, Ho H, Jamidar PA. A double-blind, randomized, sham-controlled trial of the effect of a radiation-attenuating drape on radiation exposure to endoscopy staff during ERCP. Am J Gastroenterol 2015; 110:690-6. [PMID: 25823765 DOI: 10.1038/ajg.2015.85] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 02/17/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure to the endoscopist and staff that may be significant in high-volume centers. We investigated whether a radiation-attenuating drape over the fluoroscopy image intensifier reduces radiation exposure during ERCP. METHODS We performed a prospective, randomized, double-blind trial of 100 therapeutic ERCPs at a tertiary-care university center. Procedures were randomly assigned to groups receiving lead-free radiation-attenuating drapes (n=50) or identical sham drapes (n=50). The drapes were suspended around the fluoroscopy image intensifier during ERCP. The primary end point was the effective dose of radiation measured at the endoscopist's eye and neck, and at the assisting nurse's neck. The cumulative annual radiation exposure was also estimated. RESULTS Fluoroscopy time, absorbed radiation dose, and dose area product were similar in the study groups. Mean effective dose for sham vs. radiation-attenuating drape was 0.21±0.27 vs. 0.02±0.02 mSv at the endoscopist's eye, 0.35±0.44 vs. 0.03±0.03 mSv at the endoscopist's neck, and 0.27±0.34 vs. 0.02±0.02 mSv at the nurse's neck (P<0.0001 for all comparisons). The relative risk reduction in radiation was 90%, 91%, and 93% at the three sites. At a high-volume center in which an endoscopist performs 500 therapeutic ERCPs per year, the estimated cumulative annual effective dose at the endoscopist's eye level is 126 mSv with conventional protection and 12 mSv with a radiation-attenuating drape, with the recommended limit being 20 mSv. CONCLUSIONS The addition of a radiation-attenuating drape around the image intensifier during ERCP significantly decreases radiation exposure to endoscopists and staff by ∼90%.
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Affiliation(s)
| | - Harry R Aslanian
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Loren Laine
- 1] Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA [2] VA Connecticut Healthcare System, West Haven, Connecticut, USA
| | - James Farrell
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Maria M Ciarleglio
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA
| | - Yanhong Deng
- Yale Center for Analytical Sciences, Yale School of Public Health, New Haven, Connecticut, USA
| | - Henry Ho
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
| | - Priya A Jamidar
- Section of Digestive Disease, Yale School of Medicine, New Haven, Connecticut, USA
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Kachaamy T, Harrison E, Pannala R, Pavlicek W, Crowell MD, Faigel DO. Measures of patient radiation exposure during endoscopic retrograde cholangiography: beyond fluoroscopy time. World J Gastroenterol 2015; 21:1900-1906. [PMID: 25684958 PMCID: PMC4323469 DOI: 10.3748/wjg.v21.i6.1900] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2014] [Revised: 09/07/2014] [Accepted: 10/14/2014] [Indexed: 02/06/2023] Open
Abstract
AIM To determine whether fluoroscope time is a good predictor of patient radiation exposure during endoscopic retrograde cholangiopancreatography. METHODS This is a prospective observational study of consecutive patients undergoing endoscopic retrograde cholangiopancreatography in a tertiary care setting. Data related to radiation exposure were collected. The following measures were obtained: Fluoroscopy time (FT), dose area product (DAP) and dose at reference point (DOSERP). Coefficients of determination were calculated to analyze the correlation between FT, DAP and DOSRP. Agreement between FT and DAP/DOSRP was assessed using Bland Altman plots. RESULTS Four hundred sixty-three data sets were obtained. Fluoroscopy time average was 7.3 min. Fluoroscopy related radiation accounted for 86% of the total DAP while acquisition films related radiation accounted for 14% of the DAP. For any given FT there are wide ranges of DAP and DOSERP and the variability in both increases as fluoroscopy time increases. The coefficient of determination (R(2)) on the non transformed data for DAP and DOSERP versus FT were respectively 0.416 and 0.554. While fluoroscopy use was the largest contributor to patient radiation exposure during endoscopic retrograde cholangiography (ERCP), there is a wide variability in DAP and DOSERP that is not accounted for by FT. DAP and DOSERP increase in variability as FT increases. This translates into poor accuracy of FT in predicting DAP and DOSERP at higher radiation doses. CONCLUSION DAP and DOSERP in addition to FT should be adopted as new ERCP quality measures to estimate patient radiation exposure.
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Guidi MA, Curvale C. Sphincterotomy plus large balloon dilation versus sphincterotomy alone for the extraction of complex lithiasis: A prospective analysis. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2015; 107:483-7. [DOI: 10.17235/reed.2015.3690/2015] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Radiation exposure in gastroenterology: improving patient and staff protection. Am J Gastroenterol 2014; 109:1180-94. [PMID: 24842339 DOI: 10.1038/ajg.2014.122] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2013] [Accepted: 03/30/2014] [Indexed: 12/11/2022]
Abstract
Medical imaging involving the use of ionizing radiation has brought enormous benefits to society and patients. In the past several decades, exposure to medical radiation has increased markedly, driven primarily by the use of computed tomography. Ionizing radiation has been linked to carcinogenesis. Whether low-dose medical radiation exposure will result in the development of malignancy is uncertain. This paper reviews the current evidence for such risk, and aims to inform the gastroenterologist of dosages of radiation associated with commonly ordered procedures and diagnostic tests in clinical practice. The use of medical radiation must always be justified and must enable patients to be exposed at the lowest reasonable dose. Recommendations provided herein for minimizing radiation exposure are based on currently available evidence and Working Party expert consensus.
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Romagnuolo J, Cotton PB. Recording ERCP fluoroscopy metrics using a multinational quality network: establishing benchmarks and examining time-related improvements. Am J Gastroenterol 2013; 108:1224-30. [PMID: 23912400 DOI: 10.1038/ajg.2012.388] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVES We aimed to establish benchmarks for fluoroscopy time (FT) in endoscopic retrograde cholangiopancreatography (ERCP) and assess the effect of physician practice networking on time trends. METHODS Data from the ERCP Quality Network were used to assess practice variability in FT and establish case- and provider-level benchmarks of the first 200 cases for providers entering more than 100 cases. Trends in FT and high FT, by 50-patient groupings, were assessed by multilevel multivariate linear and logistic regression models. RESULTS Median FT was 2.9 minutes, averaging 16% of procedure time. Ninetieth percentiles for the 57 eligible providers were 10 minutes and 22% (n = 9, 185 ERCP). Every 50 cases entered was associated with lower FT. In multivariate analysis, more cases entered, higher lifetime and annual volumes, lower difficulty grade, and manometry had lower FTs; academics, trainee involvement, various therapeutics, and failed cannulation had higher FTs. CONCLUSIONS FT is highly variable, and many provider and case factors predict FT. FT benchmarks are now available. Self-review of one's case FT might decrease FT.
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Affiliation(s)
- Joseph Romagnuolo
- Division of Gastroenterology and Hepatology, Medical University of South Carolina, Charleston, SC 29425, USA.
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Optimisation of Radiation Exposure to Gastroenterologists and Patients during Therapeutic ERCP. Gastroenterol Res Pract 2013; 2013:587574. [PMID: 23589714 PMCID: PMC3622381 DOI: 10.1155/2013/587574] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2012] [Revised: 01/18/2013] [Accepted: 02/04/2013] [Indexed: 01/26/2023] Open
Abstract
This study intended to optimize the radiation doses for gastroenterologists and patients during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and to compare the doses based on available data obtained by other researchers. A total of 153 patients were studied in two Gastroenterology Departments, (group A, 111; group B, 42). Thermoluminescent dosimeters (TLD) were used to measure the staff and patients entrance surface air kerma (ESAK) at different body sites. The mean ESAK and effective doses per procedure were estimated to be 68.75 mGy and 2.74 mSv, respectively. Staff was exposed to a heterogonous doses. The third examiner (trainee) was exposed to a high dose compared with other examiners because no shield was located to protect him from stray radiation. Patients and examiners doses were lower compared to the lowest values found in previous studies taking into consideration the heterogeneity of patients and equipment. Staff doses during ERCP are within the safety limit in the light of the current practice.
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Shin JM, Lee TH, Park SH, Kang SG, Lee YS, Park SJ, Ku MG, Lee SH, Chung IK, Choi HJ, Moon JH, Cha SW, Cho YD, Kim SJ. A Survey of the Radiation Exposure Protection of Health Care Providers during Endoscopic Retrograde Cholangiopancreatography in Korea. Gut Liver 2012; 7:100-5. [PMID: 23422932 PMCID: PMC3572309 DOI: 10.5009/gnl.2013.7.1.100] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2011] [Revised: 02/02/2012] [Accepted: 02/15/2012] [Indexed: 11/30/2022] Open
Abstract
Background/Aims During endoscopic retrograde cholangiopancreatography (ERCP), all efforts should be made to be aware of radiation hazards and to reduce radiation exposure. The aim of this study was to investigate the status of radiation protective equipment and the awareness of radiation exposure in health care providers performing ERCP in Korean hospitals. Methods A survey with a total of 42 questions was sent to each respondent via mail or e-mail between October 2010 and March 2011. The survey targeted nurses and radiation technicians who participated in ERCP in secondary or tertiary referral centers. Results A total of 78 providers from 38 hospitals responded to the surveys (response rate, 52%). The preparation and actual utilization rates of protective equipment were 55.3% and 61.9% for lead shields, 100% and 98.7% for lead aprons, 47.4% and 37.8% for lead glasses, 97.4% and 94.7% for thyroid shields, and 57.7% and 68.9% for radiation dosimeters, respectively. The common reason for not wearing protective equipment was that the equipment was bothersome, according to 45.7% of the respondents. Conclusions More protective equipment, such as lead shields and lead glasses, should be provided to health care providers involved in ERCP. In particular, the actual utilization rate for lead glasses was very low.
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Affiliation(s)
- Jae Min Shin
- Digestive Disease Center, Department of Internal Medicine, Soonchunhyang University College of Medicine, Cheonan, Korea
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Rehani MM, Ciraj-Bjelac O, Vañó E, Miller DL, Walsh S, Giordano BD, Persliden J. ICRP Publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department. Ann ICRP 2012; 40:1-102. [PMID: 22732420 DOI: 10.1016/j.icrp.2012.03.001] [Citation(s) in RCA: 183] [Impact Index Per Article: 14.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
An increasing number of medical specialists are using fluoroscopy outside imaging departments, but there has been general neglect of radiological protection coverage of fluoroscopy machines used outside imaging departments. Lack of radiological protection training of those working with fluoroscopy outside imaging departments can increase the radiation risk to workers and patients. Procedures such as endovascular aneurysm repair, renal angioplasty, iliac angioplasty, ureteric stent placement, therapeutic endoscopic retrograde cholangio-pancreatography,and bile duct stenting and drainage have the potential to impart skin doses exceeding Gy. Although tissue reactions among patients and workers from fluoroscopy procedures have, to date, only been reported in interventional radiology and cardiology,the level of fluoroscopy use outside imaging departments creates potential for such injuries.A brief account of the health effects of ionising radiation and protection principles is presented in Section 2. Section 3 deals with general aspects of the protection of workers and patients that are common to all, whereas specific aspects are covered in Section 4 for vascular surgery, urology, orthopaedic surgery, obstetrics and gynaecology,gastroenterology and hepatobiliary system, and anaesthetics and pain management.Although sentinel lymph node biopsy involves the use of radio-isotopic methods rather than fluoroscopy, performance of this procedure in operating theatres is covered in this report as it is unlikely that this topic will be addressed in another ICRP publication in coming years. Information on radiation dose levels to patients and workers, and dose management is presented for each speciality.
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Fluoro-less ureteral stent placement following uncomplicated ureteroscopic stone removal: a feasibility study. Urology 2012; 80:766-70. [PMID: 22950998 DOI: 10.1016/j.urology.2012.06.041] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2012] [Revised: 06/03/2012] [Accepted: 06/23/2012] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To test the feasibility of ureteral stent placement without image guidance after uncomplicated ureteral stone removal and to compare the outcomes of fluoro-less and conventional ureteral stent placement. METHODS A technique was devised to allow placement of a ureteral stent without image guidance by substituting fluoroscopy with visual and tactile cues. A retrospective review of 25 patients using fluoro-less stent placement was compared with 25 consecutive patients who underwent conventional stent placement with fluoroscopy. Stent placement was graded on a 6-point scale to assess coil symmetry and location. Comparisons between the fluoro-less stent placements and controls were performed with the Mann-Whitney U test. All hypotheses were 2-sided and conducted at an alpha level of 0.05. RESULTS All 25 ureteral stent placements were performed successfully without the use of fluoroscopy for image guidance. There was no significant difference in age, gender, body mass index, stone size, or complication rates when fluoro-less and conventional stent placements were compared. In addition, grade 1 placement was achieved in 76% of the fluoro-less group and in 64% of the conventional group. Although placement accuracy was higher in the fluoro-less group this was not statistically significant (P = .13). CONCLUSION Ureteral stent placement without fluoroscopic guidance is feasible. It maintains comparable efficacy and complication rates with conventional ureteral stent placement. This technique allows reduced radiation exposure in patients requiring ureteral stent placement.
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Feng Y, Zhu H, Chen X, Xu S, Cheng W, Ni J, Shi R. Comparison of endoscopic papillary large balloon dilation and endoscopic sphincterotomy for retrieval of choledocholithiasis: a meta-analysis of randomized controlled trials. J Gastroenterol 2012; 47:655-663. [PMID: 22361862 DOI: 10.1007/s00535-012-0528-9] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2011] [Accepted: 12/19/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Endoscopic sphincterotomy (EST) is the most frequently used technique for removal of stones from the bile duct. In recent years, endoscopic papillary large balloon dilation (EPLBD) has been shown to be a safe and effective technique for the removal of large or difficult common bile duct stones. However, comparison of EPLBD and EST for effectiveness in bile duct stone removal has given inconsistent results. The present meta-analysis was carried out to compare the effect of EPLBD and EST in retrieval of choledocholithiasis. METHODS A literature search was performed using Medline, PubMed, EMBase and the Cochrane Central Register of Controlled Trials (CENTRAL) for relevant articles published in English. A meta-analysis was performed on the retrieved studies. RESULTS Seven randomized controlled trials and 790 patients were involved. EPLBD compared with EST resulted in similar outcomes for overall successful clearance rates of bile duct stones (97.35 vs. 96.35%, OR 1.28, 95% CI 0.58-2.82, P = 0.54), stone clearance in the first ERCP session (87.87 vs. 84.15%, OR 1.31, 95% CI 0.81-2.11, P = 0.21) and removal of large sized stones (OR 1.08, 95% CI 0.21-5.64, P = 0.49). EPLBD performed with either a short or a long ballooning time did not increase the bile duct stone clearance rate. EPLBD decreased overall usage of mechanical lithotripsy in the bile duct stone removal process (OR 0.51, 95% CI 0.30-0.86, P = 0.01). However, no significant difference was found between EPLBD and EST in the use of mechanical lithotripsy for the removal of large sized stones (OR 0.67, 95% CI 0.34-1.28, P = 0.22). Compared with EST, EPLBD did not show a short ERCP duration (WMD -0.75, 95% CI -1.57 to 0.08, P = 0.08). EPLBD was associated with fewer overall complications than EST (5.8 vs. 13.1%, OR 0.41, 95% CI 0.24-0.68, P = 0.0007). Hemorrhage occurred less frequently with EPLBD than with EST (OR 0.15, 95% CI 0.04-0.50, P = 0.002). There was no significant difference in post-ERCP pancreatitis, perforation and cholangitis. CONCLUSIONS EPLBD is an effective and safe method for the removal of large or difficult common bile stones. EPLBD should be considered as an alternative to EST for patients in whom EST could not be routinely performed. Based on EPLBD causing fewer cases of hemorrhaging, EPLBD is also recommended for removal of large or difficult common bile duct stones in patients with an underlying coagulopathy or need for anticoagulation following ERCP. The long-term prognosis of EPLBD need to be further investigated.
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Affiliation(s)
- Yadong Feng
- Department of Gastroenterology, First Affiliated Hospital of Nanjing Medical University, 300 Guangzhou Road, Nanjing, 210029, China
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Oztas E, Parlak E, Kucukay F, Arhan M, Daglı U, Etik DO, Onder FO, Olcer T, Sasmaz N. The impact of endoscopic retrograde cholangiopancreatography education on radiation exposure to experienced endoscopist: 'trainee effect'. Dig Dis Sci 2012; 57:1134-43. [PMID: 22297651 DOI: 10.1007/s10620-012-2028-4] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2011] [Accepted: 01/04/2012] [Indexed: 12/09/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography(ERCP), as with other fluoroscopic procedures, carries the risk of exposure of staff to radiation. However, over the last two decades, only a few studies have investigated this risk. OBJECTIVE The aim of this work was to evaluate the dose of radiation exposure to staff participating in ERCP procedures in a busy teaching hospital that performs more than 1,850 procedures annually. METHODS The entire ERCP staff consisted of the experienced endoscopist, the assistant, and two nurses who were responsible for monitoring patients as well as keeping their heads in position during the procedure. RAD DOSE NEB.226 dosimeters, which were provided by the Turkish Atomic Energy Authority, were used for this study. RESULTS Data on 110 consecutive therapeutic ERCP procedures was recorded. The mean fluoroscopy time was 5.65 ± 4.71 min. The mean fluoroscopy time of the 61 procedures performed by an experienced endoscopist alone was 5.41 ± 4.65 min, whereas the mean fluoroscopy time for the 49 procedures during which an assistant was involved was 5.94 ± 4.81 min (p = 0.56). In terms of median dose of ionizing radiation exposure to the eyes, the dose measurement per procedure in which the primary endoscopist participated alone was 72 microsievert (μSv), compared to 92 μSv when an assistant took part in theproceedings. Considering that the recommended annual equivalent dose limit to the lens of the eye is 150 mSv, by performing 1,850 procedures annually, the primary endoscopist exceeds this limit. CONCLUSIONS Based on our results, taking into consideration the heavy workload in our hospital, it would seem that more experienced endoscopists are required to help provide training in ERCP, and that the use of lead acrylic goggles is required to decrease radiation exposure to the eyes.
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Affiliation(s)
- Erkin Oztas
- Department of Gastroenterology, Turkiye Yuksek Ihtisas Education and Research Hospital, Ankara, Turkey.
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Romagnuolo J. Quality measurement and improvement in advanced procedures. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2012. [DOI: 10.1016/j.tgie.2011.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Kim E, McLoughlin M, Lam EC, Amar J, Byrne M, Telford J, Enns R. Retrospective analysis of radiation exposure during endoscopic retrograde cholagiopancreatography: critical determinants. CANADIAN JOURNAL OF GASTROENTEROLOGY = JOURNAL CANADIEN DE GASTROENTEROLOGIE 2011; 25:555-9. [PMID: 22059160 PMCID: PMC3206549 DOI: 10.1155/2011/425297] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) has a logarithmic relationship with radiation exposure, and carries a known risk of radiation exposure to patients and staff. Factors associated with prolonged fluoroscopy duration have not been well delineated. OBJECTIVES To determine the specific patient, physician and procedural factors that affect fluoroscopy duration. METHODS A retrospective analysis of 1071 ERCPs performed at two tertiary care referral hospitals over an 18-month period was conducted. Patient, physician and procedural variables were recorded at the time of the procedure. RESULTS The mean duration of 969 fluoroscopy procedures was 4.66 min (95% CI 4.38 to 4.93). Multivariable analysis showed that the specific patient factors associated with prolonged fluoroscopy duration included age and diagnosis (both P<0.0001). The endoscopist was found to play an important role in the duration of fluoroscopy (ie, all endoscopists studied had a mean fluoroscopy duration significantly different from the reference endoscopist). In addition, the following procedural variables were found to be significant: number of procedures, basket use, biopsies, papillotomy (all P<0.0001) and use of a tritome (P=0.004). Mean fluoroscopy duration (in minutes) with 95% CIs for different diagnoses were as follows: common bile duct stones (n=443) 5.12 (3.05 to 4.07); benign biliary strictures (n=135) 3.94 (3.26 to 4.63); malignant biliary strictures (n=124) 5.82 (4.80 to 6.85); chronic pancreatitis (n=49) 4.53 (3.44 to 5.63); bile leak (n=26) 3.67 (2.23 to 5.09); and ampullary mass (n=11) 3.88 (1.28 to 6.48). When no pathology was found (n=195), the mean fluoroscopy time was 3.56 min (95% CI 3.05 to 4.07). Comparison using t tests determined that the only two diagnoses for which fluoroscopy duration was significantly different from the reference diagnosis of 'no pathology found' were common bile duct stones (P<0.0001) and malignant strictures (P<0.0001). CONCLUSIONS Factors that significantly affected fluoroscopy duration included age, diagnosis, endoscopist, and the number and nature of procedures performed. Elderly patients with biliary stones or a malignant stricture were likely to require the longest duration of fluoroscopy. These identified variables may help endoscopists predict which procedures are associated with prolonged fluoroscopy duration so that appropriate precautions can be undertaken.
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Affiliation(s)
- Edward Kim
- St Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada
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Boix J, Lorenzo-Zúñiga V. Radiation dose to patients during endoscopic retrograde cholangiopancreatography. World J Gastrointest Endosc 2011; 3:140-4. [PMID: 21860683 PMCID: PMC3159502 DOI: 10.4253/wjge.v3.i7.140] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Revised: 06/23/2011] [Accepted: 07/31/2011] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is an important tool for the diagnosis and treatment of the hepatobiliary system. The use of fluoroscopy to aid ERCP places both the patient and the endoscopy staff at risk of radiation-induced injury. Radiation dose to patients during ERCP depends on many factors, and the endoscopist cannot control some variables, such as patient size, procedure type, or fluoroscopic equipment used. Previous reports have demonstrated a linear relationship between radiation dose and fluoroscopy duration. When fluoroscopy is used to assist ERCP, the shortest fluoroscopy time possible is recommended. Pulsed fluoroscopy and monitoring the length of fluoroscopy have been suggested for an overall reduction in both radiation exposure and fluoroscopy times. Fluoroscopy time is shorter when ERCP is performed by an endoscopist who has many years experience of performing ERCP and carried out a large number of ERCPs in the preceding year. In general, radiation exposure is greater during therapeutic ERCP than during diagnostic ERCP. Factors associated with prolonged fluoroscopy have been delineated recently, but these have not been validated.
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Affiliation(s)
- Jaume Boix
- Jaume Boix, Vicente Lorenzo-Zúñiga, Endoscopy Unit, Department of Gastroenterology, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona 08916, Spain
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Sulieman A, Paroutoglou G, Kapsoritakis A, Kapatenakis A, Potamianos S, Vlychou M, Theodorou K. Reduction of radiation doses to patients and staff during endoscopic retrograde cholangiopancreatography. Saudi J Gastroenterol 2011; 17:23-9. [PMID: 21196649 PMCID: PMC3099076 DOI: 10.4103/1319-3767.74456] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND/AIM Endoscopic retrograde cholangiopancreatography (ERCP) is associated with a considerable radiation exposure for patients and staff. While optimization of the radiation dose is recommended, few studies have been published. The purpose of this study has been to measure patient and staff radiation dose, to estimate the effective dose and radiation risk using digital fluoroscopic images. Entrance skin dose (ESD), organ and effective doses were estimated for patients and staff. MATERIALS AND METHODS Fifty-seven patients were studied using digital X-ray machine and thermoluminescent dosimeters (TLD) to measure ESD at different body sites. Organ and surface dose to specific radiosensitive organs was carried out. The mean, median, minimum, third quartile and the maximum values are presented due to the asymmetry in data distribution. RESULTS The mean ESD, exit and thyroid surface dose were estimated to be 75.6 mGy, 3.22 mGy and 0.80 mGy, respectively. The mean effective dose for both gastroenterologist and assistant is 0.01 mSv. The mean patient effective dose was 4.16 mSv, and the cancer risk per procedure was estimated to be 2 × 10(-5). CONCLUSION ERCP with fluoroscopic technique demonstrate improved dose reduction, compared to the conventional radiographic based technique, reducing the surface dose by a factor of 2, without compromising the diagnostic findings. The radiation absorbed doses to the different organs and effective doses are relatively low.
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Affiliation(s)
- Abdelmoneim Sulieman
- Department of Medical Physics, University of Thessaly, University Hospital of Larissa, P.O.Box 1425, Larissa 41110, Greece.
| | - Georgios Paroutoglou
- Public Gastroenterology Department, University of Thessaly, University Hospital of Larissa, P.O.Box 1425, Larissa 41110, Greece
| | - Andreas Kapsoritakis
- University Gastroenterology Department, University of Thessaly, University Hospital of Larissa, P.O.Box 1425, Larissa 41110, Greece
| | - Anargeyros Kapatenakis
- Public Gastroenterology Department, University of Thessaly, University Hospital of Larissa, P.O.Box 1425, Larissa 41110, Greece
| | - Spiros Potamianos
- University Gastroenterology Department, University of Thessaly, University Hospital of Larissa, P.O.Box 1425, Larissa 41110, Greece
| | - Marianna Vlychou
- Radiology Department, University of Thessaly, University Hospital of Larissa, P.O.Box 1425, Larissa 41110, Greece
| | - Kiki Theodorou
- Department of Medical Physics, University of Thessaly, University Hospital of Larissa, P.O.Box 1425, Larissa 41110, Greece
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Kim YJ, Cho KB, Kim ES, Park KS, Jang BK, Chung WJ, Hwang JS. Efficacy of a Self-designed Protective Lead Shield in Reduction of Radiation Exposure Dose During Endoscopic Retrograde Cholangiopancreatography. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2011; 57:28-33. [DOI: 10.4166/kjg.2011.57.1.28] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Yun Jung Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Kwang Bum Cho
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Eun Soo Kim
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Kyung Sik Park
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Byoung Kuk Jang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Woo Jin Chung
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Jae Seok Hwang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
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Pedrosa MC, Farraye FA, Shergill AK, Banerjee S, Desilets D, Diehl DL, Kaul V, Kwon RS, Mamula P, Rodriguez SA, Varadarajulu S, Song LMWK, Tierney WM. Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc 2010; 72:227-35. [PMID: 20537638 DOI: 10.1016/j.gie.2010.01.071] [Citation(s) in RCA: 83] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 01/29/2010] [Indexed: 02/08/2023]
Abstract
The ASGE Technology Committee provides reviews of existing, new, or emerging endoscopic technologies that have an impact on the practice of GI endoscopy. Evidence-based methodology is used, by using a MEDLINE literature search to identify pertinent clinical studies on the topic and a MAUDE (U.S. Food and Drug Administration Center for Devices and Radiological Health) database search to identify the reported complications of a given technology. Both are supplemented by accessing the "related articles" feature of PubMed and by scrutinizing pertinent references cited by the identified studies. Controlled clinical trials are emphasized, but in many cases, data from randomized, controlled trials are lacking. In such cases, large case series, preliminary clinical studies, and expert opinions are used. Technical data are gathered from traditional and Web-based publications, proprietary publications, and informal communications with pertinent vendors. Technology Status Evaluation Reports are drafted by 1 or 2 members of the ASGE Technology Committee, reviewed and edited by the committee as a whole, and approved by the Governing Board of the ASGE. When financial guidance is indicated, the most recent coding data and list prices at the time of publication are provided. For this review, the MEDLINE database was searched through August 2009 for articles related to personal protection equipment by using the key words "personal protection equipment" (exp Protective Clothing/ or exp Protective Devices/ or exp Masks/ or exp Occupational Exposure/'') "infection control" paired with "Endoscopy." For the radiation section, the following key words were used: "radiation and endoscopy," "radiation and ERCP," and "radiation safety." For the ergonomics section, the following key words were used: "ergonomics of endoscopy," "endoscopist injury," "medical ergonomics," "endoscopy and musculoskeletal strain," "musculoskeletal injury and endoscopists," "occupational diseases and endoscopy," "cumulative trauma disorder and endoscopy," "repetitive strain injury and endoscopy." Technology Status Evaluation Reports are scientific reviews provided solely for educational and informational purposes. Technology Status Evaluation Reports are not rules and should not be construed as establishing a legal standard of care or as encouraging, advocating, requiring, or discouraging any particular treatment or payment for such treatment.
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Radiation doses to ERCP patients are significantly lower with experienced endoscopists. Gastrointest Endosc 2010; 72:58-65. [PMID: 20421102 PMCID: PMC2906113 DOI: 10.1016/j.gie.2009.12.060] [Citation(s) in RCA: 68] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2009] [Accepted: 12/29/2009] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients undergoing ERCP receive nontrivial doses of radiation, which may increase their risk of developing cancer, especially young patients. Radiation doses to patients during ERCP correlate closely with fluoroscopy time. OBJECTIVE The aim of this study was to determine whether endoscopist experience is associated with fluoroscopy time. DESIGN Retrospective analysis of a prospectively collected database. SETTING Data from 69 providers from 6 countries. PATIENTS 9,052 entries of patients undergoing ERCP. MAIN OUTCOME MEASUREMENTS Percent difference in fluoroscopy time associated with endoscopist experience and fellow involvement. RESULTS For procedure types that require less fluoroscopy time, compared with endoscopists who performed > 200 ERCPs in the preceding year, endoscopists who performed <100 and 100 to 200 ERCPs had 104% (95% confidence interval [CI], 85%-124%) and 27% (95% CI, 20%-35%) increases in fluoroscopy time, respectively. Every 10 years of experience was associated with a 21% decrease in fluoroscopy time (95% CI, 19%-24%). For fluoroscopy-intense procedures, compared with endoscopists who performed >200 ERCPs in the preceding year, endoscopists who performed <100 and 100 to 200 ERCPs had 59% (95% CI, 39%-82%) and 11% (95% CI, 3%-20%) increases in fluoroscopy time, respectively. Every 10 years of experience was associated with a 20% decrease in fluoroscopy time (95% CI, 18%-24%). LIMITATIONS Database used is a voluntary reporting system, which may not be generalizable. Data is self-reported and was not verified for accuracy. CONCLUSIONS Fluoroscopy time is shorter when ERCP is performed by endoscopists with more years of performing ERCP and a greater number of ERCPs in the preceding year. These findings may have important ramifications for radiation-induced cancer risk.
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Prospective analysis of fluoroscopy duration during ERCP: critical determinants. Gastrointest Endosc 2010; 72:50-7. [PMID: 20620272 DOI: 10.1016/j.gie.2010.04.012] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Accepted: 04/08/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Fluoroscopy during ERCP has a linear relationship with radiation, carrying risk of exposure. OBJECTIVE To determine patient, physician, and procedural factors affecting fluoroscopy duration. DESIGN Prospective analysis of ERCPs with evaluation of patient, physician, and procedural variables. SETTING Two tertiary-care hospitals. PATIENTS Consecutive patients undergoing ERCP. INTERVENTIONS ERCP. MAIN OUTCOME MEASUREMENTS Variables associated with prolonged fluoroscopy duration. RESULTS Mean fluoroscopy time (388 ERCPs) was 6.77 minutes (95% CI, 6.15-7.39). No patient factors were found to significantly affect fluoroscopy duration. Fluoroscopy duration was significantly lower for 2 endoscopists compared with the reference endoscopist (average of 4.16 minutes less; 95% CI, -5.48 to -2.48). Multivariable analysis identified variables associated with longer fluoroscopy duration; stent insertion (+3.11 minutes; 95% CI, 1.91-4.30), lithotripsy (+5.74 minutes; 95% CI, 0.931-10.5), needle-knife sphincterotomy (+4.44 minutes; 95% CI, 2.20-6.67), biopsies (+2.11 minutes; 95% CI, 0.025-4.18), use of a guidewire (+1.55 minutes; 95% CI, 0.025-3.07), additional guidewires (+5.61 minutes; 95% CI, 2.69-8.51), and balloon catheter (+4.27 minutes; 95% CI, 3.00-5.53). Mean fluoroscopy duration when a gastroenterology fellow was involved (n = 318) was 7.05 minutes (95% CI, 6.35-7.76) compared with 5.44 minutes (95% CI, 4.26-6.63) when no fellow present (n = 70) (P < .0451). LIMITATIONS Only 2 centers; others may have different results. Not blinded; investigators may change their practice because fluoroscopy was duration studied. Irrelevance of measuring fluoroscopy duration because endoscopists using protection may not have increased radiation exposure. CONCLUSIONS In this prospective analysis, factors associated with fluoroscopy duration included endoscopists; stent insertion; lithotripsy; biopsies; use of a needle-knife, guidewire, and balloon catheter; and involvement of a gastroenterology fellow. These identified variables may help endoscopists predict which procedures are associated with prolonged fluoroscopy duration and may lead to appropriate precautions.
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Samara ET, Stratakis J, Enele Melono JM, Mouzas IA, Perisinakis K, Damilakis J. Therapeutic ERCP and pregnancy: is the radiation risk for the conceptus trivial? Gastrointest Endosc 2009; 69:824-31. [PMID: 19243762 DOI: 10.1016/j.gie.2008.05.068] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2008] [Accepted: 05/28/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Symptomatic choledocholithiasis can be treated during pregnancy. Conceptus doses ranged from 0.1 mGy to 3 mGy in previous studies. OBJECTIVE The objectives of the current study were to investigate whether the conceptus dose may exceed the threshold of 10 mGy in the case of a pregnant patient undergoing ERCP, and to provide data for the accurate assessment of a conceptus dose. DESIGN Monte Carlo methodology and mathematical anthropomorphic phantoms were used to determine normalized conceptus dose data. Phantoms simulated pregnant patients of different body sizes and gestational stages. Monte Carlo simulations were performed to estimate the efficiency of external shielding. SETTING University hospital. PATIENTS Twenty-four consecutive patients. INTERVENTIONS All patients underwent therapeutic ERCP. Exposure parameters and dose-area product were recorded during the procedures. MAIN OUTCOME MEASUREMENTS The total dose-area product recorded during ERCP procedures ranged between 62 x 10(3) and 491 x 10(3) mGy . cm(2). RESULTS Monte Carlo normalized conceptus dose data are presented as a function of kV(p), total filtration, gestational stage, and body mass index. The conceptus dose may exceed 10 mGy when the total dose-area product surpasses 130 mGy . cm(2). LIMITATIONS Variations of conceptus location and size from the average. CONCLUSIONS Conceptus dose from ERCP may occasionally exceed 10 mGy, the dose above which the analytical dose calculation is recommended. The use of external shielding is unnecessary because the associated dose reduction is negligible. The normalized dose data may be used for the accurate estimation of conceptus dose from an ERCP procedure performed on a pregnant patient, regardless of body size, gestational stage, operating parameters, and equipment used.
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Affiliation(s)
- Eleni T Samara
- Departments of Medical Physics, Faculty of Medicine, University of Crete, Iraklion, Crete, Greece
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Endoscopic sphincterotomy combined with large balloon dilation can reduce the procedure time and fluoroscopy time for removal of large bile duct stones. Am J Gastroenterol 2009; 104:560-5. [PMID: 19174779 DOI: 10.1038/ajg.2008.67] [Citation(s) in RCA: 112] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVES We sought to evaluate the safety, efficacy, and feasibility of endoscopic sphincterotomy plus large balloon dilation (ESLBD) and to compare procedural time and fluoroscopy time of ESLBD with those of endoscopic sphincterotomy (EST) alone for patients with large bile duct stones. METHODS Retrospective analysis. RESULTS A total of 101 patients with large bile duct stones were treated: 53 were treated by ESLBD and 48 with EST alone. ESLBD resulted in similar outcomes in overall successful stone removal (100% vs. 97%) and complications (4% vs. 6%); however, although the rate of complete stone removal in the first session using ESLBD tended to be higher than when EST alone was used, it was not statistically significant (96% vs. 85%, P=0.057). Mechanical lithotripsy was required significantly more often in the EST group compared to the ESLBD group (25% vs. 6%, P<0.01). Total procedure time in the ESLBD group was significantly shorter than that of the EST group (32 vs. 40 min, P<0.05). Total fluoroscopy time in the ESLBD group was significantly shorter in the EST group (13 vs. 22 min, P<0.05). CONCLUSIONS ESLBD is an effective and safe treatment in patients with large bile duct stones. In addition, ESLBD appears to decrease procedure time and fluoroscopy time and reduce the need for mechanical lithotripsy as compared to EST alone.
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