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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: 0.5] [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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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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Barakat MT, Gugig R, Imperial J, Berquist WE. Fluoroscopy Time During Endoscopic Retrograde Cholangiopancreatography Performed for Children and Adolescents is Significantly Higher With Low-volume Endoscopists. J Pediatr Gastroenterol Nutr 2021; 72:244-249. [PMID: 32833892 DOI: 10.1097/mpg.0000000000002914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) is a fluoroscopy and endoscopy-based procedure important for diagnosis and management of pediatric pancreaticobiliary disorders. Patient, procedure, endoscopist, and facility characteristics have been shown to influence ERCP complexity and procedure outcomes as well as fluoroscopy utilization in adults; however, the extent to which this is true in pediatric patients remains under-studied and there are minimal data regarding fluoroscopy utilization in pediatric ERCP. METHODS We retrospectively analyzed ERCPs performed on patients <18 years of age at our tertiary care children's hospital from 2002 to 2017 using our institution's paper and electronic medical record system along with a prospectively maintained radiation exposure database. Procedure complexity was graded using the Stanford Fluoroscopy Complexity Score and the American Society of Gastrointestinal Endoscopy Complexity scale. High-volume endoscopists (HVE) were defined as having a cumulative annual ERCP volume >100 and low-volume endoscopists (LVE) as <100 (pediatric + adult) ERCPs/year. RESULTS Three hundred eighty-five ERCPs performed on 321 patients were included in this analysis. The mean patient age was 13.4 years (+/- 4.2 years), 77% were index ERCPs (native ampullas), and 81% were performed with therapeutic intent (87% for biliary indication and 13% for pancreatic indication). Fluoroscopy times (FTs) varied between procedures and providers. Median FT was 4.85 (+/- 2.68) minutes. Endoscopist annual ERCP volume was the strongest predictor of FT (P < 0.001). In addition to endoscopist volume, procedure-specific predictors of increased FT included pancreatic indication for the procedure, biliary or pancreatic duct stricture, patient age <4 years or >16 years at the time of ERCP (P < 0.01 for each), and native ampulla. ERCP complexity rating based on the Stanford Fluoroscopy Complexity Score correlated with FT. CONCLUSIONS Radiation exposure is higher than desirable for pediatric ERCP and varies with endoscopist as well as patient and procedure-specific factors. HVE perform ERCP with lower FT relative to LVE even though HVE procedure complexity was higher. The Stanford Fluoroscopy Score predicted FT for pediatric ERCP, but the ASGE ERCP complexity scale did not. Adaptation and refinement of pediatric-specific ERCP complexity scales including factors, such as patient size and age and indications/interventions more consistent with those encountered in pediatrics could be beneficial.
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Affiliation(s)
- Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
| | - Roberto Gugig
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
| | - Joanne Imperial
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
| | - William E Berquist
- Division of Pediatric Gastroenterology, Hepatology & Nutrition, Lucille Packard Children's Hospital at Stanford, Stanford, CA
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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: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Oh CH, Dong SH, Kim JW, Kim GA, Lee JM. Radiation exposure during endoscopic retrograde cholangiopancreatography according to clinical determinants. Medicine (Baltimore) 2020; 99:e19498. [PMID: 32221072 PMCID: PMC7220418 DOI: 10.1097/md.0000000000019498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
This study aimed to analyze the dose of radiation to which the physician is exposed during endoscopic retrograde cholangiopancreatography (ERCP) and to identify predictive factors of radiation exposure during the procedure. Furthermore, we evaluated the patient characteristics and procedural factors associated with prolonged fluoroscopy time (FT).A cross-sectional retrospective analysis of 780 ERCPs performed at a tertiary academic hospital over a 2-year period was conducted. The primary outcome was radiation exposure during ERCP as determined by FT; additionally, the association between variables and radiation exposure was determined. Moreover, we evaluated their correlations with age, sex, body mass index (BMI), diagnosis, duration of procedure, procedure name, and procedure complexity.According to the analysis of the 780 ERCPs performed in 2 years, the mean FT was 5.07 minutes (95% confidence interval [CI], 4.87-5.26). The mean radiation durations were as follows: cholelithiasis, 5.76 minutes (95% CI, 4.75-6.80); malignant biliary obstruction, 6.13 minutes (95% CI, 5.91-6.35); pancreatic disease, 5.28 minutes (95% CI, 4.45-6.28); and benign biliary stricture, 5.32 minutes (95% CI, 5.02-5.94). Significant differences affecting fluoroscopy duration between the 2 endoscopists were not observed in the present study. Multivariate analysis revealed that prolonged fluoroscopy duration was related to specific characteristics, including higher BMI (BMI >27.5 kg/m) (+4.1 minutes; 95% CI, 2.56-5.63), mechanical lithotripsy (+4.85 minutes; 95% CI, 0.45-9.25), needle-knife use (+4.5 minutes; 95% CI, 2.15-6.86), and malignant biliary obstruction (+2.34 minutes; 95% CI, 0.15-4.53).ERCPs are associated with significantly higher radiation exposure of patients on the specific procedure. Endoscopists should be aware of the determining factors, including patients with obesity, who underwent mechanical lithotripsy, who had malignant biliary obstruction, and who underwent a procedure using a needle knife, that affect FT during ERCP.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine
| | - Seok Ho Dong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine
| | - Jung-Wook Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine
| | - Gi-Ae Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine
| | - Jae Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
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Seijas R, Català J, Cepas MÁ, Sallent A, Ares O, Barastegui D. Radiation Exposure from Fluoroscopy during Hip Arthroscopy. Surg J (N Y) 2019; 5:e184-e187. [PMID: 31763460 PMCID: PMC6872459 DOI: 10.1055/s-0039-3400278] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Accepted: 09/27/2019] [Indexed: 01/21/2023] Open
Abstract
Objective Hip arthroscopy for femoroacetabular impingement treatment is a procedure that is not exempted from complications. The most common complications are related to the arthroscopic portals and the traction system. The use of fluoroscopy helps in hip arthroscopy; however, the radiation exposure is a risk that has not yet been studied. Materials and Methods A retrospective study with 100 arthroscopies was performed. Surgical indication in all cases was femoroacetabular impingement. Surgical times and radiation exposure during the procedure had been recorded and reviewed for the present study. Results A mean of 138.20 cGy cm 2 radiation exposures was observed per patient and procedure for a mean time of radiation exposure of 0.36 minutes. These values are much lower than the values described as being at risk by the nuclear security commissions. Conclusions Radiation exposure in a hip arthroscopy due to femoroacetabular impingement is in margins well below the limits at risk for the patient.
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Affiliation(s)
- Roberto Seijas
- Department of Orthopedic Surgery, Instituto Cugat, Hospital Quirón, Barcelona, Spain
- Garcia-Cugat Foundation, Barcelona, Spain
- Department of Anatomy, Universidad Internacional de Catalunya, Barcelona, Spain
| | - Jordi Català
- Department of Radiology, Instituts Guirado, Barcelona, Spain
| | | | - Andrea Sallent
- Department of Orthopedic, Hospital Vall d'Hebron, Barcelona, Spain
| | - Oscar Ares
- Department of Orthopedic and Trauma, Hospital Clínic Barcelona, Spain
| | - David Barastegui
- Department of Orthopedic Surgery, Instituto Cugat, Hospital Quirón, Barcelona, Spain
- Garcia-Cugat Foundation, Barcelona, Spain
- Mutualitat Catalana de Futbolistes, Barcelona, Spain
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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: 0.4] [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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Hayashi S, Takenaka M, Hosono M, Nishida T. Radiation exposure during image-guided endoscopic procedures: The next quality indicator for endoscopic retrograde cholangiopancreatography. World J Clin Cases 2018; 6:1087-1093. [PMID: 30613666 PMCID: PMC6306631 DOI: 10.12998/wjcc.v6.i16.1087] [Citation(s) in RCA: 10] [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: 09/25/2018] [Revised: 10/23/2018] [Accepted: 10/31/2018] [Indexed: 02/05/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is one of the most frequently used image-guided procedures in gastrointestinal endoscopy. Post-ERCP pancreatitis is an important concern, and prophylaxis, cannulation and other related technical procedures have been well documented by endoscopists. In addition, medical radiation exposure is of great concern in the general population because of its rapidly increasing frequency and its potential carcinogenic effects. International organizations and radiological societies have established diagnostic reference levels, which guide proper radiation use and serve as global standards for all procedures that use ionizing radiation. However, data on gastrointestinal fluoroscopic procedures are still lacking because the demand for these procedures has recently increased. In this review, we present the current status of quality indicators for ERCP and the methods for measuring radiation exposure in the clinical setting as the next quality indicator for ERCP. To reduce radiation exposure, knowledge of its adverse effects and the procedures for proper measurement and protection are essential. Additionally, further studies on the factors that affect radiation exposure, exposure management and diagnostic reference levels are necessary. Then, we can discuss how to manage medical radiation use in these complex fluoroscopic procedures. This knowledge will help us to protect not only patients but also endoscopists and medical staff in the fluoroscopy unit.
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Affiliation(s)
- Shiro Hayashi
- Department of Gastroenterology and Internal Medicine, Hayashi Clinic, Osaka, Suita 564-0018, Japan
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Toyonaka 560-8565, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Sayama 589-8511, Japan
| | - Makoto Hosono
- Department of Radiology, Kindai University Faculty of Medicine, Osaka, Sayama 589-8511, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Toyonaka 560-8565, Japan
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9
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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: 1.2] [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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Choi MH, Jung SE, Yoon SB, Lee IS, Byun JY. Location of Disease on Imaging may Predict Radiation Exposure During Endoscopic Retrograde Cholangiopancreatography. RADIATION PROTECTION DOSIMETRY 2018; 177:280-284. [PMID: 28402484 DOI: 10.1093/rpd/ncx041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/06/2016] [Accepted: 03/17/2017] [Indexed: 12/21/2022]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is performed for various diseases. The aim of this study is to evaluate the difference of dose-area product (DAP) during the ERCP procedures according to location of the lesion. We performed a retrospective study of consecutive 217 therapeutic ERCP examinations performed between November 2014 and April 2015 at a tertiary care center. ERCP procedures divided into two groups according to location of the lesion identified on imaging: lesions in the common hepatic duct (CHD) or the common bile duct (CBD) and lesions in the hepatic hilum or the intrahepatic duct (IHD). The mean DAP of the hilum-IHD group (48.7 Gy cm2) was significantly higher than that of the CBD-CHD group (34.9 Gy cm2) (P = 0.003). Radiation exposure during ERCP was significantly different according to location of bile duct lesion.
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Affiliation(s)
- Moon Hyung Choi
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea.,Catholic Cancer Research Institute, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea
| | - Seung Eun Jung
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea.,Catholic Cancer Research Institute, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea
| | - Seung Bae Yoon
- Catholic Cancer Research Institute, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea.,Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - In Seok Lee
- Catholic Cancer Research Institute, College of Medicine, The Catholic University of Korea, 222 Banpo-daero, Seocho-gu, Seoul 06591, Korea.,Division of Gastroenterology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea
| | - Jae Young Byun
- Department of Radiology, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Korea
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Intraoperative Computed Tomography Navigational Assistance for Transforaminal Endoscopic Decompression of Heterotopic Foraminal Bone Formation After Oblique Lumbar Interbody Fusion. World Neurosurg 2018; 115:29-34. [PMID: 29626680 DOI: 10.1016/j.wneu.2018.03.188] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2018] [Revised: 03/26/2018] [Accepted: 03/27/2018] [Indexed: 11/21/2022]
Abstract
Transforaminal endoscopic spine surgery is an emerging technique in spine surgery, but it offers 2 distinct challenges to spine surgeons looking to adopt it: 1) targeting spine pathology and 2) understanding the endoscopic anatomy visualized through the endoscope. Intraoperative computed tomography (CT)-guided navigation is also an emerging technique in spine surgery that is becoming widely adopted for its benefits in assisting surgeons in localizing pathology and guided spine instrumentation placement. In this technical note, we describe a technique that uses intraoperative CT-guided navigation concomitantly with a transforaminal endoscopic approach to decompress a L4-L5 foraminal heterotopic bone formation after an oblique lumbar interbody fusion. The addition of intraoperative CT-guided navigation proved beneficial in targeting the pathology during the procedure and ensuring that the pathology was resolved by offering postoperative CT visualization of the decompressed neural foramen.
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12
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Tsapaki V, Paraskeva KD, Tsalafoutas IA, Paspatis G, Scotiniotis H, Georgopoulos P, Finou P, Karagianis JA. THE IMPACT OF X-RAY UNIT TYPE USED FOR ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY PROCEDURES ON PATIENT DOSES. RADIATION PROTECTION DOSIMETRY 2016; 171:503-508. [PMID: 26582174 DOI: 10.1093/rpd/ncv465] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2015] [Revised: 09/17/2015] [Accepted: 10/04/2015] [Indexed: 06/05/2023]
Abstract
To investigate whether the X-ray unit type used for interventional endoscopic retrograde cholangiopancreatography (ERCP) procedures may affect patient radiation doses. A total of 471 ERCP procedures performed in 4 hospitals with 4 types of X-ray units were studied. Kerma-area product (KAP), fluoroscopy time (T) and total number of radiographs acquired (F) were recorded. KAP, T and F values exhibited a great variation, ranging from 0.1 to 130.2 Gy cm2 (mean 16 Gy cm2), 0.13 to 33.7 min (mean 5.4 min) and 0 to 26 radiographs (mean 3.5), respectively. The respective mean values for the four types of X-ray units that were investigated were as follows: KAP: 17.4, 12.5, 5.6 and 36.3 Gy cm2, T: 4.7, 5.2, 3.8 and 11.5 min and F: 1.7, 7.4, 1.9 and 4.6 radiographs. The type of the X-ray unit seems to significantly affect patient radiation dose, with the C-arm delivering the lowest and the angiography unit the highest patient doses.
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Affiliation(s)
- V Tsapaki
- Medical Physics Department, General Hospital 'Konstantopoulio', 3-5 Agias Olgas Str., 14233 Nea Ionia, Athens, Greece
| | - K D Paraskeva
- Medical Physics Department, General Hospital 'Konstantopoulio', 3-5 Agias Olgas Str., 14233 Nea Ionia, Athens, Greece
| | - I A Tsalafoutas
- General Anticancer Oncology Hospital 'Agios Savvas', Athens, Greece
| | - G Paspatis
- General Hospital 'Venizelio', Heraklion, Crete, Greece
| | | | | | - P Finou
- Department of Statistics, Athens University of Economics and Business, Athens, Greece
| | - J A Karagianis
- Medical Physics Department, General Hospital 'Konstantopoulio', 3-5 Agias Olgas Str., 14233 Nea Ionia, Athens, Greece
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Iprenburg M, Wagner R, Godschalx A, Telfeian AE. Patient radiation exposure during transforaminal lumbar endoscopic spine surgery: a prospective study. Neurosurg Focus 2016; 40:E7. [PMID: 26828888 DOI: 10.3171/2015.11.focus15485] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The aim of this study was to describe patient radiation exposure during single-level transforaminal endoscopic lumbar discectomy procedures at levels L2-5 and L5-S1. METHODS Radiation exposure was monitored in 151 consecutive patients undergoing single-level transforaminal endoscopic lumbar discectomy procedures. Two groups were studied: patients undergoing procedures at the L4-5 level or above and those undergoing an L5-S1 procedure. RESULTS For the discectomy procedures at L4-5 and above, the average duration of fluoroscopy was 38.4 seconds and the mean calculated patient radiation exposure dose was 1.5 mSv. For the L5-S1 procedures, average fluoroscopy time was 54.6 seconds and the mean calculated radiation exposure dose was 2.1 mSv. The average patient radiation exposure dose among these cases represents a 3.5-fold decrease compared with the senior surgeon's first 100 cases. CONCLUSIONS Transforaminal lumbar endoscopic discectomy can be used as a minimally invasive technique for the treatment of lumbar radiculopathy in the setting of a herniated lumbar disc without the significant concern of exposing the patient to harmful doses of radiation. One caveat is that both the surgeon and the patient are likely to be exposed to higher doses of radiation during a surgeon's early experience in minimally invasive endoscopic spine surgery.
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Affiliation(s)
| | - Ralf Wagner
- Ligamenta Spine Centre, Frankfurt am Main, Germany; and
| | | | - Albert E Telfeian
- Department of Neurosurgery, Rhode Island Hospital, The Warren Alpert Medical School of Brown University, Providence, Rhode Island
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Preliminary diagnostic reference levels for endoscopic retrograde cholangio-pancreatography in Greece. Phys Med 2016; 32:607-11. [DOI: 10.1016/j.ejmp.2016.03.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2015] [Revised: 03/24/2016] [Accepted: 03/26/2016] [Indexed: 11/19/2022] Open
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Seo D, Kim KH, Kim JS, Han S, Park K, Kim J. Evaluation of radiation doses in patient and medical staff during endoscopic retrograde cholangiopancreatography procedures. RADIATION PROTECTION DOSIMETRY 2016; 168:516-522. [PMID: 26269518 DOI: 10.1093/rpd/ncv373] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/14/2015] [Accepted: 07/04/2015] [Indexed: 06/04/2023]
Abstract
The radiation exposure dose must be optimised because the hazard resulting from an interventional radiology procedure is long term depending on the patient. The aim of this study was to measure the radiation doses received by the patients and medical staff during endoscopic retrograde cholangiopancreatography (ERCP) procedures. Data were collected during 126 ERCP procedures, including the dose-area product (DAP), entrance dose (ED), effective dose (E), fluoroscopy time (T) and number of digital radiographs (F). The medical staff members each wore a personal thermoluminescence dosemeter to monitor exposure during ERCP procedures. The mean DAP, ED, E and T were 47.06 Gy cm(2), 196.06 mGy, 8.93 mSv, 7.65 min and 9.21 images, respectively. The mean dose to the staff was 0.175 mSv and that to the assistant was 0.069 mSv. The dose to the medical staff was minimal when appropriate protective measures were used. The large variation in the patient doses must be further investigated.
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Affiliation(s)
- Deoknam Seo
- Department of Diagnostic Radiology, Korea Institute of Radiological and Medical Sciences, Seoul 139-706, Republic of Korea Department of Bio-Convergence Engineering, Korea University Graduate School, Seoul 136-703, Republic of Korea
| | - Kie Hwan Kim
- Department of Diagnostic Radiology, Korea Institute of Radiological and Medical Sciences, Seoul 139-706, Republic of Korea
| | - Jung-Su Kim
- Department of Bio-Convergence Engineering, Korea University Graduate School, Seoul 136-703, Republic of Korea
| | - Seonggyu Han
- Department of Bio-Convergence Engineering, Korea University Graduate School, Seoul 136-703, Republic of Korea
| | - Kyung Park
- Department of Diagnostic Radiology, Korea Institute of Radiological and Medical Sciences, Seoul 139-706, Republic of Korea
| | - Jungmin Kim
- Department of Radiologic Science, College of Health Science, Korea University, Seoul 136-703, Republic of Korea
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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: 2.7] [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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Saukko E, Henner A, Ahonen SM. Radiation exposure to patients during endoscopic retrograde cholangiopancreatography: A multicentre study in Finland. Radiography (Lond) 2015. [DOI: 10.1016/j.radi.2014.08.001] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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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: 1.9] [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: 10/15/2014] [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 (R2) 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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Liao C, Thosani N, Kothari S, Friedland S, Chen A, Banerjee S. Radiation exposure to patients during ERCP is significantly higher with low-volume endoscopists. Gastrointest Endosc 2015; 81:391-8.e1. [PMID: 25293825 DOI: 10.1016/j.gie.2014.08.001] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2014] [Accepted: 08/01/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Patients are exposed to radiation during ERCP, and this may increase their lifetime risk of the development of cancer and other deleterious radiation effects. OBJECTIVE To evaluate the association between the endoscopist's ERCP volume and the patient radiation dose during ERCP. DESIGN Single-center, retrospective study. SETTING Tertiary referral center. PATIENTS AND INTERVENTIONS A total of 197 patients undergoing 331 ERCPs. MAIN OUTCOME MEASUREMENTS Patient radiation exposure parameters including fluoroscopy time, total radiation dose, dose area product, and effective dose for all ERCPs performed at our academic medical center by 2 high-volume endoscopists (HVEs) (≥200 ERCPs/year) and 7 low-volume endoscopists (LVEs). Radiation exposure for each ERCP was adjusted against a validated procedure complexity scale and the Stanford Fluoroscopy Complexity Score, which was created based on the numbers of interventions that would mandate additional radiation exposure. RESULTS ERCPs performed by LVEs were associated with a significantly higher median total radiation dose (98.30 mGy vs 74.13 mGy), dose area product (13.98 Gy-cm(2) vs 8.8 Gy-cm(2)), and effective dose (3.63 mSv vs 2.28 mSv), despite lower median Stanford Fluoroscopy Complexity Scores (3.0 vs 6.0) compared with HVEs. No significant difference was noted in median fluoroscopy time (4.0 minutes vs 3.30 minutes) between LVEs and HVEs. LIMITATIONS Retrospective, single-center study at a tertiary referral center. CONCLUSION ERCPs performed by LVEs are associated with significantly higher radiation exposure to patients compared with those performed by HVEs despite the fact that procedures performed by HVEs are of greater complexity.
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Affiliation(s)
- Charles Liao
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Nirav Thosani
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Shivangi Kothari
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Ann Chen
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, Stanford, California, USA
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Mori H, Koshida K, Ishigamori O, Matsubara K. A novel removable shield attached to C-arm units against scattered X-rays from a patient’s side. Eur Radiol 2014; 24:1794-9. [DOI: 10.1007/s00330-014-3186-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2014] [Revised: 03/29/2014] [Accepted: 04/09/2014] [Indexed: 11/29/2022]
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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: 1.8] [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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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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Budd H, Patchava A, Khanduja V. Establishing the radiation risk from fluoroscopic-assisted arthroscopic surgery of the hip. INTERNATIONAL ORTHOPAEDICS 2012; 36:1803-6. [PMID: 22588691 PMCID: PMC3427451 DOI: 10.1007/s00264-012-1557-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2012] [Accepted: 04/12/2012] [Indexed: 01/26/2023]
Abstract
PURPOSE The purpose of the study was to quantify patient exposure to ionising radiation during fluoroscopic-assisted arthroscopic surgery of the hip, establish a risk profile of this exposure, and reassure patients of radiation safety during the procedure. METHODS We retrospectively analysed the dose area products for 50 consecutive patients undergoing arthroscopic hip surgery by an experienced hip arthroscopic surgeon. The effective dose and organ dose were derived using a Monte Carlo program. RESULTS The mean total fluoroscopy time was 1.10 minutes and the mean dose area product value was 297.2 cGycm(2). We calculated the entrance skin dose to be 52 mGy to the area where the beam was targeted (81 cm(2)). The mean effective dose for intra-operative fluoroscopy was 0.33 mSv, with a SD of 0.90 Sv. CONCLUSION This study confirms that fluoroscopic-assisted arthroscopic surgery of the hip is safe with a low maximum radiation dose and supports its continued use in preference to alternative imaging modalities.
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Affiliation(s)
- Henry Budd
- Department of Trauma and Orthopaedics, Addenbrooke’s - Cambridge University Hospitals NHS Trust, Box 37, Hills Road, Cambridge, UK
| | - Anushka Patchava
- Department of Trauma and Orthopaedics, Addenbrooke’s - Cambridge University Hospitals NHS Trust, Box 37, Hills Road, Cambridge, UK
| | - Vikas Khanduja
- Department of Trauma and Orthopaedics, Addenbrooke’s - Cambridge University Hospitals NHS Trust, Box 37, Hills Road, Cambridge, UK
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Kim KP, Miller DL, Berrington de Gonzalez A, Balter S, Kleinerman RA, Ostroumova E, Simon SL, Linet MS. Occupational radiation doses to operators performing fluoroscopically-guided procedures. HEALTH PHYSICS 2012; 103:80-99. [PMID: 22647920 PMCID: PMC3951010 DOI: 10.1097/hp.0b013e31824dae76] [Citation(s) in RCA: 113] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
In the past 30 y, the numbers and types of fluoroscopically-guided (FG) procedures have increased dramatically. The objective of the present study is to provide estimated radiation doses to physician specialists, other than cardiologists, who perform FG procedures. The authors searched Medline to identify English-language journal articles reporting radiation exposures to these physicians. They then identified several primarily therapeutic FG procedures that met specific criteria: well-defined procedures for which there were at least five published reports of estimated radiation doses to the operator, procedures performed frequently in current medical practice, and inclusion of physicians from multiple medical specialties. These procedures were percutaneous nephrolithotomy (PCNL), vertebroplasty, orthopedic extremity nailing for treatment of fractures, biliary tract procedures, transjugular intrahepatic portosystemic shunt creation (TIPS), head/neck endovascular therapeutic procedures, and endoscopic retrograde cholangiopancreatography (ERCP). Radiation doses and other associated data were abstracted, and effective dose to operators was estimated. Operators received estimated doses per patient procedure equivalent to doses received by interventional cardiologists. The estimated effective dose per case ranged from 1.7-56 μSv for PCNL, 0.1-101 μSv for vertebroplasty, 2.5-88 μSv for orthopedic extremity nailing, 2.0-46 μSv for biliary tract procedures, 2.5-74 μSv for TIPS, 1.8-53 μSv for head/neck endovascular therapeutic procedures, and 0.2-49 μSv for ERCP. Overall, mean operator radiation dose per case measured over personal protective devices at different anatomic sites on the head and body ranged from 19-800 (median = 113) μSv at eye level, 6-1,180 (median = 75) μSv at the neck, and 2-1,600 (median = 302) μSv at the trunk. Operators' hands often received greater doses than the eyes, neck, or trunk. Large variations in operator doses suggest that optimizing procedure protocols and proper use of protective devices and shields might reduce occupational radiation dose substantially.
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Affiliation(s)
- Kwang Pyo Kim
- Department of Nuclear Engineering, Kyung Hee University, Gyeonggi-do, Republic of Korea.
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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: 11] [Impact Index Per Article: 0.9] [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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Tsapaki V, Paraskeva KD, Mathou N, Andrikopoulos E, Tentas P, Triantopoulou C, Karagiannis JA. Patient and endoscopist radiation doses during ERCP procedures. RADIATION PROTECTION DOSIMETRY 2011; 147:111-113. [PMID: 21743074 DOI: 10.1093/rpd/ncr285] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
The aim of the study was to calculate radiation doses for patients and staff during interventional Endoscopic retrograde cholangiopancreatography (ERCP) procedures. Patient age (A), kerma-area product (KAP), fluoroscopy time (T) and total number of films (F) were collected for 157 interventional ERCP procedures. One endoscopist (>10 y of experience) monitored using a thermoluminescent dosemeter worn over the lead apron performed the ERCPs. Median (range) KAP was 3.1 Gy cm(-2) (0.1-106.7 Gy cm(-2)). Median (range) A, T and F were 72 y, 2.6 (0.2-26.0) min and 2 (1-4) images, respectively. No correlation was observed between KAP and A, T or F. Monthly endoscopist dose was negligible due to the use of lead apron, collar and two lead-articulated ceiling mounted shields. The endoscopist dose is minimal when using appropriate protective measures. Patient doses showed large variation that has to be further investigated.
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Affiliation(s)
- V Tsapaki
- Department of Gastroenterology and Radiology, Konstantopoulio General Hospital, 3-5 Agias Olgas Atr, 14233 Nea Ionia, Athens, Greece.
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Lo I, Lau SH, Kwok KH, Kao SS, Cheung MT. Ionizing radiation absorption of surgeons and endoscopy nurses during endoscopic retrograde cholangiopancreatography. SURGICAL PRACTICE 2011. [DOI: 10.1111/j.1744-1633.2011.00546.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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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: 1.8] [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, Elzaki M, Khalil M. Occupational exposure to staff during endoscopic retrograde cholangiopancreatography in Sudan. RADIATION PROTECTION DOSIMETRY 2011; 144:530-533. [PMID: 21062799 DOI: 10.1093/rpd/ncq353] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/30/2023]
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) procedure is an invasive technique that requires fluoroscopic and radiographic exposure. The purpose of this study was to determine the occupational dose of ionising radiation at three gastroenterology departments (Fedial, Soba and Ibn seena hospitals) in Khartoum, Sudan. The radiation dose was measured during 55 therapeutic ERCP procedures. Thermoluminescence dosemeters were used. The mean radiation dose for the first operator was 0.27 mGy for the eye lens, 0.21 for the thyroid, 0.32 for the chest, 0.17 for the hand and 0.22 for the leg. The mean radiation dose for the second operator was 0.21 mGy for the hand and 0.20 mGy for the chest, while the mean radiation dose for the nurse was 0.44 mGy for the hand and 0.19 for the chest. The radiation dose received by the staff in these hospitals was found to be higher than most of the values in the literature. The radiation absorbed dose received by the different organs is relatively low. Additional studies need to be conducted for radiation dose optimisation.
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Affiliation(s)
- A Sulieman
- Sudan University of Science and Technology, Collage of Radiologic Science, PO Box 1908, Khartoum, Sudan.
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Gonzalez-Gonzalez JA, Martínez-Vazquez MA, Maldonado-Garza HJ, Garza-Galindo AA. Radiation doses to ERCP patients are significantly lower with experienced endoscopists. Gastrointest Endosc 2011; 73:415. [PMID: 21295662 DOI: 10.1016/j.gie.2010.06.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2010] [Accepted: 06/04/2010] [Indexed: 12/22/2022]
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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: 1.5] [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: 80] [Impact Index Per Article: 5.7] [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: 4.9] [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: 2.6] [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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Chitnavis JP, Karthikesalingam A, Karthikesaligam A, Macdonald A, Brown C. Radiation risk from fluoroscopically-assisted anterior cruciate ligament reconstruction. Ann R Coll Surg Engl 2010; 92:330-4. [PMID: 20501019 PMCID: PMC3025191 DOI: 10.1308/003588410x12628812459814] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/08/2009] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Precise tunnel positioning is crucial for success in anterior cruciate ligament (ACL) reconstruction. The use of intra-operative fluoroscopy has been shown to improve the accuracy of tunnel placement. Although radiation exposure is a concern, we lack information on the radiation risk to patients undergoing fluoroscopically-assisted ACL reconstruction with a standard C-arm. The aim of our study was to determine the mean radiation doses received by our patients. PATIENTS AND METHODS Radiation doses were recorded for 18 months between 1 April 2007 and 30 September 2008 for 58 consecutive patients undergoing ACL reconstruction assisted by intra-operative fluoroscopy. Dose area product (DAP) values were used to calculate the entrance skin dose (ESD), an indicator of potential skin damage and the effective dose (ED), an indicator of long-term cancer risk, for each patient. RESULTS The median age of 58 patients included in data analysis was 28 years (range, 14-52 years), of whom 44 were male (76%). The mean ESD during intra-operative fluoroscopy was 0.0015 +/- 0.0029 Gy. The mean ED was 0.001 +/- 0.002 mSv. No results exceeded the threshold of 2 Gy for skin damage, and the life-time risk of developing new cancer due to intra-operative fluoroscopy is less than 0.0001%. CONCLUSIONS Radiation doses administered during fluoroscopically-assisted ACL reconstruction were safe and do not represent a contra-indication to the procedure.
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Affiliation(s)
- J P Chitnavis
- Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, UK.
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Olgar T, Bor D, Berkmen G, Yazar T. Patient and staff doses for some complex x-ray examinations. JOURNAL OF RADIOLOGICAL PROTECTION : OFFICIAL JOURNAL OF THE SOCIETY FOR RADIOLOGICAL PROTECTION 2009; 29:393-407. [PMID: 19690354 DOI: 10.1088/0952-4746/29/3/004] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Abstract
The aim of this study was to measure patient and staff doses simultaneously for some complex x-ray examinations. Measurements of dose-area product (DAP) and entrance skin dose (ESD) were carried out in a sample of 107 adult patients who underwent different x-ray examinations such as double contrast barium enema (DCBE), single contrast barium enema (SCBE), barium swallow, endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous transhepatic cholangiography (PTC), and various orthopaedic surgical procedures. Dose measurements were made separately for each projection, and DAP, thermoluminescent dosimetry (TLD), film dosimetry and tube output measurement techniques were used. Staff doses were measured simultaneously with patient doses for these examinations, with the exception of barium procedures. The measured mean DAP values were found to be 8.33, 90.24, 79.96 Gy cm(2) for barium swallow, SCBE and DCBE procedures with the fluoroscopy times of 3.1, 4.43 and 5.86 min, respectively. The calculated mean DAP was 26.33 Gy cm(2) for diagnostic and 89.76 Gy cm(2) therapeutic ERCP examinations with the average fluoroscopy times of 1.9 and 5.06 min respectively. Similarly, the calculated mean DAP was 97.53 Gy cm(2) with a corresponding fluoroscopy time of 6.1 min for PTC studies. The calculated mean entrance skin dose (ESD) was 172 mGy for the orthopaedic surgical studies. Maximum skin doses were measured as 324, 891, 1218, 750, 819 and 1397 mGy for barium swallow, SCBE, DCBE, ERCP, PTC and orthopaedic surgical procedures, respectively. The high number of radiographs taken during barium enema examinations, and the high x-ray outputs of the fluoroscopic units used in ERCP, were the main reasons for high doses, and some corrective actions were immediately taken.
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Affiliation(s)
- T Olgar
- Faculty of Engineering, Department of Engineering Physics, Ankara University, Tandoğan, Ankara, Turkey.
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Karthikesalingam A, Markar SR, Weerakkody R, Walsh SR, Carroll N, Praseedom RK. Radiation exposure during laparoscopic cholecystectomy with routine intraoperative cholangiography. Surg Endosc 2009; 23:1845-8. [PMID: 19118424 DOI: 10.1007/s00464-008-0279-0] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2008] [Accepted: 11/02/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND For many years, intraoperative cholangiography during cholecystectomy to aid definition of the biliary anatomy and to detect choledocholithiasis has been advocated. Although radiation exposure in fluoroscopic procedures is a concern, few available data exist regarding the radiation exposure incurred during intraoperative cholangiography. This study aimed to determine the average radiation exposure sustained during this procedure. METHODS Radiation dose data were recorded between 5 September 2007 and 21 July 2008 for 108 consecutive patients undergoing laparoscopic cholecystectomy with intraoperative cholangiography. Dose area product values were used to calculate the entrance skin dose, an indicator of potential skin damage, and the effective dose, an indicator of long-term cancer risk, for each patient. RESULTS The median age of the 108 patients (67% females) included in the data analysis was 51 years (range, 17-87 years). The mean entrance skin dose during intraoperative cholangiography was 0.0069 +/- 0.0066 Gy, and the mean effective dose was 0.18 +/- 0.17 mSv. No results exceeded the threshold of 2 Gy for skin damage, and the lifetime risk for the development of new cancer due to intraoperative cholangiography was less than 0.001%. CONCLUSION Radiation doses administered during intraoperative cholangiography are safe and do not represent a contraindication to this procedure.
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Affiliation(s)
- A Karthikesalingam
- Department of Surgery, Addenbrooke's Hospital, Cambridge University Hospitals NHS Foundation Trust, Box 201, Level 7, Hills Road, Cambridge, CB2 0QQ, UK.
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Giordano BD, Ryder S, Baumhauer JF, DiGiovanni BF. Exposure to direct and scatter radiation with use of mini-c-arm fluoroscopy. J Bone Joint Surg Am 2007; 89:948-52. [PMID: 17473130 DOI: 10.2106/jbjs.f.00733] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Mini-c-arm fluoroscopy has become an important resource to the orthopaedic surgeon. Exposure of the orthopaedic surgical team to radiation during standard large-c-arm fluoroscopy has been well studied; however, little is known about the amount of exposure to which a surgical team is subjected with the use of mini-c-arm fluoroscopy. Moreover, there is controversy regarding the use of protective measures with mini-c-arm fluoroscopy. METHODS We evaluated the use of mini-c-arm fluoroscopy during a simulated surgical procedure to quantify the relative radiation doses at various locations in the operative field. A standard calibrated mini-c-arm fluoroscope was used to image a phantom upper extremity with thirteen radiation dosimeters placed at various distances and angulations to detect radiation exposure. RESULTS After 155 sequential fluoroscopy exposures, totaling 300.2 seconds of imaging time, only the sensor placed in a direct line with the imaging beam recorded a substantial amount of measurable radiation exposure. CONCLUSIONS The surgical team is exposed to minimal radiation during routine use of mini-c-arm fluoroscopy, except when they are in the direct path of the radiation beam.
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Affiliation(s)
- Brian D Giordano
- Division of Foot and Ankle Surgery, Department of Orthopaedics, University of Rochester Medical Center, 601 Elmwood Avenue, Box 665, Rochester, NY 14642, USA
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Naidu LS, Singhal S, Preece DE, Vohrah A, Loft DE. Radiation exposure to personnel performing endoscopic retrograde cholangiopancreatography. Postgrad Med J 2006. [PMID: 16210465 DOI: 10.1136/pgmj.2004.031526.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) relies on the use of ionising radiation but risks to operator and patient associated with radiation exposure are unclear. The aim of this prospective study was to estimate the radiation dose received by personnel performing fluoroscopic endoscopic procedures, mainly ERCP. METHODS Consecutive procedures over a two month period were included. The use of thermoluminescent dosimeters to measure radiation exposure to the abdomen, thyroid gland, and hands of the operator permitted an estimation of the annual whole body effective dose equivalent. RESULTS During the study period 66 procedures (61 ERCP) were performed and the estimated annual whole body effective dose equivalent received by consultant operators ranged between 3.35 and 5.87 mSv. These values are similar to those received by patients undergoing barium studies and equate to an estimated additional lifetime fatal cancer risk between 1 in 7000 and 1 in 3500. While within legal safety limits for radiation exposure to personnel, these doses are higher than values deemed acceptable for the general public. CONCLUSIONS It is suggested that personnel as well as patients may be exposed to significant values of radiation during ERCP. The study emphasises the need to carefully assess the indication for, and to use measures that minimise radiation exposure during any fluoroscopic procedure.
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Affiliation(s)
- L S Naidu
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, UK.
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Naidu LS, Singhal S, Preece DE, Vohrah A, Loft DE. Radiation exposure to personnel performing endoscopic retrograde cholangiopancreatography. Postgrad Med J 2006; 81:660-2. [PMID: 16210465 PMCID: PMC1743365 DOI: 10.1136/pgmj.2004.031526] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endoscopic retrograde cholangiopancreatography (ERCP) relies on the use of ionising radiation but risks to operator and patient associated with radiation exposure are unclear. The aim of this prospective study was to estimate the radiation dose received by personnel performing fluoroscopic endoscopic procedures, mainly ERCP. METHODS Consecutive procedures over a two month period were included. The use of thermoluminescent dosimeters to measure radiation exposure to the abdomen, thyroid gland, and hands of the operator permitted an estimation of the annual whole body effective dose equivalent. RESULTS During the study period 66 procedures (61 ERCP) were performed and the estimated annual whole body effective dose equivalent received by consultant operators ranged between 3.35 and 5.87 mSv. These values are similar to those received by patients undergoing barium studies and equate to an estimated additional lifetime fatal cancer risk between 1 in 7000 and 1 in 3500. While within legal safety limits for radiation exposure to personnel, these doses are higher than values deemed acceptable for the general public. CONCLUSIONS It is suggested that personnel as well as patients may be exposed to significant values of radiation during ERCP. The study emphasises the need to carefully assess the indication for, and to use measures that minimise radiation exposure during any fluoroscopic procedure.
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Affiliation(s)
- L S Naidu
- Department of Gastroenterology, University Hospitals Coventry and Warwickshire NHS Trust, UK.
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Buls N, Pages J, Mana F, Osteaux M. Patient and staff exposure during endoscopic retrograde cholangiopancreatography. Br J Radiol 2002; 75:435-43. [PMID: 12036837 DOI: 10.1259/bjr.75.893.750435] [Citation(s) in RCA: 76] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Despite a number of efforts being put into the radiological protection of both patient and staff during interventional radiological (IR) procedures during recent years, information about radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) procedures remains scarce. The purpose of this study was to estimate both patient and staff radiation doses during therapeutic ERCP procedures by direct measurement and to compare these results with data from other IR procedures. For 54 patients, effective dose and skin dose were estimated by measuring the dose-area product. For staff, entrance surface doses to the lens of the eye, thyroid and hands were estimated by thermoluminescent dosemeters. A median effective dose of 7.3 mSv and a median entrance surface dose of 271 mGy per procedure were estimated for patients. The gastroenterologist received a median dose of 0.34 mGy to the lens of the eye, 0.30 mGy to the skin at the level of the thyroid and 0.44 mGy to the skin of the hands, per procedure. When comparing the dosimetric quantities presented in this study with data from other IR procedures, it is clear that patient skin doses and doses to staff are high owing to the use of inappropriate X-ray equipment. ERCP requires the same radiation protection practice as all IR procedures. It should be consistently included in future multicentre IR patient and staff dose survey studies at national or international level.
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Affiliation(s)
- N Buls
- Department of Radiology, Free University Hospital Brussels (AZ-VUB), Laarbeeklaan 101, B-1090 Brussels, Belgium
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Campbell N, Sparrow K, Fortier M, Ponich T. Practical radiation safety and protection for the endoscopist during ERCP. Gastrointest Endosc 2002; 55:552-7. [PMID: 11923771 DOI: 10.1067/mge.2002.122578] [Citation(s) in RCA: 59] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Nicole Campbell
- Department of Radiology and Medicine, University of Western Ontario, London, Ontario, Canada
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Johlin FC, Pelsang RE, Greenleaf M. Phantom study to determine radiation exposure to medical personnel involved in ERCP fluoroscopy and its reduction through equipment and behavior modifications. Am J Gastroenterol 2002; 97:893-7. [PMID: 12003424 DOI: 10.1111/j.1572-0241.2002.05605.x] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The aim of this work is to evaluate the potential radiation exposure to medical personnel by comparing results from phantom studies of two different fluoroscopic units used for ERCP, and to determine which equipment or behavior modification can reduce radiation exposure. METHODS Radiation exposures using an opaque tissue equivalent chest phantom with an abdominal insert were performed on a stationary dedicated fluoroscopy unit and a mobile C-arm unit, comparing varying equipment manipulations. Scatter radiation was recorded at 1) the patients' head, 2) where the endoscopist stands, and 3) where the equipment personnel stands. RESULTS Radiation exposures were significantly higher for the mobile C-arm unit, revealing a 4160-times greater dosage increase for head and neck and a 8660-times increase for body than the fixed unit. Tower position and vertically stationed lead shields facilitated exposure reduction by means of equipment manipulation. The positioning of the endoscopist away from the right corner of the units also decreased exposure. CONCLUSIONS Dedicated stationary fluoroscopy units provide significantly less radiation exposure. Equipment and behavior modification including tower positioning down and vertical shielding are essential for reduction in radiation exposure to medical personnel.
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Affiliation(s)
- Frederick C Johlin
- Department of Internal Medicine, The University of Iowa College of Medicine, Iowa City, USA
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Abstract
Fluoroscopic procedures (particularly prolonged interventional procedures) may involve high patient radiation doses. The radiation dose depends on the type of examination, the patient size, the equipment, the technique, and many other factors. The performance of the fluoroscopy system with respect to radiation dose is best characterized by the receptor entrance exposure and skin entrance exposure rates, which should be assessed at regular intervals. Management of patient exposure involves not only measurement of these rates but also clinical monitoring of patient doses. Direct monitoring of patient skin doses during procedures is highly desirable, but current methods still have serious limitations. Skin doses may be reduced by using intermittent exposures, grid removal, last image hold, dose spreading, beam filtration, pulsed fluoroscopy, and other dose reduction techniques. Proper training of fluoroscopic operators, understanding the factors that influence radiation dose, and use of various dose reduction techniques may allow effective management of patient dose.
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Affiliation(s)
- M Mahesh
- Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, 601 N Caroline St, Baltimore, MD 21287, USA.
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Abstract
BACKGROUND There is a scarcity of data regarding the radiation dose and associated risks to patients during ERCP. Dose area product (DAP) measurements can be used to estimate an effective dose (ED) to patients undergoing ERCP. This measure allows radiation risk associated with such procedures to be quantified. The aim of this study was to evaluate the ED to patients undergoing ERCP. METHODS A DAP meter was fitted to the x-ray tube before each ERCP. DAP reading (Gy-cm(2)), fluoroscopy time, average screening kVp, number of films, and kVp per film were recorded. Mean ED was estimated by using DAP readings and Monte Carlo computer software to model radiation exposure conditions. RESULTS Data were recorded on 20 subjects. Average DAP was 13.5 Gy-cm(2) (6.8-23.9) for diagnostic and 66.8 Gy-cm(2) (28.7-108.5) for therapeutic ERCP (p < 0.05). Average fluoroscopy time was 2.3 minutes (1.1-5.3) for diagnostic and 10.5 minutes (5.9-16.6) for therapeutic ERCP (p < 0.05). DAP showed a linear relationship with fluoroscopy time (R(2) = 0.928). Mean number of diagnostic and therapeutic films was 2.8 and 3.7, respectively. Fluoroscopic exposure represented 69% of the DAP for diagnostic ERCP and 90% of the DAP for therapeutic ERCP. Average ED was 3.1 mSv for diagnostic and 12.4 mSv for therapeutic ERCP. CONCLUSIONS Therapeutic ERCP is associated with significantly higher radiation exposure than diagnostic ERCP. ED in therapeutic ERCP is a result largely of fluoroscopy time as opposed to number of films.
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Affiliation(s)
- C J Larkin
- Royal Victoria Hospital, Belfast, Northern Ireland
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