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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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Predictors of Prolonged Fluoroscopy Exposure in Pediatric Endoscopic Retrograde Cholangiopancreatography: Results From the Large Pediatric Endoscopic Retrograde Cholangiopancreatography Database Initiative Multicenter Cohort. J Pediatr Gastroenterol Nutr 2022; 74:408-412. [PMID: 34724445 DOI: 10.1097/mpg.0000000000003347] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Ionizing radiation exposure during endoscopic retrograde cholangiopancreatography (ERCP) is an important quality issue especially in children. We aim to identify factors associated with extended fluoroscopy time (FT) in children undergoing ERCP. METHODS ERCP on children <18 years from 15 centers were entered prospectively into a REDCap database from May 2014 until May 2018. Data were retrospectively evaluated for outcome and quality measures. A univariate and step-wise linear regression analysis was performed to identify factors associated with increased FT. RESULTS 1073 ERCPs performed in 816 unique patients met inclusion criteria. Median age was 12.2 years (interquartile range [IQR] 9.3-15.8). 767 (71%) patients had native papillae. The median FT was 120 seconds (IQR 60-240). Factors associated with increased FT included procedures performed on patients with chronic pancreatitis, ERCPs with American Society of Gastrointestinal Endoscopy (ASGE) difficulty grade >3, ERCPs performed by pediatric gastroenterologist (GI) with adult GI supervision, and ERCPs performed at non-free standing children's hospitals. Hispanic ethnicity was the only factor associated with lower FT. CONCLUSION Several factors were associated with prolonged FTs in pediatric ERCP that differed from adult studies. This underscores that adult quality indicators cannot always be translated to pediatric patients. This data can better identify children with higher risk for radiation exposure and improve quality outcomes during pediatric ERCP.
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Kwok K, Hasan N, Duloy A, Murad F, Nieto J, Day LW. American Society for Gastrointestinal Endoscopy radiation and fluoroscopy safety in GI endoscopy. Gastrointest Endosc 2021; 94:685-697.e4. [PMID: 34399965 DOI: 10.1016/j.gie.2021.05.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 05/28/2021] [Indexed: 02/08/2023]
Affiliation(s)
- Karl Kwok
- Department of Medicine, Division of Gastroenterology, Kaiser Permanente, Los Angeles Medical Center, Los Angeles, California, USA
| | - Nazia Hasan
- Department of Medicine, Division of Gastroenterology, NorthBay Healthcare, Fairfield, California, USA
| | - Anna Duloy
- Department of Medicine, Division of Gastroenterology, University of Colorado, Anschutz Medical Campus, Aurora, Colorado, USA
| | - Faris Murad
- Department of Gastroenterology, FHN Memorial Hospital, Freeport, Illinois, USA
| | - Jose Nieto
- Department of Gastroenterology, Borland Groover Clinic, Jacksonville, Florida, USA
| | - Lukejohn W Day
- Department of Medicine, Division of Gastroenterology, University of California, San Francisco and Zuckerberg San Francisco General Hospital, San Francisco, California, USA
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Del Olmo Martínez L, Velayos Jiménez B, Muñoz Moreno MF. Assessment of radiation doses received by patients during endoscopic retrograde cholangiopancreatography according to disease location. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2020; 113:500-504. [PMID: 33244984 DOI: 10.17235/reed.2020.7335/2020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVE patients are exposed to ionizing radiation during endoscopic retrograde cholangiopancreatography (ERCP). Radiation dose depends on multiple factors. The goal of this study was to assess fluoroscopy time (FT), radiation doses and effective dose (ED) during ERCP according to the condition being treated. MATERIALS AND METHODS a descriptive study was performed of 369 consecutive ERCPs from January 2017 to June 2019. Patient demographic and procedure data were collected. FT, cumulative dose area product (DAP), fluoroscopy DAP, DA fluoroscopy, air kerma, and number of radiographs were assessed. ED was estimated using specific conversion factors. RESULTS the mean age was 73.34 years and 193 subjects were male. Mean FT was 4.56 ± 0.17 min, cumulative DAP was 2,056.73 ± 188.83 cGycm2, fluoroscopy DAP was 1,722.90 ± 82.26 cGycm2 and air kerma was 85.84 ± 4.93 mGy. The number of radiographs was 2.10 ± 0.07 and the mean ED was 5.34 ± 0.49 mSv. FT was significantly longer for choledocholithiasis (CL), proximal malignant biliary stricture (PMBS) and distal malignant biliary stricture (DMBS) versus others (OT). Cumulative DAP was higher for PMBS (p < 0.002). FT, cumulative DAP, fluoroscopy DAP and air kerma values were significantly higher for complicated CL as compared to simple CL. ED was higher for CL, DMBS and PMBS, but only significantly (p < 0.002) for PMBS. CONCLUSIONS FT for ERCP is variable and increases with exploration difficulty. Thus, it is longer in the case of PMBS, as well as with the amount of radiation received by the patients and ED.
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Yamada R, Saimyo Y, Tanaka K, Hattori A, Umeda Y, Kuroda N, Tsuboi J, Hamada Y, Takei Y. Usefulness of an additional lead shielding device in reducing occupational radiation exposure during interventional endoscopic procedures: An observational study. Medicine (Baltimore) 2020; 99:e21831. [PMID: 32846829 PMCID: PMC7447393 DOI: 10.1097/md.0000000000021831] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
Adoption of interventional endoscopic procedures is increasing with increasing prevalence of diseases. However, medical radiation exposure is concerning; therefore, radiation protection for medical staff is important. However, there is limited information on the usefulness of an additional lead shielding device during interventional endoscopic procedures. Therefore, we aimed to determine whether an additional lead shielding device protects medical staff from radiation.An X-ray unit (CUREVISTA; Hitachi Medical Systems, Tokyo, Japan) with an over-couch X-ray system was used. Fluoroscopy-associated scattered radiation was measured using a water phantom placed at the locations of the endoscopist, assistant, nurse, and clinical engineer. For each location, measurements were performed at the gonad and thyroid gland/eye levels. Comparisons were performed between with and without the additional lead shielding device and with and without a gap in the shielding device. Additionally, a clinical study was performed with 27 endoscopic retrograde cholangiopancreatography procedures.The scattered radiation dose was lower with than without additional lead shielding at all medical staff locations and decreased by 84.7%, 82.8%, 78.2%, and 83.7%, respectively, at the gonad level and by 89.2%, 86.4%, 91.2%, and 87.0%, respectively, at the thyroid gland/eye level. Additionally, the scattered radiation dose was lower without than with a gap in the shielding device at all locations.An additional lead shielding device could protect medical staff from radiation during interventional endoscopic procedures. However, gaps in protective equipment reduce effectiveness and should be eliminated.
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Affiliation(s)
| | - Yusuke Saimyo
- Department of Clinical Engineering, Ise Red Cross Hospital, Ise
| | - Kyosuke Tanaka
- Department of Endoscopy, Mie University Hospital, Tsu, Mie, Japan
| | | | - Yuhei Umeda
- Department of Gastroenterology and Hepatology
| | | | - Junya Tsuboi
- Department of Endoscopy, Mie University Hospital, Tsu, Mie, Japan
| | - Yasuhiko Hamada
- Department of Endoscopy, Mie University Hospital, Tsu, Mie, Japan
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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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Chung KH, Park YS, Ahn SB, Son BK. Radiation protection effect of mobile shield barrier for the medical personnel during endoscopic retrograde cholangiopancreatography: a quasi-experimental prospective study. BMJ Open 2019; 9:e027729. [PMID: 30898834 PMCID: PMC6527993 DOI: 10.1136/bmjopen-2018-027729] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
OBJECTIVE To investigate the effectiveness of radiation protection offered by a newly designed mobile shield barrier for medical personnel during endoscopic retrograde cholangiopancreatography (ERCP). DESIGN Quasi-experimental prospective study. SETTING ERCP procedures conducted between October 2016 and June 2017 at a single secondary referral hospital that performs approximately 250 therapeutic ERCP procedures annually. INTERVENTIONS The mobile shield barrier was a custom-made 2 mm Pb shielding plate (width: 120 cm, height: 190 cm) with a 0.5 mm Pb window (width: 115 cm, height: 60 cm) on its upper part was used. Four wheels were attached to the bottom to allow easy moving. PRIMARY AND SECONDARY OUTCOME MEASURES The radiation doses were measured during ERCP using personal thermoluminescence dosimetry (TLD) badges on both sides of the mobile shield barrier (patient's side: TLD1 and medical staff's side: TLD2). The radiation doses were also measured on the outer surface of the thyroid shield of the endoscopist (TLD3), and on the chest area inside the protective apron of the endoscopist (TLD4) and the main assistant (TLD5). The TLD was changed and reported once every 3 months. The radiation dose measured by TLD badges were compared. RESULTS During the study period, a total of 128 ERCP procedures were performed. The mean fluoroscopy time per procedure was 244.9±257.0 s and the mean number of digital radiographs per procedure was 3.7±1.0. TLD1 (outside the barrier) had a mean radiation dose of 26.85±3.47 mSv and all the other TLDs (inside the barrier) had less than 1 mSv (p<0.001). In the post hoc analysis, the difference between TLD1 and others showed a statistical significance; however, there were no significant differences between the TLDs inside the barrier. CONCLUSION Our mobile shield barrier was useful to reduce the radiation exposure of medical personnel during ERCP.
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Affiliation(s)
- Kwang Hyun Chung
- Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Young Sook Park
- Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Sang Bong Ahn
- Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Republic of Korea
| | - Byoung Kwan Son
- Department of Internal Medicine, Eulji General Hospital, Eulji University School of Medicine, Seoul, Republic of Korea
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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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Hayash S, Nishida T, Matsubara T, Osugi N, Sugimoto A, Takahashi K, Mukai K, Nakamatsu D, Yamamoto M, Fukui K, Inada M. Radiation exposure dose and influencing factors during endoscopic retrograde cholangiopancreatography. PLoS One 2018; 13:e0207539. [PMID: 30452477 PMCID: PMC6242372 DOI: 10.1371/journal.pone.0207539] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2018] [Accepted: 11/01/2018] [Indexed: 12/24/2022] Open
Abstract
Introduction Various endoscopic procedures under fluoroscopic guidance are being rapidly adopted, and radiation exposure is considered to be increasing. However, there is little concern about this issue in gastroenterology practice. This study aims to evaluate the actual radiation exposure dose (RD) during endoscopic retrograde cholangiopancreatography (ERCP) and the factors affecting the RD. Methods In this retrospective, single-center cohort study of 1157 consecutive patients who underwent ERCP between October 2012 and February 2017, we analyzed the influences of patient characteristics, procedure time (min), total fluoroscopy time (min), type of processing engine, experience of the endoscopist, and type of disease on the total RD (mGy). Results The median procedure times were 28 min for common bile duct stones (CBDS), 25 min for distal malignant biliary obstruction (MBO), and 30 min for proximal MBO. Similarly, the median fluoroscopy times were 10.3, 8.8, and 13.4 min, and the median RDs were 167, 123, and 242 mGy, respectively. Proximal MBO required significantly longer procedure time and fluoroscopy time and resulted in greater RD than distal MBO (P = 0.0006, <0.0001, <0.0001) and CBDS (P = 0.015, <0.0001, <0.0001). Multiple linear regression showed that distal MBO and a novel processing engine negatively correlate with RD (P = 0.04, <0.0001) and that proximal MBO positively correlates with RD (P = 0.0001). Discussion Procedure time and fluoroscopy time were significantly longer for proximal MBO than for CBDS and distal MBO. The type of disease and processing engine significantly influenced the RD during ERCP.
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Affiliation(s)
- Shiro Hayash
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
- Department of Gastroenterology and Internal Medicine, Hayashi Clinic, Osaka, Suita, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
- * E-mail:
| | - Tokuhiro Matsubara
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Naoto Osugi
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Aya Sugimoto
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Kei Takahashi
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Kaori Mukai
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Masashi Yamamoto
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Koji Fukui
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Masami Inada
- Department of Gastroenterology and Hepatology, Toyonaka Municipal Hospital, Toyonaka, Japan
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Angsuwatcharakon P, Janjeurmat W, Krisanachinda A, Ridtitid W, Kongkam P, Rerknimitr R. The difference in ocular lens equivalent dose to ERCP personnel between prone and left lateral decubitus positions: a prospective randomized study. Endosc Int Open 2018; 6:E969-E974. [PMID: 30083586 PMCID: PMC6070372 DOI: 10.1055/a-0599-5917] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2017] [Accepted: 03/05/2018] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND STUDY AIMS Endoscopic retrograde cholangiopancreatography (ERCP) is commonly performed in a prone or left lateral decubitus (LLD) position. The ocular lens equivalent doses between the two positions may be different because in the LLD position the tube voltage will automatically increase to maintain the image quality, and the increased distance between the image intensifier and the X-ray tube may result in more scattered radiation. We aimed to compare the ocular lens equivalent doses of ERCP personnel between the two different positions. PATIENTS AND METHODS Fifty-five patients with ERCP indications were randomized to either prone or LLD positions. One patient in an LLD position was excluded due to technical reasons. Indications for ERCP, patients' vertical thicknesses, fluoroscopy parameters, patients' skin dose rates, and the ocular-lens equivalent doses of ERCP personnel were compared. RESULTS Baseline characteristics were no different except for vertical thickness, which was significantly higher in the LLD group. The ocular lens equivalent doses (prone vs. LLD) of the primary endoscopist (19.2 vs. 30.7 µSv, P = 0.035), and the nurse anesthetist (17.3 vs. 42.2 µSv, P = 0.002) were significantly lower in the prone group than in the LLD group. The calculated annual number of procedures not to exceed the exposure allowance in prone and LLD positions were 1,042 and 651 procedures for the primary endoscopist and 1,157 and 473 procedures for the nurse anesthetist, respectively. CONCLUSIONS Ocular-radiation exposure to ERCP personnel was one-third lower in the prone than in LLD position. Therefore, more annual ERCPs could be performed by the personnel.
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Affiliation(s)
- Phonthep Angsuwatcharakon
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand,Department of Anatomy, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Worawarut Janjeurmat
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Anchali Krisanachinda
- Division of Nuclear Medicine, Department of Radiology, Faculty of Medicine Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Wiriyaporn Ridtitid
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Pradermchai Kongkam
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Rungsun Rerknimitr
- Division of Gastroenterology, Department of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Bangkok, Thailand,Corresponding author Rungsun Rerknimitr, MD, FRCP (London), Professor of Medicine Division of Gastroenterology, Department of Medicine, Faculty of Medicine Chulalongkorn University and King Chulalongkorn Memorial Hospital1873 Rama 4 Road, PatumwanBangkok 10330Thailand+ 6622564356
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Barakat MT, Thosani NC, Huang RJ, Choudhary A, Kochar R, Kothari S, Banerjee S. Effects of a Brief Educational Program on Optimization of Fluoroscopy to Minimize Radiation Exposure During Endoscopic Retrograde Cholangiopancreatography. Clin Gastroenterol Hepatol 2018; 16:550-557. [PMID: 28804031 PMCID: PMC5809234 DOI: 10.1016/j.cgh.2017.08.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Revised: 08/02/2017] [Accepted: 08/04/2017] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is increasingly performed by therapeutic endoscopists, many of whom have not received formal training in modulating fluoroscopy use to minimize radiation exposure. Exposure to ionizing radiation has significant health consequences for patients and endoscopists. We aimed to evaluate whether a 20-minute educational intervention for endoscopists would improve use of fluoroscopy and decrease ERCP-associated exposure to radiation for patients. METHODS We collected data from 583 ERCPs, performed in California from June 2010 through November 2012; 331 were performed at baseline and 252 following endoscopist education. The educational intervention comprised a 20-minute video explaining best practices for fluoroscopy, coupled with implementation of a formal fluoroscopy time-out protocol before the ERCP was performed. Our primary outcome was the effect of the educational intervention on direct and surrogate markers of patient radiation exposure associated with ERCPs performed by high-volume endoscopists (HVEs) (200 or more ERCPs/year) vs low-volume endoscopists (LVEs) (fewer than 200 ERCPs/year). RESULTS At baseline, total radiation dose and dose area product were significantly higher for LVEs, but there was no significant difference between HVEs and LVEs following education. Education was associated with significant reductions in median fluoroscopy time (48% reduction for HVEs vs 30% reduction for LVEs), total radiation dose (28% reduction for HVEs vs 52% for LVEs) and dose area product (35% reduction for HVEs vs 48% reduction for LVEs). All endoscopists significantly increased their use of low magnification and collimation following education. CONCLUSIONS A 20-minute educational program with emphasis on ideal use of modifiable fluoroscopy machine settings results in an immediate and significant reduction in ERCP-associated patient radiation exposure for low-volume and high-volume endoscopists. Training programs should consider radiation education for advanced endoscopy fellows.
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Affiliation(s)
| | | | | | | | | | | | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University Medical Center, Stanford, California.
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Saukko E, Grönroos JM, Salminen P, Henner A, Nieminen MT. Patient radiation dose and fluoroscopy time during ERCP: a single-center, retrospective study of influencing factors. Scand J Gastroenterol 2018; 53:495-504. [PMID: 29489436 DOI: 10.1080/00365521.2018.1445774] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVES Recently, both the number and the complexity with associated increased technical difficulty of therapeutic ERCP procedures have significantly increased resulting in longer procedural and fluoroscopy times. During ERCP, the patient is exposed to ionizing radiation and the consequent radiation dose depends on multiple factors. The aim of this study was to identify factors affecting fluoroscopy time and radiation dose in patients undergoing ERCP. MATERIALS AND METHODS Data related to patient demographics, procedural characteristics and radiation exposure in ERCP procedures (n = 638) performed between August 2013 and August 2015 was retrospectively reviewed and analyzed. Statistically significant factors identified by univariate analyses were included in multivariate analysis with fluoroscopy time (FT) and dose area product (DAP) as dependent variables. Effective dose (ED) was estimated from DAP measurements using conversion coefficient. RESULTS The factors independently associated with increased DAP during ERCP were age, gender, radiographer, complexity level of ERCP, cannulation difficulty grade, bile duct injury and biliary stent placement. In multivariate analysis the endoscopist, the complexity level of ERCP, cannulation difficulty grade, pancreatic duct leakage, bile duct dilatation and brushing were identified as predictors for a longer FT. The mean DAP, FT, number of acquired images and ED for all ERCP procedures were 2.33 Gy·cm2, 1.84 min, 3 and 0.61 mSv, respectively. CONCLUSIONS Multiple factors had an effect on DAP and FT in ERCP. The awareness of these factors may help to predict possible prolonged procedures causing a higher radiation dose to the patient and thus facilitate the use of appropriate precautions.
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Affiliation(s)
- Ekaterina Saukko
- a The Medical Imaging Centre of Southwest Finland, Turku University Hospital , Turku , Finland
| | - Juha M Grönroos
- b Division of Digestive Surgery and Urology , Turku University Hospital , Turku , Finland.,c Department of Surgery , University of Turku , Turku , Finland
| | - Paulina Salminen
- b Division of Digestive Surgery and Urology , Turku University Hospital , Turku , Finland.,c Department of Surgery , University of Turku , Turku , Finland
| | - Anja Henner
- d School of Health and Social Care , Oulu University of Applied Sciences , Oulu , Finland
| | - Miika T Nieminen
- e Research Unit of Medical Imaging, Physics and Technology, University of Oulu , Oulu , Finland.,f Department of Diagnostic Radiology , Oulu University Hospital , Oulu , Finland.,g Medical Research Center Oulu, University of Oulu and Oulu University Hospital , Oulu , Finland
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Consiglieri CF, Gornals JB, Busquets J, Peláez N, Secanella L, De-La-Hera M, Sanzol R, Fabregat J, Castellote J. Fluoroscopy-assisted vs fluoroless endoscopic ultrasound-guided transmural drainage of pancreatic fluid collections: A comparative study. GASTROENTEROLOGIA Y HEPATOLOGIA 2017; 41:12-21. [PMID: 28882615 DOI: 10.1016/j.gastrohep.2017.07.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/08/2017] [Revised: 07/21/2017] [Accepted: 07/25/2017] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The need for fluoroscopy guidance in patients undergoing endoscopic ultrasound-guided transmural drainage (EUS-TMD) of peripancreatic fluid collections (PFCs) remains unclear. AIMS The aim of this study was to compare general outcomes of EUS-TMD of PFCs under fluoroscopy (F) vs fluoroless (FL). METHODS This is a comparative study with a retrospective analysis of a prospective and consecutive inclusion database at a tertiary centre, from 2009 to 2015. All patients were symptomatic pseudocyst (PSC) and walled-off pancreatic necrosis (WON). Two groups were assigned depending on availability of fluoroscopy. The groups were heterogeneous in terms of their demographic characteristics, PFCs and procedure. The main outcome measures included technical and clinical success, incidences, adverse events (AEs), and follow-up. RESULTS Fifty EUS-TMD of PFCs from 86 EUS-guided drainages were included during the study period. Group F included 26 procedures, PSC 69.2%, WON 30.8%, metal stents 61.5% (46.1% lumen-apposing stent) and plastic stents 38.5%. Group FL included 24 procedures, PSC 37.5%, WON 62.5%, and metal stents 95.8% (lumen-apposing stents). Technical success was 100% in both groups, and clinical success was similar (F 88.5%, FL 87.5%). Technical incidences and intra-procedure AEs were only described in group F (7.6% and 11.5%, respectively) and none in group FL. Procedure time was less in group FL (8min, p=0.0341). CONCLUSIONS Fluoroless in the EUS-TMD of PFCs does not involve more technical incidences or intra-procedure AEs. Technical and clinical success was similar in the two groups.
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Affiliation(s)
- Claudia F Consiglieri
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Joan B Gornals
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain; Universitat Oberta de Catalunya, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain.
| | - Juli Busquets
- General and Digestive Surgery Department, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Nuria Peláez
- General and Digestive Surgery Department, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Lluis Secanella
- General and Digestive Surgery Department, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Meritxell De-La-Hera
- Endoscopy Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Resurrección Sanzol
- Anaesthesia Department, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - Joan Fabregat
- General and Digestive Surgery Department, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
| | - José Castellote
- Hepatology Unit, Department of Digestive Diseases, Hospital Universitari de Bellvitge-IDIBELL, Barcelona, Catalonia, Spain
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