Comparison of radiation exposure between endoscopic ultrasound-guided drainage and transpapillary drainage by endoscopic retrograde cholangiopancreatography for pancreatobiliary diseases

Defining standards for fluoroscopy in gastrointestinal endoscopy using Delphi methodology

Background and study aims Use of fluoroscopy in gastrointestinal endoscopy is an essential aid in advanced endoscopic interventions. However, it also raises concerns about radiation exposure. This study aimed to develop consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, prioritizing the safety and well-being of healthcare workers and patients. Methods A modified Delphi approach was employed to achieve consensus over three rounds of surveys. Proposed statements were generated in Round 1. In the second round, panelists rated potential statements on a 5-point scale, with consensus defined as ≥80% agreement. Statements were subsequently prioritized in Round 3, using a 1 (lowest priority) to 10 (highest priority) scale. Results Forty-six experts participated, consisting of 34 therapeutic endoscopists and 12 endoscopy nurses from six continents, with an overall 45.6% female representation (n = 21). Forty-three item statements were generated in the first round. Of these, 31 statements achieved consensus after the second round. These statements were categorized into General Considerations (n = 6), Education (n = 10), Pregnancy (n = 4), Family Planning (n = 2), Patient Safety (n = 4), and Staff Safety (n = 5). In the third round, accepted statements received mean priority scores ranging from 7.28 to 9.36, with 87.2% of statements rated as very high priority (mean score ≥ 9). Conclusions This study presents consensus-based statements for safe and effective use of fluoroscopy in gastrointestinal endoscopy, addressing the well-being of healthcare workers and patients. These consensus-based statements aim to mitigate risks associated with radiation exposure while maintaining benefits of fluoroscopy, ultimately promoting a culture of safety in healthcare settings.

Hepaticogastrostomy versus hepaticogastrostomy with antegrade stenting for malignant biliary obstruction: a systematic review and meta-analysis

Background

Combining antegrade stenting (AGS) and hepaticogastrostomy (HGS) is an increasingly used endoscopic ultrasound-guided intervention when stenting by endoscopic retrograde cholangiopancreatography is impossible.

Objectives

We comprehensively assessed the benefits and downsides of combined AGS and HGS (HGS procedure with AGS, HGAS).

Data sources and methods

From 788 HGS and 295 HGAS cases, a random-effects meta-analysis was performed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses protocol. Five electronic databases were searched for studies on HGS with or without AGS from inception until May 2024. The odds ratio (OR) and pooled rates were used for single and two-arm comparisons with 95% confidence intervals (CI).

Results

From 26 eligible studies. The pooled technical and clinical success was 94% (CI: 92%-96%) and 88% (CI: 84%-91%) for HGS and 89% (CI: 83%-93%) and 94% (CI: 89%-97%) for HGAS, respectively. Pooled OR of HGAS and HGS showed an OR = 0.38 (CI: 0.07-2.00) for technical success and an OR = 1.02 (CI: 0.50-2.06) for clinical success. The pooled adverse event rates were 20% (CI: 16%-25%) for HGS and 14% (CI: 9%-20%) for HGAS, whereas pooled OR showed an OR = 1.09 (CI: 0.30-3.94). For re-intervention, an OR = 0.37 (CI: 0.27-0.52) was found. Time to stent dysfunction increased, HGAS 333 (CI: 280-Not reached) and HGS 209 (CI: 120-325) with no change in overall survival HGS 117 (CI: 94-147) and 140 (CI: 105-170).

Conclusion

The use of HGAS appears to increase clinical success and reduce the need for re-intervention. Overall adverse event rates were similar but bile leakage prevalence was decreased. Time to stent dysfunction seems to increase with no change in overall survival.

Trial registration

Our protocol was prospectively registered with PROSPERO (CRD42024509412).

Endoscopic Ultrasound-Guided Rendezvous Technique Versus Precut Sphincterotomy as Salvage Technique in Patients With Benign Biliary Disease and Difficult Biliary Cannulation : A Randomized Controlled Trial

BACKGROUND

The standard salvage technique used for difficult bile duct cannulation is precut sphincterotomy, whereas endoscopic ultrasound-guided rendezvous technique (EUS-RV) is a relatively newer method. Prospective comparative data between these 2 techniques as salvage for biliary access in patients with benign biliary disease and difficult bile duct cannulation is lacking.

OBJECTIVE

To compare EUS-RV and precut sphincterotomy as salvage technique for difficult bile duct cannulation in benign biliary obstruction.

DESIGN

Participant-masked, parallel-group, superiority, randomized controlled trial. (Clinical Trials Registry of India: CTRI/2020/07/026613).

SETTING

Tertiary care academic institute from July 2020 to May 2021.

PARTICIPANTS

All patients with benign biliary disease and difficult bile duct cannulation requiring salvage strategy.

INTERVENTION

Patients were randomly assigned by computer-generated randomized blocks sequence in 1:1 fashion to either EUS-RV or precut sphincterotomy. Patients with failure in EUS-RV were crossed over to precut sphincterotomy and vice versa.

MEASUREMENTS

The primary outcome measure was technical success. The other outcome measures included procedure time, radiation dose, and adverse events.

RESULTS

In total, 100 patients were randomly assigned to EUS-RV (n = 50) and precut sphincterotomy (n = 50). The technical success rate (92% vs. 90%; P = 1.00; relative risk, 1.02 [95% CI, 0.90 to 1.16]), median procedure time (10.1 vs. 9.75 minutes), and overall complication rate (12% vs. 10%; relative risk, 1.20 [CI, 0.39 to 3.68]) were similar between the 2 groups. Five patients (10%) in the EUS-RV group and 5 patients (10%) in the precut sphincterotomy group had developed post-endoscopic retrograde cholangiopancreatography pancreatitis. All failed cases in either salvage group could be successfully cannulated when crossed over to the other group.

LIMITATION

Single center study done by experts.

CONCLUSION

Endoscopic ultrasound-guided rendezvous technique and precut sphincterotomy have similar success rates as salvage techniques in the technically challenging cohort of difficult bile duct cannulation for benign biliary disease, with acceptable complications rates.

PRIMARY FUNDING SOURCE

None.

Low-dose pulsed vs standard pulsed fluoroscopy during ERCP to reduce radiation without change in image quality: Prospective randomized study

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of radiation exposure (RE) to patients and staff and increases the risk of adverse biological effects such as cataracts, sterility, and cancer. Newer fluoroscopy equipment (C-Arm) provides options to limit radiation in the form of lower radiation dose and frame rate or time-limited "pulsed" settings. However, the impact of lower settings on image quality has not been assessed, and no standard protocol exists for fluoroscopy settings used during ERCP. Patients and methods This was a single-center, double-blind, prospective randomized study of consecutive adult patients undergoing standard-of-care ERCP at a tertiary academic medical center. Patients were randomized into two groups: 1) standard-dose pulsed and 2) low-dose pulsed. Pulsed mode (8 fps) was defined as x-ray exposure either in the manufacturer standard-dose or low-dose settings limited to 3 seconds each time the foot-operated switch was depressed. Results Seventy-eight patients undergoing ERCP were enrolled and randomized. No difference in age, gender, or body mass index was found between the two groups. No significant difference in image quality was found between standard-dose and low-dose fluoroscopy P = 0.925). The low-dose group was exposed to significantly less radiation when compared with standard-dose P < 0.05). Fluoroscopy time (minutes) was similar in both groups (2.0 vs 1.9), further suggesting that group assignment had no impact on image quality or procedure time. Conclusions Low-dose pulsed fluoroscopy is a reliable method that substantially reduces radiation without compromising image quality or affecting procedure or fluoroscopy times. This underscores the need for standardization in ERCP fluoroscopy settings to limit radiation exposure.

ERCP using balloon-assisted endoscopes versus EUS-guided treatment for common bile duct stones in Roux-en-Y gastrectomy

BACKGROUND AND AIMS

We compared ERCP using a balloon-assisted endoscope (BE-ERCP) with EUS-guided antegrade treatment (EUS-AG) for removal of common bile duct (CBD) stones in patients with Roux-en-Y (R-Y) gastrectomy.

METHODS

Consecutive patients who had previous R-Y gastrectomy undergoing BE-ERCP or EUS-AG for CBD stones in 16 centers were retrospectively analyzed.

RESULTS

BE-ERCP and EUS-AG were performed in 588 and 59 patients, respectively. Baseline characteristics were similar, except for CBD diameter and angle. The technical success rate was 83.7% versus 83.1% (P = .956), complete stone removal rate was 78.1% versus 67.8% (P = .102), and early adverse event rate was 10.2% versus 18.6% (P = .076) in BE-ERCP and EUS-AG, respectively. The mean number of endoscopic sessions was smaller in BE-ERCP (1.5 ± .8 vs 1.9 ± 1.0 sessions, P = .01), whereas the median total treatment time was longer (90 vs 61.5 minutes, P = .001). Among patients with biliary access, the complete stone removal rate was significantly higher in BE-ERCP (93.3% vs 81.6%, P = .009). Negative predictive factors were CBD diameter ≥15 mm (odds ratio [OR], .41) and an angle of CBD <90 degrees (OR, .39) in BE-ERCP and a stone size ≥10 mm (OR, .07) and an angle of CBD <90 degrees (OR, .07) in EUS-AG. The 1-year recurrence rate was 8.3% in both groups.

CONCLUSIONS

Effectiveness and safety of BE-ERCP and EUS-AG were comparable in CBD stone removal for patients after R-Y gastrectomy, but complete stone removal after technical success was superior in BE-ERCP.

Radiation exposure during modern therapeutic endoscopic ultrasound procedures and standard alternatives

Background and study aims  Therapeutic EUS (t-EUS) is increasingly being adopted in clinical practice in tertiary referral centers; however, little is known about radiation exposure (RE) metrics and diagnostic reference limits for it. Methods  Kerma-area product (KAP [Gy·cm ² ]), Air Kerma and fluoroscopy time were retrospectively evaluated for all consecutive t-EUS procedures performed in San Raffaele Institute between 2019 and 2021. For EUS-guided choledochoduodenostomies (EUS-CDS) and gastroenterostomies (EUS-GE), an equal number of endoscopic retrograde cholangiopancreatographies (ERCPs) plus metal stenting and duodenal stents were included respectively for comparison. Results  Data from 141 t-EUS procedures were retrieved (49 % pancreatic cancer, 38 % peripancreatic fluid collections). EUS-CDS (N = 44) were mainly performed fluoroless, while ERCPs required a significantly higher RE (KAP = 25 [17-55], P < 0.0001). Fluid collection drainage (EUS-FCD) with lumen apposing metal stents (LAMS, N = 26) were performed fluoroless, while EUS-FCD with double-pigtail plastic stents (DPPS, N = 28) required higher RE (KAP = 23 [13-45]). EUS-guided gallbladder drainage (EUS-GBD, N = 6) required scarce RE (KAP = 9 [3-21]) for coaxial DPPS placement. EUS-GE (N = 27) required higher RE than duodenal stenting (KAP = 44 [28-88] versus 29 [19-46], P = 0.03). EUS-guided hepaticogastrostomies (EUS-HGS, N = 10) had the highest RE among t-EUS procedures (KAP = 81 [49-123]). Procedure complexity or intervening complications were evaluated and resulted in higher RE within each procedure. Conclusions  t-EUS procedures have different RE ( P  < 0.000001). EUS-CDS, EUS-GBD, and EUS-FCD with LAMS can be performed with no-to-mild radioscopy, unlike standard alternatives. However, radioscopy remains essential in case of technical difficulties or complications. EUS-GE and EUS-HGS involve a high RE. Endoscopists involved in t-EUS might experience RE higher than category standards, which indicates a need for increased awareness and personalized preventive measures.

How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology?

Fluoroscopy-guided endoscopic procedures (FGEPs) are rapidly gaining popularity in the field of gastroenterology. Radiation is a well-known health hazard. Gastroenterologists who perform FGEPs are required to protect themselves, patients, as well as nurses and radiologists engaged in examinations from radiation exposure. To achieve this, all gastroenterologists must first understand and adhere to the International Commission on Radiological Protection Publication. In particular, it is necessary to understand the three principles of radiation protection (Justification, Optimization, and Dose Limits), the As Low As Reasonably Achievable principle, and the Diagnostic Reference Levels (DRLs) according to them. This review will mainly explain the three principles of radiation exposure protection, DRLs, and occupational radiological protection in interventional procedures while introducing related findings. Gastroenterologists must gain knowledge of radiation exposure protection and keep it updated.

The radiation doses and radiation protection on the endoscopic retrograde cholangiopancreatography procedures

Although many interventions involving radiation exposure have been replaced to endoscopic procedure in the gastrointestinal and hepatobiliary fields, there remains no alternative for enteroscopy and endoscopic retrograde cholangiopancreatography (ERCP), which requires the use of radiation. In this review, we discuss the radiation doses and protective measures of endoscopic procedures, especially for ERCP. For the patient radiation dose, the average dose area product for diagnostic ERCP was 14-26 Gy.cm², while it increased to as high as 67-89 Gy.cm² for therapeutic ERCP. The corresponding entrance skin doses for diagnostic and therapeutic ERCP were 90 and 250 mGy, respectively. The mean effective doses were 3- 6 mSv for diagnostic ERCP and 12-20 mSv for therapeutic ERCP. For the occupational radiation dose, the typical doses were 94 μGy and 75 μGy for the eye and neck, respectively. However, with an over-couch-type X-ray unit, the eye and neck doses reached as high as 550 and 450 μGy, with maximal doses of up to 2.8 and 2.4 mGy/procedure, respectively.A protective lead shield was effective for an over couch X-ray tube unit. It lowered scattered radiation by up to 89.1% in a phantom study. In actual measurements, the radiation exposure of the endoscopist closest to the unit was reduced to approximately 12%. In conclusion, there is a clear need for raising awareness among medical personnel involved endoscopic procedures to minimise radiation risks to both the patients and staff.