Phantom study to determine radiation exposure to medical personnel involved in ERCP fluoroscopy and its reduction through equipment and behavior modifications

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.

Acute Pancreatitis during and after Pregnancy: A Review

During pregnancy and in the post-partum period, several diseases may arise or become exacerbated. Acute pancreatitis is an inflammatory disease with an increasing incidence in Western countries. The incidence of acute pancreatitis during pregnancy is not different with respect to the general population, but this incidence increases in the first 2 years after delivery. Biliary sludge and stones are the most frequent aetiologies, followed by hypertriglyceridemia. Taking care of the mother and foetus through a potentially severe disease requires a team consisting of an obstetrician, a gastroenterologist, an anaesthesiologist, and a surgeon. It is necessary to monitor the health of the foetus/child and the mother during pregnancy, childbirth, and puerperium. The management of this care depends on the systemic and local complications, the severity of the acute pancreatitis, and the trimester of pregnancy. Some diagnostic tools and many drugs are not safe for foetuses, while interventional endoscopy and surgery have limitations and can only be used after an accurate evaluation of benefit/risk ratios. Despite these limitations, maternal mortality due to acute pancreatitis is low during pregnancy, mainly thanks to multidisciplinary approaches for these patients. A careful diet to prevent obesity, alcohol abstinence, routine serum triglyceride control, and breastfeeding for at least three months may prevent acute pancreatitis during and after pregnancy.

Minimizing radiation exposure in endoscopic retrograde cholangiopancreatography: a review for medical personnel

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.

Use of Artificial Intelligence to Reduce Radiation Exposure at Fluoroscopy-Guided Endoscopic Procedures

OBJECTIVES

Exposure to ionizing radiation remains a hazard for patients and healthcare providers. We evaluated the utility of an artificial intelligence (AI)-enabled fluoroscopy system to minimize radiation exposure during image-guided endoscopic procedures.

METHODS

We conducted a prospective study of 100 consecutive patients who underwent fluoroscopy-guided endoscopic procedures. Patients underwent interventions using either conventional or AI-equipped fluoroscopy system that uses ultrafast collimation to limit radiation exposure to the region of interest. The main outcome measure was to compare radiation exposure with patients, which was measured by dose area product. Secondary outcome was radiation scatter to endoscopy personnel measured using dosimeter.

RESULTS

Of 100 patients who underwent procedures using traditional (n = 50) or AI-enabled (n = 50) fluoroscopy systems, there was no significant difference in demographics, body mass index, procedural type, and procedural or fluoroscopy time between the conventional and the AI-enabled fluoroscopy systems. Radiation exposure to patients was lower (median dose area product 2,178 vs 5,708 mGym, P = 0.001) and scatter effect to endoscopy personnel was less (total deep dose equivalent 0.28 vs 0.69 mSv; difference of 59.4%) for AI-enabled fluoroscopy as compared to conventional system. On multivariate linear regression analysis, after adjusting for patient characteristics, procedural/fluoroscopy duration, and type of fluoroscopy system, only AI-equipped fluoroscopy system (coefficient 3,331.9 [95% confidence interval: 1,926.8-4,737.1, P < 0.001) and fluoroscopy duration (coefficient 813.2 [95% confidence interval: 640.5-985.9], P < 0.001) were associated with radiation exposure.

DISCUSSION

The AI-enabled fluoroscopy system significantly reduces radiation exposure to patients and scatter effect to endoscopy personnel (see Graphical abstract, Supplementary Digital Content, http://links.lww.com/AJG/B461).

Radiation exposure during endoscopic retrograde cholangiopancreatography according to clinical determinants

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.

Radiation protection effect of mobile shield barrier for the medical personnel during endoscopic retrograde cholangiopancreatography: a quasi-experimental prospective study

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.

Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography

AIM

To systematically review safety/efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography (ERCP) performed during pregnancy, considering fetal viability, fetal teratogenicity, premature delivery, and future postpartum development of the infant.

METHODS

Systematic computerized literature search performed using PubMed with the key words “ERCP” and “pregnancy”. Two clinicians independently reviewed the literature, and decided on which articles to incorporate in this review based on consensus and preassigned priorities. Large clinical trials, meta-analyses, systematic reviews, and controlled trials were assigned higher priority than review articles or small clinical series, and individual case reports were assigned lowest priority. Dr. Cappell has formal training and considerable experience in conducting systematic reviews, with 4 published systematic reviews in peer-reviewed journals indexed in PubMed during the last 2 years, and with a PhD in neurophysiology that involved 5 years of training and research in biomedical statistics.

RESULTS

Advances in imaging modalities, including abdominal ultrasound, MRCP, and endoscopic ultrasound, have generally obviated the need for diagnostic ERCP in non-pregnant and pregnant patients. Clinical experience with performing ERCP during pregnancy is burgeoning, with > 500 cases of therapeutic ERCP reported in the literature, aside from a national registry study of 58 patients. These studies show that therapeutic ERCP has a very high rate of technical success in clearing the bile duct of gallstones, and has a relatively low and acceptable rate of maternal and fetal complications. The great majority of births after therapeutic ERCP are full-term, have normal birth weights, and are healthy. A recent trend is performing ERCP without radiation to eliminate radiation teratogenicity. Systematic literature review reveals 147 cases of ERCP without fluoroscopy in 8 clinical series. These studies demonstrate extremely high technical success in endoscopically removing choledocholithiasis, favorable maternal outcomes with rare maternal ERCP complications, and excellent fetal outcomes. ERCP without fluoroscopy generally confirms proper biliary cannulation by aspiration of yellow bile per sphincterotome or leakage of yellow bile around an inserted guide-wire.

CONCLUSION

This systematic literature review reveals ERCP is relatively safe and efficacious during pregnancy, with relatively favorable maternal and fetal outcomes after ERCP. Recommendations are provided about ERCP indications, special ERCP techniques during pregnancy, and prospects for future research.

Occupation-associated health hazards for the gastroenterologist/endoscopist

Advances in the field of endoscopy have allowed gastroenterologists to obtain detailed imaging of anatomical structures and to treat gastrointestinal diseases with endoscopic therapies. However, these technological developments have exposed endoscopists and staff to hazards such as musculoskeletal injuries, exposure to infectious agents, and ionizing radiation. We aimed to review the occupational hazards for the gastroenterologist and endoscopist. Using PubMed, Medline, Medscape, and Google Scholar, we identified peer-reviewed articles with the keywords “occupational hazards,” “health hazards,” “occupational health hazards,” “endoscopy,” “gastroenterologist,” “infectious agents,” “musculoskeletal injuries,” and “radiation.” Strategies for reducing exposure to infectious agents, radiation, and the risk of musculoskeletal injuries related to gastroenterology include compliance with established standard measures, the use of thyroid shields and radioprotective eyewear, and ergonomic practices. We conclude that educating endoscopic personnel and trainees in these practices, in addition to further research in these areas, will likely lead to the development of more efficient and user-friendly workspaces that are safer for patients and personnel.

A simple ergonomic measure reduces fluoroscopy time during ERCP: A multivariate analysis

Background and study aims Endoscopic retrograde cholangiopancreatgraphy (ERCP) carries a radiation risk to patients undergoing the procedure and the team performing it. Fluoroscopy time (FT) has been shown to have a linear relationship with radiation exposure during ERCP. Recent modifications to our ERCP suite design were felt to impact fluoroscopy time and ergonomics. This multivariate analysis was therefore undertaken to investigate these effects, and to identify and validate various clinical, procedural and ergonomic factors influencing the total fluoroscopy time during ERCP. This would better assist clinicians with predicting prolonged fluoroscopic durations and to undertake relevant precautions accordingly. Patients and methods A retrospective analysis of 299 ERCPs performed by 4 endoscopists over an 18-month period, at a single tertiary care center was conducted. All inpatients/outpatients (121 males, 178 females) undergoing ERCP for any clinical indication from January 2012 to June 2013 in the chosen ERCP suite were included in the study. Various predetermined clinical, procedural and ergonomic factors were obtained via chart review. Univariate analyses identified factors to be included in the multivariate regression model with FT as the dependent variable. Results Bringing the endoscopy and fluoroscopy screens next to each other was associated with a significantly lesser FT than when the screens were separated further (-1.4 min, P = 0.026). Other significant factors associated with a prolonged FT included having a prior ERCP (+ 1.4 min, P = 0.031), and more difficult procedures (+ 4.2 min for each level of difficulty, P < 0.001). ERCPs performed by high-volume endoscopists used lesser FT vs. low-volume endoscopists (-1.82, P = 0.015). Conclusions Our study has identified and validated various factors that affect the total fluoroscopy time during ERCP. This is the first study to show that decreasing the distance between the endoscopy and fluoroscopy screens in the ERCP suite significantly reduces the total fluoroscopy time, and therefore radiation exposure to patients and staff involved in the procedure.

Evaluation of radiation doses in patient and medical staff during endoscopic retrograde cholangiopancreatography procedures

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.

A double-blind, randomized, sham-controlled trial of the effect of a radiation-attenuating drape on radiation exposure to endoscopy staff during ERCP

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%.

Non-radiation endoscopic removal of common bile duct stone assisted with abdominal ultrasonography in a pregnant patient

A common bile duct stone was detected in a pregnant patient who was in her second trimester. Avoiding the use of fluoroscopy, abdominal ultrasonography-assisted endoscopic removal of the stone was successful.

Predicting native papilla biliary cannulation success using a multinational Endoscopic Retrograde Cholangiopancreatography (ERCP) Quality Network

Background

Success in deep biliary cannulation via native ampullae of Vater is an accepted measure of competence in ERCP training and practice, yet prior studies focused on predicting adverse events alone, rather than success. Our aim is to determine factors associated with deep biliary cannulation success, with/ without precut sphincterotomy.

Methods

The ERCP Quality Network is a unique prospective database of over 10,000 procedures by over 80 endoscopists over several countries. After data cleaning, and eliminating previously stented or cut papillae, two multilevel fixed effect multivariate models were used to control for clustering within physicians, to predict biliary cannulation success, with and without allowing “precut” to assist an initially failed cannulation.

Results

13018 ERCPs were performed by 85 endoscopists (March 2007 - May 2011). Conventional (without precut) and overall cannulation rates were 89.8% and 95.6%, respectively. Precut was performed in 876 (6.7%). Conventional success was more likely in outpatients (OR 1.21), but less likely in complex contexts (OR 0.59), sicker patients (ASA grade (II, III/V: OR 0.81, 0.77)), teaching cases (OR 0.53), and certain indications (strictures, active pancreatitis). Overall cannulation success (some precut-assisted) was more likely with higher volume endoscopists (> 239/year: OR 2.79), more efficient fluoroscopy practices (OR 1.72), and lower with moderate (versus deeper) sedation (OR 0.67).

Conclusion

Biliary cannulation success appears influenced by both patient and practitioner factors. Patient- and case-specific factors have greater impact on conventional (precut-free) cannulation success, but volume influences ultimate success; both may be used to select appropriate cases and can help guide credentialing policies.

Optimisation of Radiation Exposure to Gastroenterologists and Patients during Therapeutic ERCP

This study intended to optimize the radiation doses for gastroenterologists and patients during therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and to compare the doses based on available data obtained by other researchers. A total of 153 patients were studied in two Gastroenterology Departments, (group A, 111; group B, 42). Thermoluminescent dosimeters (TLD) were used to measure the staff and patients entrance surface air kerma (ESAK) at different body sites. The mean ESAK and effective doses per procedure were estimated to be 68.75 mGy and 2.74 mSv, respectively. Staff was exposed to a heterogonous doses. The third examiner (trainee) was exposed to a high dose compared with other examiners because no shield was located to protect him from stray radiation. Patients and examiners doses were lower compared to the lowest values found in previous studies taking into consideration the heterogeneity of patients and equipment. Staff doses during ERCP are within the safety limit in the light of the current practice.

The impact of endoscopic retrograde cholangiopancreatography education on radiation exposure to experienced endoscopist: 'trainee effect'

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.

Retrospective analysis of radiation exposure during endoscopic retrograde cholagiopancreatography: critical determinants

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.

Patient and endoscopist radiation doses during ERCP procedures

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.

Radiation dose to patients during endoscopic retrograde cholangiopancreatography

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.

Systematic review and meta-analysis of intraoperative versus preoperative endoscopic sphincterotomy in patients with gallbladder and suspected common bile duct stones

BACKGROUND

Most patients with gallbladder and common bile duct stones are treated by preoperative endoscopic sphincterotomy (POES) followed by laparoscopic cholecystectomy. Recently, intraoperative endoscopic sphincterotomy (IOES) during laparoscopic cholecystectomy has been suggested as an alternative treatment.

METHODS

Data from randomized clinical trials related to safety and effectiveness of IOES versus POES were extracted by two independent reviewers. Risk ratios (RRs) or mean differences were calculated with 95 per cent confidence intervals based on intention-to-treat analysis whenever possible.

RESULTS

Four trials with 532 patients comparing IOES with POES were included. There were no deaths. There was no significant difference in rates of ampullary cannulation (RR 1·01, 0·97 to 1·04; P = 0·70) or stone clearance by ES (RR 0·99, 0·96 to 1·02; P = 0·58) between the groups. The proportion of patients with at least one post-ES complication, including pancreatitis, bleeding, perforation, cholangitis, cholecystitis or gastric ulcer, was significantly lower in the IOES group (RR 0·37, 0·18 to 0·78; P = 0·009). There was no significant difference in morbidity after laparoscopic cholecystectomy or requirement for open operation between the groups. Mean hospital stay was 3 days shorter in the IOES group: mean difference - 2·83 (-3·66 to - 2·00) days (P < 0·001).

CONCLUSION

In patients with gallbladder and common bile duct stones, IOES is as effective and safe as POES and results in a significantly shorter hospital stay.

Occupational exposure to staff during endoscopic retrograde cholangiopancreatography in Sudan

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.

ERCP in the sitting position--an alternative technique with potential benefits (with video)

The authors describe a new technique of performing endoscopic retrograde cholangiopancreatography in the sitting position with special emphasis on methods of stabilization of the duodenoscope during the procedure. The article is accompanied by an instructional video. The benefits of this comfortable alternative to the standard standing position and its potential limitations are discussed.

Reduction of radiation doses to patients and staff during endoscopic retrograde cholangiopancreatography

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.

Prospective analysis of fluoroscopy duration during ERCP: critical determinants

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.

Endoscopic sphincterotomy combined with large balloon dilation can reduce the procedure time and fluoroscopy time for removal of large bile duct stones

OBJECTIVES

We sought to evaluate the safety, efficacy, and feasibility of endoscopic sphincterotomy plus large balloon dilation (ESLBD) and to compare procedural time and fluoroscopy time of ESLBD with those of endoscopic sphincterotomy (EST) alone for patients with large bile duct stones.

METHODS

Retrospective analysis.

RESULTS

A total of 101 patients with large bile duct stones were treated: 53 were treated by ESLBD and 48 with EST alone. ESLBD resulted in similar outcomes in overall successful stone removal (100% vs. 97%) and complications (4% vs. 6%); however, although the rate of complete stone removal in the first session using ESLBD tended to be higher than when EST alone was used, it was not statistically significant (96% vs. 85%, P=0.057). Mechanical lithotripsy was required significantly more often in the EST group compared to the ESLBD group (25% vs. 6%, P<0.01). Total procedure time in the ESLBD group was significantly shorter than that of the EST group (32 vs. 40 min, P<0.05). Total fluoroscopy time in the ESLBD group was significantly shorter in the EST group (13 vs. 22 min, P<0.05).

CONCLUSIONS

ESLBD is an effective and safe treatment in patients with large bile duct stones. In addition, ESLBD appears to decrease procedure time and fluoroscopy time and reduce the need for mechanical lithotripsy as compared to EST alone.

Endoscopy in pregnancy

Endoscopy is rarely required during pregnancy. The potential risks of endoscopy during pregnancy include foetal hypoxia due to sedative drugs and exposure to radiation. There is no evidence that endoscopy precipitates premature labour, and studies in this area have concluded that endoscopy during pregnancy is generally safe. There should be a strong indication for the procedure, which should be deferred whenever possible to the second trimester. Procedures should be performed without any sedation, or with the lowest dose of sedative medication. Radiation exposure should be kept to a minimum. Support should be obtained from specialists in obstetrics and anaesthesia. Indications for endoscopy during pregnancy are as follows: (1) gastroscopy: upper gastrointestinal bleeding, dysphagia, uncontrolled nausea/vomiting; (2) sigmoidoscopy/colonoscopy: rectal bleeding, diarrhoea; and (3) ERCP: choledocholithiasis, biliary pancreatitis. Sedative drugs, such as midazolam appear to be safe if used carefully. Radiation exposure during ERCP can be kept well below the danger level for teratogenicity.

Time-limited fluoroscopy to reduce radiation exposure during ERCP: a prospective randomized trial

BACKGROUND

Measures should be used to limit radiation exposure of the staff and patients during ERCP.

OBJECTIVE

To determine whether "time-limited fluoroscopy" reduces radiation exposure and fluoroscopy time (FT) compared with continuous fluoroscopy.

DESIGN

Prospective randomized trial.

SETTING

Tertiary academic medical center.

PATIENTS

Consecutive adult patients presenting for ERCP.

INTERVENTIONS

Subjects were randomized into 2 fluoroscopy setting groups: (1) time-limited, where x-ray exposure is limited to 3 seconds each time the foot-operated switch is depressed; (2) continuous, where x-ray exposure continues for as long as the switch is depressed.

MAIN OUTCOMES MEASUREMENTS

FT, patient, and procedure-related data were recorded. Radiation dosimetry badges were used to estimate cumulative exposure.

RESULTS

Ninety-nine procedures were performed in the time-limited group and 100 by using continuous fluoroscopy. The mean FT for time-limited fluoroscopy was 284.4 seconds (95% confidence interval [CI] 247.1-321.6) and for continuous fluoroscopy was 314 seconds (95% CI 265.6-362.4; P=.34). Longer FT was associated with moderate or difficult cannulation (P=.008), lithotripsy (P<.001), stent placement (P=.007), sphincterotomy (P<.001), and longer overall procedure length (P<0.001). After controlling for confounding factors and interactions with a multiple linear regression model, time-limited fluoroscopy was associated with a 16.4% lower FT (P=.029). The average radiation dose was not amenable to multivariate analysis, and, therefore, no significant difference between groups was found.

LIMITATIONS

Endoscopists were not blinded to the study group assignments.

CONCLUSIONS

FT and radiation exposure are dependent upon numerous patient-, operator-, and procedure-related factors. This study found that, after controlling for the impact of confounding factors, time-limited fluoroscopy significantly decreases FTs.

Evaluation of non-lead-based protective radiological material in spinal surgery

BACKGROUND CONTEXT

Traditionally, lead-based garments are the standard method of intraoperative radiation protection during fluoroscopy. Unfortunately, the lead used is heavy, lacks durability, is difficult to launder, and its disposal is associated with environmental hazards.

PURPOSE

An evaluation of the protective radiation efficiency of three commercially available radiation protective garments compared with a standardized lead protective shield.

STUDY DESIGN/SETTING

Measured radiation transmission through lead and three commercially available lightweight radiological protective garments (Xenolite, EarthSafe, and Demron) was performed using a standard, calibrated dosimeter.

METHODS

Radiation transmission, attenuation, lead equivalencies as well as garment weight comparisons were measured. The tests were repeated through a range of voltage and tube current settings that are common to clinical radiological applications (60-120 keV).

RESULTS

All materials tested demonstrated effectiveness at common clinically relevant energy exposures (100 keV). EarthSafe and Xenolite demonstrated 0.5 mm lead equivalency protection at 80 and 100 keV X-ray energies but not at higher energy levels (>100 keV), which is where most radiological procedures are performed utilizing more advanced technological imaging equipment. Demron was best able to effectively shield ionizing radiation at higher energy levels (>100 keV). The lightweight nature of these lead-free materials may result in less fatigue and musculoskeletal complaints by the wearer.

CONCLUSIONS

Of the tested lead-free garments, Demron appears to offer equivalent levels of protection to standard lead-based shields within traditional energy zones but with less weight than standard lead-based shields.

Effect of physician training on fluoroscopy time during ERCP

Our purpose was to compare fluoroscopy time during endoscopic retrograde cholangiopancreatography (ERCP) between endoscopists with different levels of experience. We performed a cross-sectional analysis of 269 consecutive ERCPs at an academic hospital during 1 year. Median fluoroscopy time was significantly longer in more complex cases, such as in therapeutic (406.5 s [IQR, 235.5-685]) compared to diagnostic (202 s [IQR, 141-481]; P = 0.002) procedures. The experience (number of prior ERCPs) of gastroenterology fellows involved in procedures was an independent predictor of shorter fluoroscopy time when controlling for patient and procedure characteristics (P < 0.0001). Median fluoroscopy time was 2.73 min shorter after at least 50 procedures had been performed (P = 0.039). Time for ERCPs involving fellows was not significantly longer than cases by attending physicians alone (P = 0.23). Increased experience is associated with lower radiation exposure during ERCP training. Radiation reduction methods should be prospectively investigated and integrated into training programs.