Radiation Training, Radiation Protection, and Fluoroscopy Utilization Practices Among US Therapeutic Endoscopists

Patient Radiation Exposure during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy (with Video)

BACKGROUND

Fluoroscopy must be used cautiously during endoscopic retrograde cholangiopancreatography (ERCP). Radiation exposure data in patients with surgically altered anatomy undergoing enteroscopy-assisted ERCP (EA-ERCP) are scarce.

METHODS

34 consecutive EA-ERCP procedures were compared with 68 conventional ERCP (C-ERCP) procedures. Patient and procedure characteristics and radiation data were collected.

RESULTS

Surgical reconstructions were gastrojejunostomy, Roux-en-Y hepaticojejunostomy, Roux-en-Y total gastrectomy, Roux-en-Y gastric bypass and Whipple's duodenopancreatectomy. Procedures were restricted to biliary indications. Mean fluoroscopy time was comparable in both groups (370 ± 30 s EA-ERCP vs. 393 ± 40 s C-ERCP, p = 0.7074), whereas total mean radiation dose was lower in EA-ERCP (83 ± 6 mGy) compared to C-ERCP (110 ± 11 mGy, p = 0.0491) and dose area product (DAP) was higher in EA-ERCP (2216 ± 173 µGy*m2) compared to C-ERCP (1600 ± 117 µGy*m2, p = 0.0038), as was total procedure time (77 ± 5 min vs. 39 ± 3 min, p < 0.0001). Enteroscope insertion to reach the bile duct during EA-ERCP took 28 ± 4 min, ranging from 4 to 90 min. These results indicate that C-ERCP procedures are generally more complex, needing magnified fluoroscopy, whereas EA-ERCP procedures take more time for enteroscope insertion under wide field fluoroscopic guidance (increased DAP) with less complex ERCP manipulation (lower total radiation dose).

CONCLUSIONS

Radiation exposure during EA-ERCP in surgically altered anatomy is different as compared to C-ERCP. EA-ERCP takes longer with a higher DAP because of the enteroscope insertion, but with lower total radiation dose because these ERCP procedures are usually less complex.

A follow-up questionnaire survey 2022 on radiation protection among 464 medical staff from 34 endoscopy-fluoroscopy departments in Japan

Objectives

We surveyed and reported low protective equipment usage and insufficient knowledge among endoscopy-fluoroscopy departments in Japan in 2020. Two years later, we conducted a follow-up survey of doctors, nurses, and technologists in Japan.

Methods

We conducted a questionnaire survey on radiation protection from May to June 2022. The participants were medical staff, including doctors, nurses, and radiological and endoscopy technicians in endoscopy-fluoroscopy departments. The questionnaire included 17 multiple-choice questions divided into three parts: background, equipment, and knowledge.

Results

We surveyed 464 subjects from 34 institutions. There were 267 doctors (58%), 153 nurses (33%), and 44 technologists (9%). The rate of wearing a lead apron was 98% in this study. The rates of wearing a thyroid collar, lead glasses, and radiation dosimeter were 27%, 35%, and 74%, respectively. The trend of the protective equipment rate was similar to that of our previous study; however, radiation dosimetry among doctors was still low at 58%. The percentage of subjects who knew the radiation exposure (REX) dose of each procedure was low at 18%. Seventy-six percent of the subjects attended lectures on radiation protection, and 73% knew about the three principles of radiation protection; however, the concept of diagnostic reference levels was not well known (18%). Approximately 60% of the subjects knew about the exposure dose increasing cancer mortality (63%) and the 5-year lens REX limit (56%).

Conclusions

There was some improvement in radiation protection equipment or education, but relatively little compared to the 2020 survey of endoscopy departments.

Quantifying Radiation Doses in Common Endoscopic Retrograde Cholangiopancreatography Scenarios: An Evaluation of Radiation Safety Measures in a Real-World Environment

Introduction Radiation safety training remains variable among gastroenterologists performing endoscopic retrograde cholangiopancreatography (ERCP). This study sought to ascribe dosimeter readings to various real-world ERCP scenarios to provide data supporting the 3 pillars of radiation safety: distance, time, and shielding. Methods An ERCP fluoroscopy unit was used to generate radiation scatter from 2 differently sized anthropomorphic phantoms. Radiation scatter was measured at various distances from the emitter, with and without a lead apron, and at various frame rates (measured in frames per second, fps) and degrees of fluoroscopy pedal actuation. An image quality phantom was used to assess resolution at various frame rates and air gaps. Results Increasing the distance resulted in a decrease in measured scatter (from 0.75 mR/h at 1.5 ft to 0.15 mR/h at 9 ft with the average phantom and from 50 mR/h at 1.5 ft to 3.06 mR/h at 9 ft with the large phantom). Depressing the fluoroscopy pedal less frequently, or decreasing the frame rate (ie, increasing the time per frame), resulted in a linear decrease in scatter (from 55 mR/h at 8 fps to 24.5 mR/h at 4 fps and 13.60 mR/h at 2 fps). Providing shielding through the presence of a 0.5-mm lead apron reduced scatter (from 4.10 to 0.11 mR/h with the average phantom; from 15.30 mR/h to 0.43 mR/h with the large phantom). However, decreasing the frame rate from 8 fps to 2 fps did not change the number of line pairs identified on the image phantom. A greater air gap increased the number of line pairs resolved. Conclusions Implementing the 3 pillars of radiation safety led to a quantifiable, clinically significant decrease in radiation scatter. The authors hope that these findings spark greater implementation of radiation safety measures among practitioners utilizing fluoroscopy.

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.

Diagnostic Reference Levels for Fluoroscopy-guided Gastrointestinal Procedures in Japan from the REX-GI Study: A Nationwide Multicentre Prospective Observational Study

BACKGROUND

Diagnostic reference levels (DRLs) are required to optimize medical exposure. However, data on DRLs for interventional fluoroscopic procedures are lacking, especially in gastroenterology. This study aimed to prospectively collect currently used radiation doses and help establish national DRLs for fluoroscopy-guided gastrointestinal procedures in Japan.

METHODS

This multicentre, prospective, observational study collected actual radiation dose data from endoscopic retrograde cholangiopancreatography (ERCP), interventional endoscopic ultrasound (EUS), balloon-assisted enteroscopy (BAE), enteral metallic stent placement, and enteral tube placement from May 2019 to December 2020. The study outcomes were fluoroscopy time (FT: min), air kerma at the patient entrance reference point (Ka,r: mGy), air kerma area product (PKA: Gycm2), and radiation dose rate (RDR: mGy/min). Additionally, the basic settings of fluoroscopy equipment and the factors related to each procedure were investigated. This study was registered in the UMIN Clinical Trial Registry (UMIN 000036525).

FINDINGS

Overall, 12959 fluoroscopy-guided gastrointestinal procedures were included from 23 hospitals in Japan. For 11162 ERCPs, the median/third quartile values of Ka,r (mGy), PKA (Gycm2), and FT (min) were 69/145 mGy, 16/32 Gycm2, and 11/20 min, respectively. Similarly, these values were 106/219 mGy, 23/41 Gycm2 and 17/27 min for 374 interventional EUSs; 53/104 mGy, 16/32 Gycm2 and 10/15 min for 523 metallic stents; 56/104 mGy, 28/47 Gycm2, and 12/18 min for 599 tube placements; and 35/81 mGy, 16/43 Gycm2 and 7/15 min for 301 BAEs, respectively. For the overall radiation dose rate, the median/third quartile values of RDR were 5.9/9.4 (mGy/min). The RDR values at each institution varied widely.

INTERPRETATION

This study reports the current radiation doses of fluoroscopy-guided gastrointestinal procedures expressed as DRL quantities. This will serve as a valuable reference for national DRL values.

FUNDING

This work was supported by a clinical research grant from the Japanese Society of Gastroenterology.

Predictors of Prolonged Fluoroscopy Exposure in Pediatric Endoscopic Retrograde Cholangiopancreatography: Results From the Large Pediatric Endoscopic Retrograde Cholangiopancreatography Database Initiative Multicenter Cohort

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.

Endoscopic retrograde cholangiopancreatography and endoscopic ultrasound in children

Gastrointestinal endoscopy is fundamental to diagnostic and therapeutic procedures in pediatric gastroenterology. In the decades since endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasound (EUS) for hepatobiliary and pancreatic disease were introduced into clinical practice, there has been increasing interest in these procedures, and practice guidelines and position papers that clearly define the role of ERCP and EUS in children have been published. Based on the distinction of endoscopy between children and adults, this review focuses on the current state of ERCP and EUS procedures in children, including the types of endoscopes used in children, general anesthesia and radiation exposure, biliary and pancreatic indications, considerations of education and training for ERCP and EUS procedures in children, and expectations for development of endoscopes for children.

Strategy to Reduce the Collective Equivalent Dose for the Lens of the Physician's Eye Using Short Radiation Protection Curtains to Prevent Cataracts

A short curtain that improves on the low versatility of existing long curtains was developed as a dedicated radiation protective device for the over-table tube fluorographic imaging units. The effect of this short curtain in preventing cataracts was then examined. First, the physician lens dose reduction rate was obtained at the position of the lens. Next, the reduction rate in the collective equivalent dose for the lens of the physician's eye was estimated. The results showed that lens dose reduction rates with the long curtain and the short curtain were 88.9% (literature-based value) and 17.6%, respectively, higher with the long curtain. In our hospital, the reduction rate in the collective equivalent dose for the lens of the physician's eye was 9.8% and 17.6% with a procedures mixture, using the long curtain where technically possible and no curtain in all other procedures, and the short curtain in all procedures, respectively, higher with the short curtain. Moreover, a best available for curtains raised the reduction rate in the collective equivalent dose for the lens of the physician's eye a maximum of 25.5%. By introducing the short curtain, it can be expected to have an effect in preventing cataracts in medical staff.

Does Surgical Experience Decrease Radiation Exposure in the Operating Room?

BACKGROUND

Intraoperative fluoroscopy facilitates minimally invasive surgery, and although it is irreplaceable in terms of intraoperative guidance, it results in substantial radiation exposure to the patient and surgical team. Although the risk of radiation exposure because of equipment factors has been described, there is little known about the impact of surgeon experience on radiation exposure. The aim of this study was to determine whether there is a relationship between years of surgical experience and total dose of radiation used for an archetypal pediatric orthopaedic surgical procedure that requires intraoperative fluoroscopy.

METHODS

This was a retrospective cohort study of children undergoing closed reduction and percutaneous pinning for supracondylar humerus fractures at a level I pediatric trauma center. Information pertaining to radiation dosage was gathered including fluoroscopic time, total images acquired, magnification use, and dose area product (DAP). Regression analysis was used to evaluate the effect of surgeon experience on the outcome variables.

RESULTS

A total of 759 pediatric patients treated by 17 attending surgeons were included. The median surgeon experience was 8.94 years (interquartile range, 5.9 to 19.8). Increased number of pins was associated with increased DAP (P<0.001) and lower years of experience (P=0.025). There was significantly higher fluoroscopy time in seconds (56.9 vs. 42.1 s, P=0.001), DAP (179.9 vs. 110.3 mGy-cm2, P=0.001), use of magnification (39.5 vs. 31.9 s, P=0.043), and total number of images obtained (74.5 vs. 57.6, P=0.008) in attending surgeons with <1 year of experience compared with those with greater experience. An operator extremity was visible in at least 1 saved image in 263 of 759 (35%) cases.

CONCLUSION

Increased surgical experience was significantly associated with decreased fluoroscopy usage, including time, number of images, and dose. Surgeon inexperience increases radiation exposure for patients and staff by over 60% when treating supracondylar humerus fractures. This study clearly identifies methods to reduce radiation exposure, including use of pulsed fluoroscopy instead of continuous fluoroscopy, decreasing use of magnification, removing the operator's extremity from the field, and judicious use and placement of each additional pin.

LEVEL OF EVIDENCE

Level III.

Radiation protection among health care workers: knowledge, attitude, practice, and clinical recommendations: a systematic review

OBJECTIVES

This study was performed to determine the knowledge, attitude, and practice (KAP) of health care workers (HCWs) towards radiation protection.

METHODS

In this systematic review study, three international databases (Web of Science, PubMed, Scopus) were searched for related published articles in the English language from 1 January 2000 to 1 February 2020. The quality of the included studies was evaluated using the Hoy et al. tool.

RESULTS

Out of the 1,848 studies examined, 41 studies that were performed on 11,050 HCWs were included in the final stage. The results indicated that in most studies, more than half (50%) of the participants had average knowledge. Furthermore, 60% of the participants had a positive attitude, but in most studies, they had average practice regarding radiation protection. The most important recommendation for improving KAP among the participants was incorporating radiation protection standards in the student curriculum.

CONCLUSION

Considering the results of the study, further attention should be paid to proper education regarding radiation protection standards and improvement of HCW performance.

A questionnaire survey on radiation protection among 282 medical staff from 26 endoscopy-fluoroscopy departments in Japan

BACKGROUND AND AIMS

It is essential for endoscopists, technologists, and nurses to understand radiation protection. However, protective equipment usage is still low, and there is little awareness of radiation protection in practice.

METHODS

We conducted a questionnaire survey on radiation protection from January to February 2020. The participants were medical staff, including medical doctors, nurses, and radiological and endoscopy technician in endoscopy-fluoroscopy departments. The questionnaire included 14 multiple-choice questions divided among three parts: background, equipment, and knowledge.

RESULTS

We surveyed a total of 282 subjects from 26 institutions. There were 168 medical doctors (60%), 90 nurses (32%), and 24 technologists (9%). Although almost all staff members (99%) always wore a lead apron, only a few wore a thyroid collar (32%) and lead glasses (21%). The rate of wearing a radiation dosimeter was insufficient (69%), especially among doctors (52%). A few subjects knew the radiation exposure dose of each procedure (15%), and slightly over half had attended lectures on radiation protection (64%) and knew about the three principles of radiation protection (59%). Protection adherence did not differ by years of experience, knowledge of fluoroscopy, awareness of radiation exposure doses, or attendance at basic lectures on radiation protection. However, medical doctors who were aware of the radiation exposure dose of each procedure were significantly more likely to wear dosimeters than those who were not (p = 0.0008).

CONCLUSION

Medical staff in endoscopy departments in Japan do not have enough radiation protection equipment or education.

Use of Biological Dosimetry for Monitoring Medical Workers Occupationally Exposed to Ionizing Radiation

Medical workers are the largest group exposed to man-made sources of ionizing radiation. The annual doses received by medical workers have decreased over the last several decades, however for some applications, like fluoroscopically guided procedures, the occupational doses still remain relatively high. Studies show that for some procedures the operator and staff still use insufficient protective and dosimetric equipment, which might cause an underestimation of medical exposures. Physical dosimetry methods are a staple for estimating occupational exposures, although due to the inconsistent use of protection measures, an alternative method such as biological dosimetry might complement the physical methods to achieve a more complete picture. Such methods were used to detect exposures to doses as low as 0.1 mSv/year, and could be useful for a more accurate assessment of genotoxic effects of ionizing radiation in medical workers. Biological dosimetry is usually based on the measurement of the effects present in peripheral blood lymphocytes. Although some methods, such as chromosome aberration scoring or micronucleus assay, show promising results, currently there is no one method recognized as most suitable for dosimetric application in the case of chronic, low-dose exposures. In this review we decided to evaluate different methods used for biological dosimetry in assessment of occupational exposures of medical workers.

A multicenter study of radiation doses to the eye lenses of clinical physicians performing radiology procedures in Japan

PURPOSE

We investigated occupational dose to the lens of the eye for physicians engaged in radiology procedures. We evaluated the potential for compliance with the new-equivalent dose limits to the lens of the eye. Further, a "multiple radiation protection" protocol was proposed according to the basic principles of occupational health, and its effectiveness was estimated.

METHODS

Physicians engaged in radiology procedure at medical facilities in Japan were included in this study. The eye lens dose (3-mm dose equivalent: Hp (3)) for each participant was measured using a small radio-photoluminescence glass dosimeter mounted on lead glasses. Physicians were directed to procedure multiple radiation protection measures to evaluate their usefulness.

RESULTS

The Hp (3) was reduced by multiple radiation protection in all physicians. In particular, the Hp (3) reduced from 207.7 to 43.2 μSv/procedure and from 21.6 to 10.2 μSv/procedure in cardiovascular internal physician and cerebrovascular physician, respectively, after the implementation of the proposed multiple radiation protection measures. The dose reduction rate of these measures was 53% (range: 37%-79%).

CONCLUSIONS

The radiation doses received by the eye lenses of physicians engaged in radiology procedure may exceed the dose limits to the lens of the eye if radio-protective equipment and imaging conditions are not properly controlled. However, based on the lens equivalent dose data, the implementation of "multiple radiation protection" according to the basic principles of occupational health can ensure compliance with the new-equivalent dose limits to the lens of the eye without placing an undue burden on individual physicians or medical facilities.

Time Trend of the Radiation Exposure Dose in Endoscopic Retrograde Cholangiopancreatography Over an 8-Year Period: A Single-Center Retrospective Study

INTRODUCTION

The global needs for a reduction in radiation exposure (RE) are increasing. Endoscopic retrograde cholangiopancreatography (ERCP) is a significant fluoroscopic procedure in the gastrointestinal field. However, the actual RE in ERCP and its annual trend are still unclear. Therefore, we examined the yearly trend of RE in ERCP.

METHODS

This retrospective, single-center cohort study included consecutive cases of ERCP from September 2012 to June 2019. We measured the air kerma (AK, mGy), dose area product (DAP, Gycm2), and fluoroscopy time (FT, min). We also evaluated the annual trend of the RE before and after the fluoroscopy device update.

RESULTS

In total, 2,174 patients receiving ERCP were enrolled. Among these, the mean age was 74.3 years, and 913 patients were women (42.0%). The median/third quartile values of AK (mGy), DAP (Gycm2), and FT (min) were 109/234 mGy, 13.3/25.8 Gycm2, and 18.2/27.7 minutes. The annual AK, DAP, and FT from 2012 to 2019 were 138, 207, 173, 177, 106, 71.0, 45.0, and 33.3 mGy; 23, 21.4, 19, 18.3, 11.9, 9.0, 6.8, and 6.4 Gycm2; and 12.5, 12.1, 9.7, 9.8, 8.2, 10.8, 9.4, and 10.3 minutes, respectively. The corresponding values before and after the update in July 2016 were 177 and 52 mGy (P < 0.0001), 19.2 and 7.6 Gycm2 (P < 0.0001), and 10.2, and 9.9 minutes (P = 0.05), respectively.

DISCUSSION

The RE from ERCP tended to decrease every year, especially after fluoroscopy device updates.

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).