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Nishida T, Hayashi S, Takenaka M, Hosono M. Managing radiation safety and protection in gastroenterology in Japan: insights from the REX-GI study. J Gastroenterol 2024; 59:437-441. [PMID: 38703187 DOI: 10.1007/s00535-024-02106-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024]
Abstract
Fluoroscopy-guided gastrointestinal procedures, including gastrointestinal stenting, balloon-assisted endoscopy (BAE), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS), are essential for diagnosis and treatment in gastroenterology. Such procedures involve radiation exposure that necessitates strict safety measures to protect patients, doctors, and medical staff. The April 2020 update to Japan's Ionizing Radiation Injury Prevention Regulations for occupational exposure reduced the lens exposure dose limit to approximately one-seventh of its previous level. This change highlights the need for improved safety protocols. Without adaptation, the sustainability of fluoroscopy-based endoscopic techniques could be at risk due to the potential to exceed these new limits. This review examines the current state of medical radiation exposure in the field of gastroenterology in Japan and discusses the findings of the REX-GI study.
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Affiliation(s)
- Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan.
| | - Shiro Hayashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, 4-14-1 Shibahara, Toyonaka, Osaka, 560-8565, Japan
- Hayashi Clinic, Suita, Osaka, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Makoto Hosono
- Department of Radiology, Kindai University, Faculty of Medicine, Osaka-Sayama, Osaka, Japan
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Ridtitid W, Rerknimitr R, Ramchandani M, Lakhtakia S, Shah RJ, Shah JN, Thosani N, Goenka MK, Costamagna G, Wagh MS, Perri V, Peetermans J, Goswamy PG, Liu Z, Yin S, Banerjee S. Endoscopic clearance of non-complex biliary stones using fluoroscopy-free direct solitary cholangioscopy: Initial multicenter experience. DEN OPEN 2024; 4:e241. [PMID: 37273518 PMCID: PMC10235796 DOI: 10.1002/deo2.241] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/27/2023] [Accepted: 04/11/2023] [Indexed: 06/06/2023]
Abstract
Background and Aims Fluoroscopy-free endoscopic retrograde cholangiopancreatography for common bile duct stone (CBDS) clearance is usually offered only to pregnant patients. We initiated a multicenter, randomized controlled trial comparing clearance of non-complex CBDSs using fluoroscopy-free direct solitary cholangioscopy (DSC) to standard endoscopic retrograde cholangiography (ERC) to evaluate the wider applicability of the DSC-based approach. Here we report the initial results of stone clearance and safety in roll-in cases for the randomized controlled trial. Methods Twelve expert endoscopists at tertiary care centers in four countries prospectively enrolled 47 patients with non-complex CBDSs for DSC-assisted CBDS removal in an index procedure including fluoroscopy-free cannulation. Successful CBDS clearance was first determined by DSC and subsequently validated by final occlusion cholangiogram as the ERC gold standard. Results Fully fluoroscopy-free cannulation was successful in 42/47 (89.4%) patients. Brief fluoroscopy with minimal contrast injection was used in 4/47 (8.5%) patients during cannulation. Cannulation failed in 1/47 (2.1%) patients. Fluoroscopy-free complete stone clearance was reached in 38/46 (82.6%) cases. Residual stones were detected in the validation ERC occlusion cholangiogram in three cases. Overall serious adverse event rate was 2.1% (95% confidence interval 0.1-11.3): postprocedural pancreatitis in one patient. Conclusions In patients with non-complex CBDS, the fluoroscopy-free technique is easily transferred to endoscopic retrograde cholangiopancreatography experts with acceptable rates of cannulation and stone clearance and few serious adverse events. (ClinicalTrials.gov number, NCT03421340).
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Affiliation(s)
- Wiriyaporn Ridtitid
- Department of Medicine, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial HospitalThai Red Cross SocietyBangkokThailand
| | - Rungsun Rerknimitr
- Department of Medicine, Faculty of MedicineChulalongkorn University and King Chulalongkorn Memorial HospitalThai Red Cross SocietyBangkokThailand
| | | | | | - Raj J Shah
- Division of Gastroenterology and HepatologyUniversity of Colorado HospitalAuroraUSA
| | - Janak N Shah
- Division of GastroenterologyOchsner Clinic FoundationNew OrleansUSA
| | - Nirav Thosani
- Ertan Digestive Disease Center‐Texas Medical CenterHoustonUSA
| | - Mahesh K Goenka
- Institute of Gastrosciences and LiverApollo Multispeciality HospitalsKolkataIndia
| | - Guido Costamagna
- Digestive Endoscopy UnitDepartment of Translational Medicine and SurgeryFondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | - Mihir S Wagh
- Division of Gastroenterology and HepatologyUniversity of Colorado HospitalAuroraUSA
| | - Vincenzo Perri
- Digestive Endoscopy UnitDepartment of Translational Medicine and SurgeryFondazione Policlinico Universitario Agostino Gemelli IRCCS, Università Cattolica del Sacro CuoreRomeItaly
| | | | | | - Zoe Liu
- Boston Scientific CorporationMarlboroughUSA
| | - Srey Yin
- Boston Scientific CorporationMarlboroughUSA
| | - Subhas Banerjee
- Division of Gastroenterology and HepatologyStanford UniversityStanfordUSA
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Lim YP, Leow VM, Koong JK, Subramaniam M. Is there a role for routine intraoperative cholangiogram in diagnosing CBD stones in patients with normal liver function tests? A prospective study. Innov Surg Sci 2024; 9:37-45. [PMID: 38826633 PMCID: PMC11138406 DOI: 10.1515/iss-2023-0059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/19/2024] [Indexed: 06/04/2024] Open
Abstract
Objectives Cholecystectomy with or without intraoperative cholangiogram (IOC) is an accepted treatment for cholelithiasis. Up to 11.6 % of cholecystectomies have incidental common bile duct (CBD) stones on IOC and 25.3 % of undiagnosed CBD stones will develop life-threatening complications. These will require additional intervention after primary cholecystectomy, further straining the healthcare system. We seek to examine the role of IOC in patients with normal LFTs by evaluating its predictive values, intending to treat undiagnosed CBD stones and therefore ameliorate these issues. Methods All patients who underwent cholecystectomies with normal LFTs from October 2019 to December 2020 were prospectively enrolled. IOC was done, ERCPs were performed for filling defects and documented as "true positive" if ERCP was congruent with the IOC. "False positives" were recorded if ERCP was negative. "True negative" was assigned to normal IOC and LFT after 2 weeks of follow-up. Those with abnormal LFTs were subjected to ERCP and documented as "false negative". Sensitivity, specificity, and predictive values were calculated. Results A total of 180 patients were analysed. IOC showed a specificity of 85.5 % and a NPV of 88.1 % with an AUC of 73.7 %. The positive predictive value and sensitivity were 56.5 and 61.9 % respectively. Conclusions Routine IOC is a specific diagnostic tool with good negative predictive value. It is useful to exclude the presence of CBD stones when LFT is normal. It does not significantly prolong the length of hospitalization or duration of the cholecystectomy hence reducing the incidence of undetected retained stones and preventing its complications effectively.
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Affiliation(s)
- Yi Ping Lim
- Department of Surgery, University Malaya, Kuala Lumpur, Malaysia
| | - Voon Meng Leow
- USMMC, Bertam, Kepala Batas, USM, Penang, Malaysia
- Hepatobiliary Unit, Department of General Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
| | - Jun Kit Koong
- Department of Surgery, University Malaya, Kuala Lumpur, Malaysia
| | - Manisekar Subramaniam
- Hepatobiliary Unit, Department of General Surgery, Hospital Sultanah Bahiyah, Alor Setar, Kedah, Malaysia
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Görücü R, Ayoğlu T, Kaplan Aydin R. The Effect of Radiation on Nurses Working in Endoscopic Retrograde Cholangiopancreatography. Gastroenterol Nurs 2024; 47:101-110. [PMID: 38567853 DOI: 10.1097/sga.0000000000000792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 09/20/2023] [Indexed: 04/05/2024] Open
Abstract
The ionizing radiation used during endoscopic retrograde cholangiopancreatography (ERCP) can have harmful effects on patients and staff. The aim of the study was to determine the effect of radiation on nurses working in an ERCP unit. A descriptive, cross-sectional study was completed between June and August 2022 with the voluntary participation of 114 ERCP nurses. The data were collected using WhatsApp messenger through a Google Form. It was determined that, of the nurses, 68.4% received training on radiation safety, all of them took protective measures, 98.2% had knowledge about the effects of radiation, and 93.9% used dosimeters. Nurses stated that they mostly experienced fatigue (94.7%), loss of energy (68.4%), headache (39.3%), hair loss (35.1%), weakness (18%), leg and joint pain (15.1%), thyroid diseases (12.3%), skin discoloration (7.9%), and anemia (7.9%) as the possible effects of radiation during the period they worked in ERCP. The study found that 3.5% of the nurses were diagnosed with cancer while working in the endoscopic retrograde cholangiopancreatography unit. Additionally, ERCP nurses experienced the negative effects of radiation at different rates, but there was no significant relationship between demographic and health characteristics and experiencing the negative effects of radiation.
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Affiliation(s)
- Rabia Görücü
- Rabia Görücü, MSc, RN, is Research Assistant, Department of Surgical Nursing, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Tuluha Ayoğlu, PhD, is Academic Member, Department of Surgical Nursing, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Rahşan Kaplan Aydin, is Nurse, Istanbul Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Tuluha Ayoğlu
- Rabia Görücü, MSc, RN, is Research Assistant, Department of Surgical Nursing, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Tuluha Ayoğlu, PhD, is Academic Member, Department of Surgical Nursing, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Rahşan Kaplan Aydin, is Nurse, Istanbul Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
| | - Rahşan Kaplan Aydin
- Rabia Görücü, MSc, RN, is Research Assistant, Department of Surgical Nursing, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Tuluha Ayoğlu, PhD, is Academic Member, Department of Surgical Nursing, Florence Nightingale Faculty of Nursing, Istanbul University-Cerrahpasa, Istanbul, Turkey
- Rahşan Kaplan Aydin, is Nurse, Istanbul Prof. Dr. Cemil Tascioglu City Hospital, Istanbul, Turkey
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Monino L, Moreels TG. Patient Radiation Exposure during Enteroscopy-Assisted Endoscopic Retrograde Cholangiopancreatography in Surgically Altered Anatomy (with Video). Diagnostics (Basel) 2024; 14:142. [PMID: 38248019 PMCID: PMC10814473 DOI: 10.3390/diagnostics14020142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/01/2024] [Accepted: 01/03/2024] [Indexed: 01/23/2024] Open
Abstract
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.
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Affiliation(s)
| | - Tom G. Moreels
- Department of Gastroenterology & Hepatology, Cliniques Universitaires Saint-Luc, 1200 Brussels, Belgium;
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Hedström J, Nilsson J, Andersson B. Cholecystectomy and ERCP in pregnancy: a nationwide register-based study. Int J Surg 2024; 110:324-331. [PMID: 37800571 PMCID: PMC10793794 DOI: 10.1097/js9.0000000000000812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/18/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE The objective was to examine the outcomes of cholecystectomy and endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy and compare these outcomes with those in nonpregnant women of fertile age. SUMMARY BACKGROUND DATA Although both laparoscopic cholecystectomy and ERCP are considered safe and feasible in pregnant patients, there is still concern and uncertainty regarding gallstone intervention during pregnancy. This study aimed to investigate outcomes in pregnant patients compared to outcomes in nonpregnant patients. METHODS Data on all female patients aged 18-45 years were retrieved from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography. The patients were divided into groups according to intervention: cholecystectomy, ERCP, or a combination thereof. Differences between pregnant and nonpregnant patients were analyzed. RESULTS A total of 21 328 patients were included, with 291 cholecystectomy and 63 ERCP procedures performed in pregnant patients. At the 30-day follow-up, more complications after cholecystectomy were registered for pregnant patients. However, pregnancy was not a significant risk factor for adverse events when adjusting for previous complicated gallstone disease, intraoperative complications, emergency surgery, and common bile duct stones. There were no differences in outcomes when comparing cholecystectomy among the different trimesters. ERCP had no significant effect on outcomes at the 30-day follow-up. CONCLUSION Cholecystectomy, ERCP, and combinations thereof are safe during pregnancy.
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Affiliation(s)
| | - Johan Nilsson
- Department of Cardiothoracic Surgery, Skåne University Hospital
- Department of Translational Medicine, Lund University, Lund, Sweden
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Hayashi S, Takenaka M, Kogure H, Yakushijin T, Nakai Y, Ikezawa K, Yamaguhci S, Fujisawa T, Tamaru Y, Maetani I, Maruyama H, Asai S, Takagi T, Nagaike K, Hori Y, Sumiyoshi T, Tsumura H, Doyama H, Yoshio T, Hara K, Abe S, Oda I, Kato M, Nebiki H, Mikami T, Miyazaki M, Matsunaga K, Hosono M, Nishida T. A follow-up questionnaire survey 2022 on radiation protection among 464 medical staff from 34 endoscopy-fluoroscopy departments in Japan. DEN OPEN 2023; 3:e227. [PMID: 37064420 PMCID: PMC10102737 DOI: 10.1002/deo2.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 02/22/2023] [Accepted: 03/08/2023] [Indexed: 04/18/2023]
Abstract
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.
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Affiliation(s)
- Shiro Hayashi
- Department of Gastroenterology and Internal MedicineHayashi ClinicOsakaJapan
- Department of GastroenterologyToyonaka Municipal HospitalOsakaJapan
| | - Mamoru Takenaka
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Hirofumi Kogure
- Division of Gastroenterology and HepatologyDepartment of MedicineNihon University School of MedicineTokyoJapan
| | - Takayuki Yakushijin
- Department of Gastroenterology and HepatologyOsaka General Medical CenterOsakaJapan
| | - Yousuke Nakai
- Department of GastroenterologyGraduate School of MedicineThe University of TokyoTokyoJapan
- Department of Endoscopy and Endoscopic SurgeryThe University of Tokyo HospitalTokyoJapan
| | - Kenji Ikezawa
- Department of Hepatobiliary and Pancreatic OncologyOsaka International Cancer InstituteOsakaJapan
| | - Shinjiro Yamaguhci
- Department of Gastroenterology and HepatologyKansai Rosai HospitalHyogoJapan
| | - Toshio Fujisawa
- Department of GastroenterologyJuntendo University, Hongo CampusTokyoJapan
| | - Yuzuru Tamaru
- Department of GastroenterologyNational Hospital Organization Kure Medical Center and Chugoku Cancer CenterHiroshimaJapan
| | - Iruru Maetani
- Division of Gastroenterology and HepatologyDepartment of Internal MedicineToho University Ohashi Medical CenterTokyoJapan
| | | | - Satoshi Asai
- Department of GastroenterologyTane General HospitalOsakaJapan
| | - Tadayuki Takagi
- Department of GastroenterologyFukushima Medical University School of MedicineFukushimaJapan
| | - Koji Nagaike
- Department of Gastroenterology and HepatologySuita Municipal HospitalOsakaJapan
| | - Yasuki Hori
- Department of Gastroenterology and MetabolismNagoya City University Graduate School of Medical SciencesAichiJapan
| | | | - Hidetaka Tsumura
- Department of Gastroenterological OncologyHyogo Cancer CenterHyogoJapan
| | - Hisashi Doyama
- Department of GastroenterologyIshikawa Prefectural Central HospitalIshikawaJapan
| | - Toshiyuki Yoshio
- Department of GastroenterologyCancer Institute HospitalTokyoJapan
| | - Kazuo Hara
- Department of GastroenterologyAichi Cancer CenterAichiJapan
| | - Seiichiro Abe
- Endoscopy DivisionNational Cancer Center HospitalTokyoJapan
| | - Ichiro Oda
- Department of Internal MedicineKawasaki Rinko General HospitalKanagawaJapan
| | - Motohiko Kato
- Department of GastroenterologyKeio University School of Medicine Graduate School of MedicineTokyoJapan
| | - Hiroko Nebiki
- Department of GastroenterologyOsaka City General HospitalOsakaJapan
| | - Tatsuya Mikami
- Department of GastroenterologyHirosaki UniversityAomoriJapan
| | - Masanori Miyazaki
- Department of Gastroenterology and HepatologyOsaka Police HospitalOsakaJapan
| | - Kazuhiro Matsunaga
- Department of Gastroenterological EndoscopyKanazawa Medical UniversityIshikawaJapan
| | - Makoto Hosono
- Department of RadiologyKindai University Faculty of MedicineOsakaJapan
| | - Tsutomu Nishida
- Department of GastroenterologyToyonaka Municipal HospitalOsakaJapan
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Morishima Y, Chida K, Ito O. New Radioprotective Device that can be Used for Fluoroscopic Exam: Possibility to Contribute to Staff Exposure Protection During VFSS. Dysphagia 2022; 37:1519-1524. [PMID: 35169874 DOI: 10.1007/s00455-022-10411-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 01/19/2022] [Indexed: 12/16/2022]
Abstract
The videofluoroscopic swallowing study (VFSS) is a recognized standard diagnostic imaging technique that is used to investigate swallowing disorders and dysphagia. Patients were assessed in a seated posture on a chair or wheelchair. Using X-ray fluoroscopy, the state of patients' swallowing was checked by eating and drinking according to the physician's instructions. VFSS procedures are prolonged, and VFSS staff members are exposed to radiation. Therefore, we evaluated original lead shielding device (OLSD) that can be attached to the handrail of a table and placed vertically. The OLSD has a lead-equivalent thickness of 0.3 mmPb, weighs about 6 kg, and has the dimensions 50 cm × 50 cm × 8.0 mm. We used a human phantom and a radiation survey meter with and without protection from scattered radiation at the positions of the physician and medical staff at the height of 150 cm above the floor (i.e., the height of the eye's crystalline lens). After measuring the scattered radiation, we created radiation maps with and without the OLSD. The dose rate at the physician's position without and with the OLSD was 190 µSv/h and 92 µSv/h, respectively, and a dose reduction of 51.6% with the plate. Moreover, the radiation maps added clarity to the distribution of the scattered radiation. Such information should lead to greater awareness about exposures to physicians and other medical staff. Thus, the OLSD effectively provided protection from scattered radiation at the physician's position during fluoroscopy. It may contribute to the reduction of staff exposure for VFSS.
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Affiliation(s)
- Yoshiaki Morishima
- Department of Radiology, Tohoku Medical and Pharmaceutical University Hospital, 1-12-1 Fukumuro, Miyagino-ku, Sendai, 983-8512, Japan. .,Department of Radiological Technology, Tohoku University School of Health Sciences, Sendai, 980-8575, Japan.
| | - Koichi Chida
- Department of Radiological Technology, Tohoku University School of Health Sciences, Sendai, 980-8575, Japan
| | - Osamu Ito
- Rehabilitation Center, Tohoku Medical and Pharmaceutical University Hospital, Sendai, 983-8512, Japan
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Vanella G, Dell’Anna G, Loria A, Petrone MC, Del Vecchio A, Arcidiacono PG. Radiation exposure during modern therapeutic endoscopic ultrasound procedures and standard alternatives. Endosc Int Open 2022; 10:E1105-E1111. [PMID: 36247073 PMCID: PMC9558486 DOI: 10.1055/a-1853-0451] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Accepted: 05/12/2022] [Indexed: 10/24/2022] Open
Abstract
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.
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Affiliation(s)
- Giuseppe Vanella
- Pancreatobiliary endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | - Giuseppe Dell’Anna
- Pancreatobiliary endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Loria
- Medical Physics Department, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Maria Chiara Petrone
- Pancreatobiliary endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, IRCSS San Raffaele Scientific Institute, Milan, Italy
| | | | - Paolo Giorgio Arcidiacono
- Pancreatobiliary endoscopy and Endosonography Division, Pancreas Translational and Clinical Research Centre, IRCSS San Raffaele Scientific Institute, Milan, Italy
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Takenaka M, Hosono M, Hayashi S, Nishida T, Kudo M. How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology? Dig Endosc 2022; 34:890-900. [PMID: 34850457 PMCID: PMC9543255 DOI: 10.1111/den.14208] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 11/08/2021] [Accepted: 11/29/2021] [Indexed: 02/08/2023]
Abstract
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.
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Affiliation(s)
- Mamoru Takenaka
- Departments of Gastroenterology and HepatologyKindaiOsakaJapan
| | - Makoto Hosono
- Department of RadiologyKindai University Faculty of MedicineOsakaJapan
| | - Shiro Hayashi
- Department of Gastroenterology and Internal MedicineHayashi ClinicOsakaJapan
| | - Tsutomu Nishida
- Department of GastroenterologyToyonaka Municipal HospitalOsakaJapan
| | - Masatoshi Kudo
- Departments of Gastroenterology and HepatologyKindaiOsakaJapan
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12
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Mahjoubi MF, Dhaou AB, Karoui Y, Rezgui B, Essid N, Moussa MB. Acute lithiasis cholangitis in pregnant women: About three cases. Clin Case Rep 2022; 10:e5995. [PMID: 35782218 PMCID: PMC9233165 DOI: 10.1002/ccr3.5995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 04/29/2022] [Accepted: 06/03/2022] [Indexed: 12/07/2022] Open
Abstract
Acute lithiasis cholangitis is a rare non-obstetric emergency during pregnancy, which may threaten fetus and mother's life. It requires a codified management in order to avoid complications. In this current study, we aimed to report our center experience in the management of acute lithiasis cholangitis occurring in three pregnant women.
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Affiliation(s)
- Mohamed Farès Mahjoubi
- Department of Surgery ACharles Nicolle HospitalTunisTunisia
- Faculty of Medicine of TunisUniversity Tunis El ManarTunisTunisia
| | - Anis Ben Dhaou
- Department of Surgery ACharles Nicolle HospitalTunisTunisia
- Faculty of Medicine of TunisUniversity Tunis El ManarTunisTunisia
| | - Yasser Karoui
- Department of Surgery ACharles Nicolle HospitalTunisTunisia
- Faculty of Medicine of TunisUniversity Tunis El ManarTunisTunisia
| | - Bochra Rezgui
- Department of Surgery ACharles Nicolle HospitalTunisTunisia
- Faculty of Medicine of TunisUniversity Tunis El ManarTunisTunisia
| | - Nada Essid
- Department of Surgery ACharles Nicolle HospitalTunisTunisia
- Faculty of Medicine of TunisUniversity Tunis El ManarTunisTunisia
| | - Mounir Ben Moussa
- Department of Surgery ACharles Nicolle HospitalTunisTunisia
- Faculty of Medicine of TunisUniversity Tunis El ManarTunisTunisia
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13
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Comparison of Radiation Exposure between Endoscopic Ultrasound-Guided Hepaticogastrostomy and Hepaticogastrostomy with Antegrade Stenting. J Clin Med 2022; 11:jcm11061705. [PMID: 35330030 PMCID: PMC8951780 DOI: 10.3390/jcm11061705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/01/2022] [Accepted: 03/11/2022] [Indexed: 02/01/2023] Open
Abstract
Fluoroscopy forms an essential part of endoscopic ultrasound-guided hepaticogastrostomy (EUS-HGS) and hepaticogastrostomy with antegrade stenting (EUS-HGAS). To date, no study has assessed and compared radiation exposure between EUS-HGS and EUS-HGAS. This study aimed to compare the radiation exposure parameters between EUS-HGS and EUS-HGAS. This retrospective single-center cohort study included consecutive patients who underwent EUS-HGS or EUS-HGAS from October 2017 to March 2019. The air kerma (AK: mGy), kerma–area product (KAP: Gycm2), fluoroscopy time (FT: min), and procedure time (PT: min) were assessed and compared between the two procedures. Altogether, 45 and 24 patients underwent EUS-HGS and EUS-HGAS, respectively. The median AK, KAP, FT, and PT were higher in the EUS-HGAS group than in the EUS-HGS group. A comparison revealed no difference in the technical success rate, complications rate, adverse event occurrence rate, and re-intervention rate between both procedures. This is the first report in which radiation exposure was used as a comparative parameter between EUS-HGS and EUS-HGAS. This study revealed that radiation exposure is significantly higher in EUS-HGAS than in EUS-HGS. Increased awareness on radiation exposure is warranted among gastroenterologists so that they choose the procedure with lower radiation exposure in cases where both procedures are indicated.
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14
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Hayashi S, Takenaka M, Hosono M, Kogure H, Hasatani K, Suda T, Maruyama H, Matsunaga K, Ihara H, Yoshio T, Nagaike K, Yamada T, Yakushijin T, Takagi T, Tsumura H, Kurita A, Asai S, Ito Y, Kuwai T, Hori Y, Maetani I, Ikezawa K, Iwashita T, Matsumoto K, Fujisawa T, Nishida T. Diagnostic Reference Levels for Fluoroscopy-guided Gastrointestinal Procedures in Japan from the REX-GI Study: A Nationwide Multicentre Prospective Observational Study. THE LANCET REGIONAL HEALTH. WESTERN PACIFIC 2022; 20:100376. [PMID: 35036979 PMCID: PMC8749231 DOI: 10.1016/j.lanwpc.2021.100376] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Shiro Hayashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
- Department of Gastroenterology and Internal Medicine, Hayashi Clinic, Suita, Osaka, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Makoto Hosono
- Department of Radiology, Kindai University, Faculty of Medicine, Osaka-Sayama, Osaka, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui, Fukui, Japan
| | - Takahiro Suda
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | - Hirotsugu Maruyama
- Department of Gastroenterology, Osaka City University Graduate School of Medicine, Osaka, Osaka, Japan
| | - Kazuhiro Matsunaga
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Hideyuki Ihara
- Department of Gastroenterology, Tonan Hospital, Sapporo, Hokkaido, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Ariake, Tokyo, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Osaka, Japan
| | - Takuya Yamada
- Department of Gastroenterology and Hepatology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Takayuki Yakushijin
- Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Osaka, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hidetaka Tsumura
- Department of Gastroenterological Oncology, Hyogo Cancer Center, Akashi, Japan
| | - Akira Kurita
- Department of Gastroenterology and Hepatology, Digestive Disease Center, Kitano Hospital, Tazuke Kofukai Medical Research Institute, Osaka, Osaka, Japan
| | - Satoshi Asai
- Department of Gastroenterology, Tane General Hospital, Osaka, Osaka, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Tokyo, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, National Hospital Organization, Kure Medical Center and Chugoku Cancer Center, Kure, Japan
| | - Yasuki Hori
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Kenji Ikezawa
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Osaka, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Kengo Matsumoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Toshio Fujisawa
- Department of Gastroenterology, Graduate School of Medicine, Juntendo University, Tokyo, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
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15
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Zeng C, Zhang Y, Yang H, Hong J. Prevention of pancreatitis after stent implantation for distal malignant biliary strictures: systematic review and meta-analysis. Expert Rev Gastroenterol Hepatol 2022; 16:141-154. [PMID: 35020545 DOI: 10.1080/17474124.2022.2027239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
INTRODUCTION Biliary stent placement remains a palliative treatment for patients with unresectable distal malignant biliary strictures (DMBS). The incidence of post-ERCP-pancreatitis (PEP) significantly increases in patients receiving fully covered self-expandable metal stents (FCSEMS) who undergo endoscopic retrograde cholangiopancreatography (ERCP). AREAS COVERED This review provides an overview of prevention of PEP after stent implantation for DMBSs. The following operational variables were evaluated: (1) stent type (plastic or metal stent); (2) stent location (above or across the sphincter of Oddi); (3) prophylactic pancreatic duct stent placement; (4) endoscopic sphincterotomy (EST). PubMed, EMBASE, and Cochrane database were searched to identify eligible studies up to October 2021. The odds ratio (OR) with 95% confidence intervals (CI) were pooled using fixed- or random- effects models. EXPERT OPINION 1. PEP occurs more frequently in DMBS patients with self-expandable metal stents (SEMS) compared to that plastic stent (PS). 2. The PEP incidence is higher in covered stents than that in uncovered self-expandable metal stents (USEMS), but not significantly. 3. PEP incidence increases in patients receiving transpapillary FCSEMS placement, particularly when there is an absence of pancreatic duct dilation, and prophylactic pancreatic stenting is recommended for these patients. 4. Limited studies with small sample indicate that there is no significant difference in PEP incidence between transpapillary and suprapapillary stents placement for DMBS. 5. Limited studies indicate that EST does not significantly affect the incidence of pancreatitis in DMBS patients.
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Affiliation(s)
- Chuanfei Zeng
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China.,Medical College of Nanchang University, Nanchang, China
| | - Yiling Zhang
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China.,Medical College of Nanchang University, Nanchang, China
| | - Hui Yang
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China.,Medical College of Nanchang University, Nanchang, China
| | - Junbo Hong
- Department of Gastroenterology, First Affiliated Hospital of Nanchang University, Nanchang, China
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16
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A pilot randomized trial to study the success rate of early precut fistulotomy and its effect on radiation dose in patients with difficult biliary cannulation. Acta Gastroenterol Belg 2021. [DOI: 10.51821/84.4.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
Background: Role of precut fistulotomy in reducing fluoroscopy time and the radiation dose in difficult selective biliary cannulation is unknown.
Methods: We performed a randomized trial where patients with difficult biliary cannulation were randomized into 2 groups: early precut fistulotomy (precut five minutes after failed standard biliary cannulation) or late precut fistulotomy (precut fifteen minutes after failed standard biliary cannulation). We compared the success rates of selective biliary cannulation, fluoroscopy time, radiation dose, complication rates, need for repeat endoscopic retrograde cholangiography (ERC) and need for other interventions
Results: Of the 130 eligible patients screened, 40 patients were randomized. The technical success was comparable between early and late group. The fluoroscopy time and radiation dose were significantly less in the early group [4 minutes (3, 6) vs 15 minutes (8, 28), p=0.001] and [1.35 mGy (0.90, 1.63) vs 2.40 mGy (1.58, 3.25), p=0.010] respectively. In the late group, 60% required need for rescue precut fistulotomy. One patient from late group developed post ERC pancreatitis while 1 from early group developed perforation. Three needed other interventions due to failed second attempt.
Conclusion: Early precut fistulotomy has comparable technical success and reduces the radiation dose as compared to late precut fistulotomy for difficult biliary cannulation.
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17
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Feng Y, Xu W, Liu Y, Sun X, Liang Y, Bu C, Li Y, Zhang Y, Zhang J, Shi R. Digital Cholangioscopy-assisted Nonradiation Endoscopic Retrograde Cholangiopancreatography for Retrieval of Common Bile Duct Stone. Surg Laparosc Endosc Percutan Tech 2021; 32:203-208. [PMID: 34653113 DOI: 10.1097/sle.0000000000001015] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 08/24/2021] [Indexed: 12/18/2022]
Abstract
BACKGROUND The use of nonradiation endoscopic retrograde cholangiopancreatography (NR-ERCP) for choledocholithiasis is still limited. Hereby, we introduced our experience of digital cholangioscopy (DCS)-assisted NR-ERCP for retrieval of common bile duct stones. METHODS Altogether, data of 132 patients who underwent DCS-assisted NR-ERCP for choledocholithiasis were collected. Procedure details, complications, and short-term follow-up were reviewed and analyzed and were compared with those of conventional endoscopic retrograde cholangiopancreatography (ERCP). RESULTS Routine stone extraction and laser lithotripsy were planned in 116 and 16 patients, respectively. Biliary access was successfully achieved by standard biliary cannulation and by advanced techniques in 99 and 33 patients, respectively. Complete stone removal was achieved in a single session in all patients. Routine stone extraction was performed in 117 patients, and laser lithotripsy was applied in 15 patients, among whom 14 patients with planned lithotripsy and 1 unexpected impacted stone found during the procedure. Unexpected right localized intrahepatic stones and purulent cholecystitis were found in 1 and 3 patients, respectively. Three mild and 1 moderate pancreatitis, 5 cases of hyperamylasemia, and 2 cases of leukocytosis occurred as complications. Short-term follow-up revealed no stone residual. Procedure details, technical success, and complications were not statistically different than conventional ERCP. CONCLUSIONS DCS-assisted NR-ERCP is technically feasible, efficient, and safe for retrieval of common bile duct stones. This novel method is superior to conventional ERCP on detecting unexpected concomitant biliary diseases.
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Affiliation(s)
- Yadong Feng
- Department of Gastroenterology, Zhongda Hospital Affiliated to Southeast University, Nanjing, Jiangsu Province, China
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18
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Takenaka M, Hosono M, Hayashi S, Nishida T, Kudo M. The radiation doses and radiation protection on the endoscopic retrograde cholangiopancreatography procedures. Br J Radiol 2021; 94:20210399. [PMID: 34379457 DOI: 10.1259/bjr.20210399] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
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.
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Affiliation(s)
- Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Makoto Hosono
- Department of Radiation Oncology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
| | - Shiro Hayashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan.,Department of Gastroenterology and Internal Medicine, Hayashi Clinic, Suita, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Japan
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-sayama, Japan
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19
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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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20
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Bocian S, Granato A, Cain M, Friis CM, Loyola M, Robertson L. RADIATION SAFETY IN THE GASTROENTEROLOGY SETTING. Gastroenterol Nurs 2021; 44:368-371. [PMID: 34417405 DOI: 10.1097/sga.0000000000000622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Susan Bocian
- Society of Gastroenterology Nurses and Associates, Inc, 330 N Wabash Ave., Suite 2000, Chicago, IL 60611, Tel: 312-321-5165, Fax: 312-673-6694, Online:
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21
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Hayashi S, Takenaka M, Kogure H, Yakushijin T, Maruyama H, Hori Y, Yoshio T, Ikezawa K, Takagi T, Asai S, Matsunaga K, Matsumoto K, Tsumura H, Yamaguchi S, Sumiyoshi T, Nagaike K, Tamaru Y, Hara K, Fujisawa T, Oda I, Ohnita K, Kato M, Nebiki H, Mikami T, Nishihara A, Egawa S, Minami R, Hosono M, Nishida T. A questionnaire survey on radiation protection among 282 medical staff from 26 endoscopy-fluoroscopy departments in Japan. DEN OPEN 2021; 1:e5. [PMID: 35310150 PMCID: PMC8828237 DOI: 10.1002/deo2.5] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/28/2020] [Revised: 01/11/2021] [Accepted: 01/30/2021] [Indexed: 04/25/2023]
Abstract
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.
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Affiliation(s)
- Shiro Hayashi
- Department of Gastroenterology and Internal MedicineHayashi ClinicOsakaJapan
- Department of GastroenterologyToyonaka Municipal HospitalOsakaJapan
| | - Mamoru Takenaka
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Hirofumi Kogure
- Department of GastroenterologyThe University of TokyoTokyoJapan
| | - Takayuki Yakushijin
- Department of Gastroenterology and HepatologyOsaka General Medical CenterOsakaJapan
| | - Hirotsugu Maruyama
- Department of GastroenterologyOsaka City University Graduate School of MedicineOsakaJapan
| | - Yasuki Hori
- Department of Gastroenterology and MetabolismNagoya City University HospitalAichiJapan
| | - Toshiyuki Yoshio
- Department of GastroenterologyCancer Institute HospitalTokyoJapan
| | - Kenji Ikezawa
- Department of Hepatobiliary and Pancreatic OncologyOsaka International Cancer InstituteOsakaJapan
| | - Tadayuki Takagi
- Department of GastroenterologyFukushima Medical University School of MedicineFukushimaJapan
| | - Satoshi Asai
- Department of GastroenterologyTane General HospitalOsakaJapan
| | - Kazuhiro Matsunaga
- Department of GastroenterologyIshikawa Prefectural Central HospitalIshikawaJapan
| | - Kengo Matsumoto
- Department of GastroenterologyToyonaka Municipal HospitalOsakaJapan
| | - Hidetaka Tsumura
- Department of Grastroenterological OncologyHyogo Cancer CenterHyogoJapan
| | - Shinjiro Yamaguchi
- Department of Gastroenterology and HepatologyKansai Rosai HospitalHyogoJapan
| | | | - Koji Nagaike
- Department of Gastroenterology and HepatologySuita Municipal HospitalOsakaJapan
| | - Yuzuru Tamaru
- Department of GastroenterologyKure Medical Center and Chugoku Cancer CenterHiroshimaJapan
| | - Kazuo Hara
- Department of GastroenterologyAichi Cancer CenterAichiJapan
| | | | - Ichiro Oda
- Endoscopy DivisionNational Cancer Center HospitalTokyoJapan
| | - Ken Ohnita
- Department of Gastroenterology and HepatologyShunkaikai Inoue HospitalNagasakiJapan
| | - Motohiko Kato
- Department of GastroenterologyKeio University School of MedicineTokyoJapan
| | - Hiroko Nebiki
- Department of GastroenterologyOsaka City General HospitalOsakaJapan
| | - Tatsuya Mikami
- Division of EndoscopyHirosaki University HospitalAomoriJapan
| | | | - Satoshi Egawa
- Department of GastroenterologyOsaka Police HospitalOsakaJapan
| | - Ryuki Minami
- Department of GastroenterologyTenri HospitalNaraJapan
| | - Makoto Hosono
- Department of RadiologyKindai University Faculty of MedicineOsakaJapan
| | - Tsutomu Nishida
- Department of GastroenterologyToyonaka Municipal HospitalOsakaJapan
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22
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Kakodkar S, Haider A, Hoff RT, Zamfirova I, Chi K. Reduced Fluoroscopy Time With Physician-Controlled Fluoroscopy During Endoscopic Retrograde Cholangiopancreatography: A Community Hospital Experience. Cureus 2021; 13:e13771. [PMID: 33842147 PMCID: PMC8026404 DOI: 10.7759/cureus.13771] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
Background and objective Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) is associated with radiation exposure and related health risks. Either the physician or the radiology technologist can activate fluoroscopy during ERCP. The aim of this study was to determine if physician-controlled fluoroscopy is associated with decreased fluoroscopy time, which may correspond to less radiation exposure to patients and staff. Methods We conducted a single-center, retrospective study; data were collected on ERCP performed using physician-controlled and technologist-controlled fluoroscopy. Fluoroscopy time, procedure complexity level, and Stanford Fluoroscopy Score were compared between the two groups. Results The median fluoroscopy time significantly differed between the two groups with 108 seconds for physician-controlled and 146 seconds for technologist-controlled procedures (p=0.004). The ratio of median fluoroscopy time to procedure complexity level was significantly lower in the physician-controlled group at 73.0 seconds compared to 97.0 seconds in the technologist-controlled group (p=0.002). The ratio of median fluoroscopy time to Stanford Fluoroscopy Score was 25.5 seconds in the physician-controlled group compared to 39.3 seconds in the technologist-controlled group, which was also statistically significant (p<0.001). A subgroup analysis of physicians with advanced training in ERCP also showed a significantly reduced median fluoroscopy time to Stanford Fluoroscopy Complexity Score ratio: 25.5 seconds for physician-controlled versus 35.0 seconds for technologist-controlled (p=0.001). Conclusion The ERCP technique with physician-controlled fluoroscopy may be associated with shorter fluoroscopy time. This may correspond to decreased radiation exposure to patients compared to radiology technologist-controlled fluoroscopy. Further investigations with larger, prospective studies are warranted.
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Affiliation(s)
- Samir Kakodkar
- Department of Medicine, Division of Gastroenterology, Advocate Lutheran General Hospital, Park Ridge, USA
| | - Ali Haider
- Department of Medicine, Division of Gastroenterology, Advocate Lutheran General Hospital, Park Ridge, USA
| | - Ryan T Hoff
- Department of Medicine, Division of Gastroenterology, Advocate Lutheran General Hospital, Park Ridge, USA
| | - Ina Zamfirova
- Russell Research Institute, Advocate Lutheran General Hospital, Park Ridge, USA
| | - Kenneth Chi
- Department of Medicine, Division of Gastroenterology, Advocate Lutheran General Hospital, Park Ridge, USA
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Endoscopy in the CT Scanner: a Multidisciplinary Approach to Difficult Cases. J Gastrointest Surg 2021; 25:866-867. [PMID: 33169318 DOI: 10.1007/s11605-020-04840-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 10/17/2020] [Indexed: 01/31/2023]
Abstract
Endoscopic interventions have been made safer with the use of fluoroscopy. This technique has limitations in patients with challenging anatomy. The combined use of endoscopy and CT fluoroscopy provides the added precision necessary to accomplish difficult interventions. In this video, we present two cases where endoscopy and CT fluoroscopy were used concurrently. While other publications have demonstrated the use of CT guidance to perform endoscopic interventions, this video also demonstrates the reverse-how endoscopic guidance can be used to make a CT-guided procedure possible. This video demonstrates the enhanced patient care possible when a multidisciplinary approach between interventional radiologists and surgeons is followed.
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Time Trend of the Radiation Exposure Dose in Endoscopic Retrograde Cholangiopancreatography Over an 8-Year Period: A Single-Center Retrospective Study. Am J Gastroenterol 2021; 116:100-105. [PMID: 32947320 DOI: 10.14309/ajg.0000000000000838] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/03/2020] [Indexed: 12/11/2022]
Abstract
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.
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Siau K, Webster G, Wright M, Maher B, Stedman B, Johnson G, Ahmad S, Tehami N. Attitudes to radiation safety and cholangiogram interpretation in endoscopic retrograde cholangiopancreatography (ERCP): a UK survey. Frontline Gastroenterol 2020; 12:550-556. [PMID: 34917311 PMCID: PMC8640384 DOI: 10.1136/flgastro-2020-101521] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 10/01/2020] [Accepted: 11/18/2020] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Fluoroscopy during endoscopic retrograde cholangiopancreatography (ERCP) exposes staff and patients to potentially harmful ionizing radiation. We performed a UK survey to explore trainee and trainer attitudes to radiation protection and cholangiogram interpretation in ERCP. METHODS An electronic 10-point survey was prospectively distributed to endoscopy unit leads, training programme directors between October and November 2019. Only UK-based ERCP trainees and trainers with hands-on procedural exposure were eligible for the survey. RESULTS The survey was completed by 107 respondents (58 trainees and 49 trainers), with an estimated overall response rate of 46%. Overall, 49% of respondents were up to date with their radiation protection course, 38% were aware of European Basic safety standards directive (BSSD), 38% wore radiation protection goggles, and 40% were aware of the average radiation screening dose per ERCP procedure. Compared with trainers, trainees were less likely to routinely wear thyroid protection shields (76% vs 92%; p=0.028), have awareness of the BSSD (20% vs 49%; p=0.037) or know their average procedural radiation dosages (21% vs 63%; p<0.001). With regard to cholangiogram interpretation, only 26% had received formal training, with 97% of trainees expressing a desire for further training. CONCLUSION This survey highlights a relative complacency in safety attitudes to radiation protection during ERCP. These data provide impetus to improve training and quality assurance in radiation protection, which should be regarded as a mandatory safety aspect prior to commencing hands-on ERCP training.
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Affiliation(s)
- Keith Siau
- Department of Gastroenterology, Dudley Group of Hospitals NHS Trust, Dudley, West Midlands, UK,Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - George Webster
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Mark Wright
- Department of Hepatology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Ben Maher
- Department of Interventional Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Brian Stedman
- Department of Interventional Radiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Gavin Johnson
- Department of Gastroenterology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Saqib Ahmad
- Department of Gastroenterology, Sherwood Forest Hospitals NHS Foundation Trust, Sutton-In-Ashfield, Nottinghamshire, UK
| | - Nadeem Tehami
- Department of Gastroenterology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
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Hayashi S, Nishida T, Kuriki S, Chang LS, Aochi K, Meren E, Sakamoto T, Tomita R, Higaki Y, Osugi N, Sugimoto A, Takahashi K, Mukai K, Matsumoto K, Nakamatsu D, Yamamoto M, Fukui K, Takenaka M, Hosono M, Inada M. Radiation exposure dose of fluoroscopy-guided gastrointestinal procedures: A single-center retrospective study. Endosc Int Open 2020; 8:E1872-E1877. [PMID: 33269323 PMCID: PMC7695514 DOI: 10.1055/a-1287-9066] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 09/21/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims Fluoroscopy-guided gastrointestinal procedures (FGPs) are increasingly common. However, the radiation exposure (RE) to patients undergoing FGPs is still unclear. We examined the actual RE of FGPs. Patients and methods This retrospective, single-center cohort study included consecutive FGPs, including endoscopic retrograde cholangiopancreatography (ERCP), interventional endoscopic ultrasound (EUS), enteral stenting, balloon-assisted enteroscopy, tube placement, endoscopic injection sclerotherapy (EIS), esophageal balloon dilatation and repositioning for sigmoid volvulus, from September 2012 to June 2019. We measured the air kerma (AK, mGy), dose area product (DAP, Gycm 2 ), and fluoroscopy time (FT, min) for each procedure. Results In total, 3831 patients were enrolled. Overall, 2778 ERCPs were performed. The median AK, DAP, and FT were as follows: ERCP: 109 mGy, 13.3 Gycm 2 and 10.0 min; self-expandable enteral stenting (SEMS): 62 mGy, 12.4 Gycm 2 and 10.4 min; tube placement: 40 mGy, 13.8 Gycm 2 and 11.1 min; balloon-assisted enteroscopy: 43 mGy, 22.4 Gycm 2 and 18.2 min; EUS cyst drainage (EUS-CD): 96 mGy, 18.3 Gycm 2 and 10.4 min; EIS: 36 mGy, 8.1 Gycm 2 and 4.4 min; esophageal balloon dilatation: 9 mGy, 2.2 Gycm 2 and 1.8 min; and repositioning for sigmoid volvulus: 7 mGy, 4.7 Gycm 2 and 1.6 min. Conclusion This large series reporting actual RE doses of various FGPs could serve as a reference for future prospective studies.
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Affiliation(s)
- Shiro Hayashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
- Department of Gastroenterology and Internal Medicine, Hayashi Clinic, Osaka, Japan
| | - Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Shinji Kuriki
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Li-sa Chang
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Kazuki Aochi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Emi Meren
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Tatsuya Sakamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Ryo Tomita
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Yu Higaki
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Naoto Osugi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Aya Sugimoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Kei Takahashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Kaori Mukai
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Kengo Matsumoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Dai Nakamatsu
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Masahi Yamamoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Koji Fukui
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Makoto Hosono
- Department of Radiology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Masami Inada
- Department of Gastroenterology, Toyonaka Municipal Hospital, Osaka, Japan
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Laudanno O, Garrido J, Ahumarán G, Gollo P, Khoury M. Long-term follow-up after fetal radiation exposure during endoscopic retrograde cholangiopancreatography. Endosc Int Open 2020; 8:E1909-E1914. [PMID: 33269328 PMCID: PMC7695519 DOI: 10.1055/a-1293-7783] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 09/29/2020] [Indexed: 02/07/2023] Open
Abstract
Background and study aims The main concern about endoscopic retrograde cholangiopancreatography (ERCP) during pregnancy is the risk of radiation exposure to the fetus. The potential exists not only in the short-term, but also in the long-term and includes growth and development problems and the possibility of childhood cancer. Little is known about the long-term effects of fetal radiation exposure at the time of ERCP. The aim of the study was to report the long-term outcome of babies born after radiation exposure to mothers who underwent ERCP during pregnancy. Patients and methods This was a single-center retrospective cohort study. We included 24 consecutive pregnant patients who underwent ERCP due to choledocholithiasis and their children, between June 1997 and June 2015. All patients and their babies were followed up until birth to assess their short-term outcome. To assess long-term outcomes, from September 2014 to September 2015, a comprehensive medical interview was conducted with the mothers and their children. We also evaluated medical records, lab tests, school report cards, and the families completed a questionnaire inquiring about perceived health status of the children. Results Fifteen patients had full-term pregnancies. One patient had a preterm delivery (32 weeks) due to preeclampsia. There were no cases of miscarriage, stillbirth or fetal malformations. Long-term follow-up was performed at a mean age of 11.08 years (range 1-18) for the children, with no developmental delays, poor school performance, or malignancies found. Conclusions Long-term outcome in children born after radiation exposure during ERCP was unremarkable.
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Affiliation(s)
- Oscar Laudanno
- Instituto de Investigaciones Medicas Doctor Alfredo Lanari – Gastroenterology, Buenos Aires, Argentina
| | - Jose Garrido
- Hospital C. Boccalandro, Tres de Febrero, Gastroenterology, Buenos Aires, Argentina
| | - Gabrial Ahumarán
- Hospital C. Boccalandro, Tres de Febrero, Gastroenterology, Buenos Aires, Argentina
| | - Pablo Gollo
- Hospital C. Boccalandro, Tres de Febrero, Gastroenterology, Buenos Aires, Argentina
| | - Marina Khoury
- Instituto de Investigaciones Medicas Doctor Alfredo Lanari – Gastroenterology, Buenos Aires, Argentina
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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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Affiliation(s)
- Horst Neuhaus
- EVK Düsseldorf - Internal Medicine, Düsseldorf, Germany
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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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Use of Artificial Intelligence to Reduce Radiation Exposure at Fluoroscopy-Guided Endoscopic Procedures. Am J Gastroenterol 2020; 115:555-561. [PMID: 32195731 DOI: 10.14309/ajg.0000000000000565] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
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).
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Oh CH, Dong SH, Kim JW, Kim GA, Lee JM. Radiation exposure during endoscopic retrograde cholangiopancreatography according to clinical determinants. Medicine (Baltimore) 2020; 99:e19498. [PMID: 32221072 PMCID: PMC7220418 DOI: 10.1097/md.0000000000019498] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
This study aimed to analyze the dose of radiation to which the physician is exposed during endoscopic retrograde cholangiopancreatography (ERCP) and to identify predictive factors of radiation exposure during the procedure. Furthermore, we evaluated the patient characteristics and procedural factors associated with prolonged fluoroscopy time (FT).A cross-sectional retrospective analysis of 780 ERCPs performed at a tertiary academic hospital over a 2-year period was conducted. The primary outcome was radiation exposure during ERCP as determined by FT; additionally, the association between variables and radiation exposure was determined. Moreover, we evaluated their correlations with age, sex, body mass index (BMI), diagnosis, duration of procedure, procedure name, and procedure complexity.According to the analysis of the 780 ERCPs performed in 2 years, the mean FT was 5.07 minutes (95% confidence interval [CI], 4.87-5.26). The mean radiation durations were as follows: cholelithiasis, 5.76 minutes (95% CI, 4.75-6.80); malignant biliary obstruction, 6.13 minutes (95% CI, 5.91-6.35); pancreatic disease, 5.28 minutes (95% CI, 4.45-6.28); and benign biliary stricture, 5.32 minutes (95% CI, 5.02-5.94). Significant differences affecting fluoroscopy duration between the 2 endoscopists were not observed in the present study. Multivariate analysis revealed that prolonged fluoroscopy duration was related to specific characteristics, including higher BMI (BMI >27.5 kg/m) (+4.1 minutes; 95% CI, 2.56-5.63), mechanical lithotripsy (+4.85 minutes; 95% CI, 0.45-9.25), needle-knife use (+4.5 minutes; 95% CI, 2.15-6.86), and malignant biliary obstruction (+2.34 minutes; 95% CI, 0.15-4.53).ERCPs are associated with significantly higher radiation exposure of patients on the specific procedure. Endoscopists should be aware of the determining factors, including patients with obesity, who underwent mechanical lithotripsy, who had malignant biliary obstruction, and who underwent a procedure using a needle knife, that affect FT during ERCP.
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Affiliation(s)
- Chi Hyuk Oh
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine
| | - Seok Ho Dong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine
| | - Jung-Wook Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine
| | - Gi-Ae Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Kyung Hee University College of Medicine
| | - Jae Min Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Republic of Korea
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Nishida T, Hayashi S, Takenaka M, Hosono M, Kogure H, Hasatani K, Yamaguchi S, Maruyama H, Doyama H, Ihara H, Yoshio T, Nagaike K, Yamada T, Yakushijin T, Takagi T, Tsumura H, Kurita A, Asai S, Ito Y, Kuwai T, Hori Y, Maetani I, Ikezawa K, Iwashita T, Matsumoto K, Inada M. Multicentre prospective observational study protocol for radiation exposure from gastrointestinal fluoroscopic procedures (REX-GI study). BMJ Open 2020; 10:e033604. [PMID: 32107268 PMCID: PMC7202697 DOI: 10.1136/bmjopen-2019-033604] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 12/20/2019] [Accepted: 12/20/2019] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Recently, the use of various endoscopic procedures under X-ray fluoroscopic guidance, such as endoscopic retrograde cholangiopancreatography (ERCP), interventional endoscopic ultrasonography (EUS), enteral endoscopy and stenting, has been rapidly increasing because of the minimally invasive nature of these procedures compared with that of surgical intervention. With the spread of CT and fluoroscopic interventions, including endoscopic procedures under X-ray guidance, high levels of radiation exposure (RE) from medical imaging have led to major concerns throughout society. However, information about RE related to these image-guided procedures in gastrointestinal endoscopy is scarce, and the RE reference levels have not been established. The aim of this study is to prospectively collect the actual RE dose and to help establish diagnostic reference levels (DRLs) in the field of gastroenterology in Japan. METHODS AND ANALYSIS This is a multicentre, prospective observational study that is being conducted to collect the actual RE from treatments and diagnostic procedures, including ERCP, interventional EUS, balloon-assisted enteroscopy, enteral metallic stent placement and enteral tube placement. We will measure the total fluoroscopy time (min), the total dose-area product (Gycm2) and air-kerma (mGy) of those procedures. Because we are collecting the actual RE data and identifying the influential factors through a prospective, nationwide design, this study will provide guidance regarding the DRLs of ERCP, interventional EUS, balloon-assisted enteroscopy, enteral metallic stent placement and enteral tube placement. ETHICS AND DISSEMINATION Approval was obtained from the Institutional Review Board of Toyonaka Municipal Hospital (25 April 2019). The need for informed consent will be waived via the opt-out method of each hospital website. TRIAL REGISTRATION NUMBER The UMIN Clinical Trials Registry, UMIN000036525.
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Affiliation(s)
- Tsutomu Nishida
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Shiro Hayashi
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
- Department of Gastroenterology and Internal Medicine, Hayashi Clinic, Suita, Japan
| | - Mamoru Takenaka
- Department of Gastroenterology and Hepatology, Kindai University, Osaka-Sayama, Osaka, Japan
| | - Makoto Hosono
- Department of Radiology, Kindai University, Osaka-Sayama, Osaka, Japan
| | - Hirofumi Kogure
- Department of Gastroenterology, The University of Tokyo, Bunkyo-ku, Tokyo, Japan
| | - Kenkei Hasatani
- Department of Gastroenterology, Fukui Prefectural Hospital, Fukui, Japan
| | - Shinjiro Yamaguchi
- Department of Gastroenterology and Hepatology, Kansai Rosai Hospital, Amagasaki, Hyogo, Japan
| | | | - Hisashi Doyama
- Department of Gastroenterology, Ishikawa Prefectural Central Hospital, Kanazawa, Ishikawa, Japan
| | - Hideyuki Ihara
- Department of Gastroenterology, Tonan Hospital, Sapporo, Hokkaido, Japan
| | - Toshiyuki Yoshio
- Department of Gastroenterology, Cancer Institute Hospital, Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Koji Nagaike
- Department of Gastroenterology and Hepatology, Suita Municipal Hospital, Suita, Osaka, Japan
| | - Takuya Yamada
- Department of Gastroenterology and Hepatology, Osaka Rosai Hospital, Sakai, Osaka, Japan
| | - Takayuki Yakushijin
- Department of Gastroenterology and Hepatology, Osaka General Medical Center, Osaka, Japan
| | - Tadayuki Takagi
- Department of Gastroenterology, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Hidetaka Tsumura
- Department of Gastroenterological Oncology, Hyogo Cancer Center, Akashi, Hyogo, Japan
| | - Akira Kurita
- Department of Gastroenterology and Hepatology, Digestive Disease Center, Kitano Hospital, Osaka, Japan
| | - Satoshi Asai
- Department of Gastroenterology, Tane General Hospital, Osaka, Japan
| | - Yukiko Ito
- Department of Gastroenterology, Japanese Red Cross Medical Center, Shibuya, Tokyo, Japan
| | - Toshio Kuwai
- Department of Gastroenterology, Kure Medical Center, Kure, Hiroshima, Japan
| | - Yasuki Hori
- Department of Gastroenterology and Metabolism, Nagoya City University Graduate School of Medical Sciences, Nagoya, Aichi, Japan
| | - Iruru Maetani
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Kenji Ikezawa
- Department of Hepatobiliary and Pancreatic Oncology, Osaka International Cancer Institute, Osaka, Japan
| | - Takuji Iwashita
- First Department of Internal Medicine, Gifu University Hospital, Gifu, Japan
| | - Kengo Matsumoto
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
| | - Masami Inada
- Department of Gastroenterology, Toyonaka Municipal Hospital, Toyonaka, Osaka, Japan
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Hirosawa A, Matsubara K, Takei Y, Kobayashi I. [Reduction of Radiation Exposure to Operator with Radiation Protective Device in ERCP Procedure Using Over-coach X-ray TV System]. Nihon Hoshasen Gijutsu Gakkai Zasshi 2020; 76:54-63. [PMID: 31956187 DOI: 10.6009/jjrt.2020_jsrt_76.1.54] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
It is important to reduce the dose received by medical staffs. The purpose of this study was to evaluate the effect of protective curtain and the property of small optically stimulated luminescence (OSL) dosimeters used for ambient dose measurement in fluoroscopy. The property of small OSL dosimeters was investigated in terms of uniformity, changing fluoroscopy time and polymethyl methacrylate (PMMA) thickness, and angular dependence. Paper pipes were assembled in glid shape and ambient dose was investigated by using small OSL dosimeters that were put on them with and without protective curtain. Air kerma was investigated by small OSL dosimeters that were put on a head phantom at the position of eyes. Dose response of small OSL dosimeters was independent of fluoroscopy time and PMMA thickness, so it is appropriate to measure ambient dose by small OSL dosimeters. In relation to ambient dose, there was significant difference with and without protective curtain (p<0.001, paired-t-test). These air kerma on the head phantom were reduced to approximately 20% by attaching protective curtain. In order to reduce the dose received by operators, it is desirable to use protective curtain.
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Affiliation(s)
- Ayaka Hirosawa
- Department of Medical Technology, Toyama Prefectural Central Hospital.,Division of Health Sciences, Graduate School of Medical Sciences, Kanazawa University
| | - Kosuke Matsubara
- Department of Quantum Medical Technology, Faculty of Health Sciences, Institute of Medical, Pharmaceutical and Health Sciences, Kanazawa University
| | - Yasutaka Takei
- Department of Medical Radiological Technology, Faculty of Health Science and Technology, Kawasaki University of Medical Welfare
| | - Ikuo Kobayashi
- Research Institute of Nuclear Engineering, University of Fukui.,Nagase Landauer, Ltd
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Azab M, Bharadwaj S, Jayaraj M, Hong AS, Solaimani P, Mubder M, Yeom H, Yoo JW, Volk ML. Safety of endoscopic retrograde cholangiopancreatography (ERCP) in pregnancy: A systematic review and meta-analysis. Saudi J Gastroenterol 2019; 25:341-354. [PMID: 31744939 PMCID: PMC6941455 DOI: 10.4103/sjg.sjg_92_19] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND/AIMS Endoscopic retrograde cholangiopancreatography (ERCP) is a technically challenging procedure rarely associated with severe postprocedure complications. Hormonal changes during pregnancy promote cholelithiasis, but there are limited clinical data available on the outcomes of ERCP in pregnant women. ERCP techniques without irradiation were recently introduced as potential alternative. We performed a systematic review and meta-analysis to assess the safety of ERCP in pregnancy and to compare outcomes of radiation versus nonradiation ERCP. MATERIALS AND METHODS A systematic search of PubMed, Medline/Ovid, Web of Science, and Google Scholar through April 18th, 2018 using PRISMA and MOOSE guidelines identified 27 studies reporting the outcomes of ERCP in pregnancy. Random effects pooled event rate and 95% confidence intervals (CIs) were estimated. Heterogeneity was measured by I2, and meta-regression analysis was conducted. Adverse outcomes were divided into fetal, maternal pregnancy-related, and maternal nonpregnancy-related. RESULTS In all, 27 studies reporting on 1,307 pregnant patients who underwent ERCP were identified. Median age was 27.1 years. All results were statistically significant (P < 0.01). The pooled event rate for overall adverse outcomes was 15.9% (95% CI = 0.132-0.191) in all studies combined, 17.6% (95% CI = 0.109-0.272) in nonradiation ERCP (NR-ERCP) subgroup and 21.6% (95% CI = 0.154-0.294) in radiation ERCP subgroup. There was no significant difference in the pooled event rate for fetal adverse outcomes in NR-ERCP 6.2% (95% CI = 0.027-0.137) versus 5.2% (95% CI = 0.026-0.101) in radiation ERCP group. There was no significant difference in maternal pregnancy-related adverse outcome event rate between NR-ERCP (8.4%) (95% CI = 0.038-0.173) and radiation ERCP (7.1%) (95% CI = 0.039-0.125). Maternal nonpregnancy-related adverse outcome event rate in NR-ERCP was 7.6% (95% CI = 0.038-0.145), which was half the event rate in radiation ERCP group of 14.9% (95% CI = 0.102-0.211). CONCLUSIONS ERCP done by experienced endoscopists is a safe procedure during pregnancy. Radiation-free techniques appear to reduce the rates of nonpregnancy-related complications, but not of fetal and pregnancy-related complications.
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Affiliation(s)
- Mohamed Azab
- Department of Gastroenterology and Hepatology, Loma Linda University Medical Center, California, USA,Address for correspondence: Dr. Mohamed Azab, Department of Gastroenterology, Loma Linda University School of Medicine, 11234 Anderson Street, MC 1503A, Loma Linda, California - 92354, USA. E-mail:
| | - Shishira Bharadwaj
- Department of Gastroenterology and Hepatology, Loma Linda University Medical Center, California, USA
| | - Mahendran Jayaraj
- Department of Gastroenterology, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Annie S. Hong
- Department of Internal Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Pejman Solaimani
- Department of Gastroenterology and Hepatology, Loma Linda University Medical Center, California, USA
| | - Mohamad Mubder
- Department of Internal Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Hyeyoung Yeom
- Department of School of Community Health Sciences, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Ji Won Yoo
- Department of Internal Medicine, University of Nevada Las Vegas, Las Vegas, Nevada, USA
| | - Michael L. Volk
- Department of Gastroenterology and Hepatology, Loma Linda University Medical Center, California, USA
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Waldthaler A, Reuterwall-Hansson M, Arnelo U, Kadesjö N. Radiation dose in cone beam CT guided ERCP. Eur J Radiol 2019; 123:108789. [PMID: 31864145 DOI: 10.1016/j.ejrad.2019.108789] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2019] [Revised: 11/27/2019] [Accepted: 12/09/2019] [Indexed: 11/25/2022]
Abstract
PURPOSE To evaluate the practical and radiation safety considerations in utilization of 3-D imaging through cone beam computed tomography (CBCT) in endoscopic retrograde cholangiopancreatography (ERCP). METHOD ERCP procedures were performed using an Artis Q interventional suite (Siemens Healthineers), including 42 procedures with CBCT. Some CBCT cases used the standard "DR" exposure protocol and some used the low dose protocol "DR care". Data on x-ray radiation doses were retrospectively collected and to help optimize technical factors surrounding the procedure and compared to radiation exposure data of patients undergoing conventional ERCP. RESULTS The median dose area product was 24.4 Gycm2 for one DR volume and 5.07 Gycm2 for one DR care volume. The median total dose area product was 6.52 Gycm2 for conventional ERCP, 48.9 Gycm2 for procedures using DR and 19.7 Gycm2 when using DR care. Conventional ERCP resulted in a significantly lower radiation dose than procedures using either CBCT protocols (p < 0.001). However, conventional ERCP showed a large number of outliers with higher dose at the level of, or surpassing, CBCT procedures. CONCLUSIONS For less complex procedures with small x-ray doses and short fluoroscopy times conventional 2-D x-ray technique is clinically sufficient and utilizes less radiation dose than CBCT methods, but there is a wide range of doses and extreme outliers have been observed. CBCT can facilitate ERCP in cases with difficult ducal anatomy, possibly reducing procedural time, x-ray exposure time and need for contrast injections. Methods for prediction on high radiation ERCPs are needed to standardize and optimize patient selection for CBCT-ERCP.
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Affiliation(s)
- Alexander Waldthaler
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden.
| | - Marcus Reuterwall-Hansson
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden; Department of Surgery, Ersta Hospital, Stockholm, Sweden
| | - Urban Arnelo
- Department of Upper GI Diseases, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Science, Intervention and Technology (CLINTEC), Karolinska Institutet, Stockholm, Sweden
| | - Nils Kadesjö
- Medical Radiation Physics, Karolinska University Hospital, Stockholm, Sweden; Department of Dental Medicine, Karolinska Institutet, Stockholm, Sweden
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Tsapaki V, Papastergiou V, Giannakopoulos A, Angelogiannopoulou P, Delatolas V, Triantopoulou S, Theocharis S, Paraskeva K. Management of difficult bile duct stones and indeterminate bile duct structures: Reduced ERCP radiation exposure with adjunct use of digital single-operator cholangioscopy. Phys Med 2019; 64:69-73. [PMID: 31515037 DOI: 10.1016/j.ejmp.2019.06.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2019] [Revised: 05/25/2019] [Accepted: 06/07/2019] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Endoscopic Retrograde Cholangio-Pancreatography (ERCP) is an well-established endoscopic procedure for the management of biliary diseases. The use of fluoroscopy during ERCP has often raised concerns regarding potential risks from radiation exposure, particularly in complex cases. We investigated whether a new digital single-operator cholangioscopy (D-SOC) system, used adjunctively to ERCP, actually reduces patient radiation exposure. MATERIALS AND METHODS We retrospectively analyzed a prospective database (April 2016 to October 2018) including consecutive patients who underwent successful management of difficult-to-treat biliary stones or indeterminate biliary strictures by using either conventional ERCP (ERCP cohort) or ERCP in conjunction with D-SOC (ERCP/D-SOC cohort). The overall patient radiation exposure outcomes were compared in terms of Kerma Area Product (KAP), Fluoroscopy time (T) and the total number of films (F). RESULTS Overall, 47 patients (mean 71.8 years, 59.6% males) were included (ERCP cohort = 29, ERCP/D-SOC cohort = 18), referred either for difficult bile duct stones (n = 36) or indeterminate biliary strictures (n = 11). The median KAP, T and F in the ERCP/D-SOC cohort were 12.3 Gycm2, 3.7 min and 4 films respectively, compared with 52.1 Gycm2, 8.4 min, and 5 films respectively in the ERCP cohort. Statistically significant differences (P = 0.0001) were found for KAP and T. CONCLUSIONS Adjunct use of a digital cholangioscopy platform appears to significantly reduce radiation exposure in patients undergoing ERCP for the management of difficult bile stones or indeterminate biliary strictures.
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Affiliation(s)
- V Tsapaki
- Konstantopoulio General Hospital, 142 33 Nea Ionia, Athens, Greece.
| | - V Papastergiou
- Konstantopoulio General Hospital, 142 33 Nea Ionia, Athens, Greece
| | - A Giannakopoulos
- Konstantopoulio General Hospital, 142 33 Nea Ionia, Athens, Greece
| | | | - V Delatolas
- Konstantopoulio General Hospital, 142 33 Nea Ionia, Athens, Greece
| | - S Triantopoulou
- Konstantopoulio General Hospital, 142 33 Nea Ionia, Athens, Greece
| | - S Theocharis
- Konstantopoulio General Hospital, 142 33 Nea Ionia, Athens, Greece
| | - K Paraskeva
- Konstantopoulio General Hospital, 142 33 Nea Ionia, Athens, Greece
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Sethi S, Barakat MT, Friedland S, Banerjee S. Radiation Training, Radiation Protection, and Fluoroscopy Utilization Practices Among US Therapeutic Endoscopists. Dig Dis Sci 2019; 64:2455-2466. [PMID: 30911863 PMCID: PMC7313385 DOI: 10.1007/s10620-019-05564-z] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 02/25/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Fluoroscopy use during ERCP exposes patients and providers to deleterious effects of radiation. Formal training in fluoroscopy/radiation protection is not widely emphasized during therapeutic endoscopy training, and radiation use during GI endoscopy has not previously been characterized in the USA. In this study, we evaluated radiation training, fluoroscopy use patterns, and radiation protection practices among US therapeutic endoscopists. METHODS An anonymous electronic survey was distributed to US therapeutic endoscopists, and responses were analyzed using descriptive statistics. State-specific requirements for fluoroscopy utilization were determined from state radiologic health branches. RESULTS A total of 159 endoscopists (response rate 67.8%) predominantly those working in university hospitals (69.2%) with > 5 years of experience performing ERCP (74.9%) completed the questionnaire. Although the majority of endoscopists (61.6%) reported that they personally controlled fluoroscopy during ERCP, most (56.6%) had not received training on operating their fluoroscopy system. Only a minority (18-31%) of all respondents reported consistently utilizing modifiable fluoroscopy system parameters that minimize patient radiation exposure (pulsed fluoroscopy, frame rate modification or collimation). Endoscopists appear to undertake adequate personal radiation protective measures although use of a dosimeter was not consistent in half of respondents. The majority of states (56.8%) do not have any stated requirement for certification of non-radiologist physicians who intend to operate fluoroscopy. CONCLUSIONS Most US gastroenterologists performing ERCP have not received formal training in operating their fluoroscopy system or in minimizing radiation exposure to themselves and to their patients. Such formal training should be included in all therapeutic endoscopy training programs, and fluoroscopy system-specific training should be offered at all hospitals.
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Affiliation(s)
- Saurabh Sethi
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA
| | - Monique T Barakat
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA
| | - Shai Friedland
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA
| | - Subhas Banerjee
- Division of Gastroenterology and Hepatology, Stanford University School of Medicine, 300 Pasteur Drive, MC 5244, Stanford, CA, 94305, USA.
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Lee B, Kim MS, Eum D, Min KT. The radiation environment of anaesthesiologists in the endoscopic retrograde cholangiopancreatography room. Sci Rep 2019; 9:9124. [PMID: 31235744 PMCID: PMC6591287 DOI: 10.1038/s41598-019-45610-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2019] [Accepted: 06/10/2019] [Indexed: 12/16/2022] Open
Abstract
Anaesthesiologists are increasingly involved in nonoperating room anaesthesia (NORA) for fluoroscopic procedures. However, the radiation exposure of medical staff differs among NORA settings. Therefore, we aimed to investigate the radiation environment generated by fluoroscopic endoscopic retrograde cholangiopancreatography (ERCP) and the radiation exposure of anaesthesiologists. The dose area product (DAP), radiation entrance dose (RED), and fluoroscopy time (FT) according to the procedures and monthly cumulative radiation exposure were analysed at two sites (neck and wrist) from 363 procedures in 316 patients performed within 3 months. The total RED and DAP were 43643.1 mGy and 13681.1 Gy cm2, respectively. DAP and RED (r = 0.924) were strongly correlated and DAP and FT (r = 0.701) and RED and FT (r = 0.749) were moderately correlated. The radiation environment per procedure varied widely, DAP and RED per FT were the highest during stent insertion with esophagogastroduodenoscopy. Monthly cumulative deep dose equivalents at the wrist and neck ranged between 0.31-1.27 mSv and 0.33-0.59 mSv, respectively, but they were related to jaw thrust manipulation (r = 0.997, P = 0.047) and not to the radiation environment. The anaesthesiologists may be exposed to high dose of radiation in the ERCP room, which depends on the volume of procedures performed and perhaps the anaesthesiologists' practice patterns.
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Affiliation(s)
- Bora Lee
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Min-Soo Kim
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Darhae Eum
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea
| | - Kyeong Tae Min
- Department of Anaesthesiology and Pain Medicine, Severance Hospital, Anaesthesia and Pain Research Institute, Yonsei University College of Medicine, 50-1 Yonsei-ro, Seodaemun-Gu, Seoul, 03722, Republic of Korea.
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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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Wilson‐Stewart K, Shanahan M, Fontanarosa D, Davidson R. Occupational radiation exposure to nursing staff during cardiovascular fluoroscopic procedures: A review of the literature. J Appl Clin Med Phys 2018; 19:282-297. [PMID: 30294978 PMCID: PMC6236819 DOI: 10.1002/acm2.12461] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/19/2018] [Accepted: 07/14/2018] [Indexed: 11/16/2022] Open
Abstract
Fluoroscopy is a method used to provide real time x-ray imaging of the body during medical procedures to assist with medical diagnosis and treatment. Recent technological advances have seen an increase in the number of fluoroscopic examinations being performed. Nurses are an integral part of the team conducting fluoroscopic investigations and are often located close to the patient resulting in an occupational exposure to radiation. The purpose of this review was to examine recent literature which investigates occupational exposure received by nursing staff during cardiovascular fluoroscopic procedures. Articles published between 2011 and 2017 have been searched and comprehensively reviewed on the referenced medical search engines. Twenty-four relevant studies were identified among which seventeen investigated nursing dose comparative to operator dose. Seven researched the effectiveness of interventions in reducing occupational exposure to nursing staff. While doctors remain at the highest risk of exposure during procedures, evidence suggests that nursing staff may be at risk of exceeding recommended dose limits in some circumstances. There is also evidence of inconsistent use of personal protection such as lead glasses and skull caps by nursing staff to minimize radiation exposure. Conclusions: The review has highlighted a lack of published literature focussing on dose to nurses. There is a need for future research in this area to inform nursing staff of factors which may contribute to high occupational doses and of methods for minimizing the risk of exposure, particularly regarding the importance of utilizing radiation protective equipment.
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Affiliation(s)
- Kelly Wilson‐Stewart
- School of Clinical SciencesQueensland University of TechnologyBrisbaneQldAustralia
- Cardiovascular SuitesGreenslopes Private HospitalBrisbaneQldAustralia
- Faculty of HealthUniversity of CanberraCanberraACTAustralia
| | | | - Davide Fontanarosa
- School of Clinical SciencesQueensland University of TechnologyBrisbaneQldAustralia
- Institute of Health and Biomedical InnovationQueensland University of TechnologyBrisbaneQldAustralia
| | - Rob Davidson
- Faculty of HealthUniversity of CanberraCanberraACTAustralia
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Cappell MS, Stavropoulos SN, Friedel D. Systematic review of safety and efficacy of therapeutic endoscopic-retrograde-cholangiopancreatography during pregnancy including studies of radiation-free therapeutic endoscopic-retrograde-cholangiopancreatography. World J Gastrointest Endosc 2018; 10:308-321. [PMID: 30364767 PMCID: PMC6198312 DOI: 10.4253/wjge.v10.i10.308] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2018] [Revised: 07/13/2018] [Accepted: 08/27/2018] [Indexed: 02/06/2023] Open
Abstract
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.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology and Hepatology, William Beaumont Hospital, Royal Oak, MI 48073, United States
- Oakland University William Beaumont School of Medicine, Royal Oak, MI 48073, United States
| | | | - David Friedel
- Division of Gastroenterology, New York University Winthrop Medical Center, Mineola, NY 11501, United States
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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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Zeng HZ, Liu Q, Chen HL, Liu W, Zeng QS, Wu CC, Hu B. A pilot single-center prospective randomized trial to assess the short-term effect of a flashing warning light on reducing fluoroscopy time and radiation exposure during ERCP. Gastrointest Endosc 2018; 88:261-266. [PMID: 29559225 DOI: 10.1016/j.gie.2018.03.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Accepted: 03/11/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND AND AIMS ERCP has the risk of exposure to ionizing radiation. Performers may unconsciously increase fluoroscopy time (FT) because of a lack of radiation protection awareness. This study investigates whether a flashing warning light adopted as a behavioral intervention for performers reduces FT and radiation exposure during ERCP. METHODS We conducted a prospective randomized trial of 200 therapeutic ERCPs. A flashing warning light was placed on top of the endoscopy monitor. Cases were consecutively enrolled and randomly assigned to 2 groups in a 1:1 ratio. In the warning light group, the light was on when the fluoroscopy foot pedal was depressed; in the control group, the light was off. Fluoroscopy and procedure-related data were recorded. RESULTS The median FT and dose-area product (DAP) for the warning light group versus the control group were 142.5 seconds versus 175.0 seconds (P = .045) and 856.8 μGy∙m2 versus 1054.4 μGy∙m2 (P = .043). In a multivariable analysis, the use of the warning light was found to reduce FT by 15.4% (-27.0 seconds; P = .042). DAP reduction because of the decreased FT was 15.2% (160.3 μGy∙m2). The reduction in patient effective dose per case was .42 mSv, equivalent to 21 chest radiographs. No adverse events or interference with the procedures because of the warning light were noted. CONCLUSIONS The use of a flashing warning light is a feasible way to reduce FT and radiation exposure during ERCP. (Clinical trial registration number: ChiCTR-IPR-14005349.).
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Affiliation(s)
- Hong-Ze Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qin Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hong-Lin Chen
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Wei Liu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Qi-Shan Zeng
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chun-Cheng Wu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Bing Hu
- Department of Gastroenterology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Ofori E, Ramai D, John F, Reddy M, Ghevariya V. Occupation-associated health hazards for the gastroenterologist/endoscopist. Ann Gastroenterol 2018; 31:448-455. [PMID: 29991889 PMCID: PMC6033760 DOI: 10.20524/aog.2018.0265] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 03/11/2018] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Emmanuel Ofori
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy)
| | - Daryl Ramai
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy).,St George's University School of Medicine, True Blue, Grenada, W.I. (Daryl Ramai)
| | - Febin John
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy)
| | - Madhavi Reddy
- Division of Gastroenterology and Hepatology, The Brooklyn Hospital Center, Academic Affiliate of The Icahn School of Medicine at Mount Sinai, Clinical Affiliate of The Mount Sinai Hospital, New York (Emmanuel Ofori, Daryl Ramai, Febin John, Madhavi Reddy)
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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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