Purpose:
To survey a radiation dose index of peripheral and trunk fluoroscopic interventional procedures at a tertiary care pediatric hospital. These results allow the correlation of a patient dose ...index to the patient thickness, age, weight, and body mass index (BMI) to be analyzed.
Methods:
Radiation dose structured reports were retrospectively collected for pediatric and adult interventional fluoroscopic cases. Kerma Area Product (KAP), air Kerma (AK), fluoroscopy time (FT), thickness of body part irradiated, patient's age, height, and weight were collected. Cumulative AK was divided by fluoroscopy time to normalize the dose index by the complexity of the case. This index for each study was analyzed as a function of thickness of body part irradiated, patient age, weight, and BMI. Non‐parametric correlation coefficients along with the 95% confidence intervals were computed to investigate which parameter correlates best with patient dose.
Results:
A total of 522 cases were included in the study. The patients’ irradiated body part thicknesses, ages, masses, and heights ranged from 1–35 cm, 0.01–61 years, 1.4–145.5 kg, and 37.5–190 cm respectively. The FT and AK of the cases ranged from 0.1–100 min and 0.1–2756 mGy respectively. The correlation with 95% confidence interval of AK/FT to each patient parameter is listed in the supporting document. Each patient parameter is statistically correlated with patient dose (p‐value < 0.0001), however the correlation with patient thickness statistically provides the highest correlation whereas the three other parameters are of similar, lower correlation.
Conclusion:
Fluoroscopy‐guided patient dose indices should be reported as a function of patient thickness irradiated as opposed to the patient's age, weight, or BMI. If the thickness of the patient is unknown, our results suggest that any of the other three patient charateristics could be used.
K Strauss serves as a consultant to Philips Healthcare upon their request. R Nachabe is a paid employee of Phillips Healthcare.
Introduction
Atrial fibrillation (AF) ablation requires access to the left atrium (LA) via transseptal puncture (TP). TP is traditionally performed with fluoroscopic guidance. Use of intracardiac ...echocardiography (ICE) and three‐dimensional mapping allows for zero fluoroscopy TP.
Objective
To demonstrate safety and efficacy of zero fluoroscopy TP using multiple procedural approaches.
Methods
Patients undergoing AF ablation between January 2015 and November 2017 at five institutions were included. ICE and three‐dimensional mapping were used for sheath positioning and TP. Variable technical approaches were used across centers including placement of J wire in the superior vena cava with ICE guidance followed by dragging down the transseptal sheath into the interatrial septum, or guiding the transseptal sheath directly to the interatrial septum by localizing the ablation catheter with three‐dimensional mapping and replacing it with the transseptal needle once in position. In patients with pacemaker/implantable cardiac defibrillator leads, pre‐/poststudy device interrogation was performed.
Results
A total of 747 TPs were performed (646 patients, age 63.1 ± 13.1, 67.5% male, LA volume index 34.5 ± 15.8 mL/m2, ejection fraction 57.7 ± 10.9%) with 100% success. No punctures required fluoroscopy. Two pericardial effusions, two pericardial tamponades requiring pericardiocentesis, and one transient ischemic attack were observed during the overall ablation procedure, with a total complication rate of 0.7%. There were no other periprocedural complications related to TP, including intrathoracic bleeding, stroke, or death both immediately following TP and within 30 days of the procedure. In patients with intracardiac devices, no device‐related complications were observed.
Conclusion
TP can be safely and effectively performed without the need for fluoroscopy.
Purpose
Navigation is emerging as a useful adjunct in percutaneous, minimally invasive spinal surgery (MIS). The aim of this study was to compare C-Arm navigated, O-Arm navigated and conventional ...2D-fluoroscopy assisted MIS thoracic and lumbosacral spine fixation techniques in terms of operating time, radiation exposure and accuracy of pedicle screw (PS) placement.
Methods
Retrospective observational study of 152 consecutive adults who underwent MIS fixations for spinal instability: 96 2D-fluoroscopy assisted, 39 3D-C-Arm navigated and 27 using O-Arm navigated.
Results
O-Arm navigation significantly reduced PS misplacement (1.23%,
p
) compared to 3D-C-Arm navigation (7.29%,
p
= 0.0082) and 2D-fluoro guided placement (5.16%,
p
= 0379). 3D-C-Arm navigation was associated with lower procedural radiation exposure of the patient (0.4 mSv) than O-Arm navigation (3.24 mSv) or 2D-fluoro guidance (1.5 mSv). Operative time was comparable between three modalities.
Conclusions
O-Arm navigation provides greater accuracy of percutaneous instrumentation placement with an acceptable procedural radiation dose delivered to the patients and comparable operative times.
Graphical abstract
These slides can be retrieved under Electronic Supplementary material.
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.
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.
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).
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).
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.
Incisionless near-infrared fluorescent cholangiography (NIFC) is emerging as a promising tool to enhance the visualization of extrahepatic biliary structures during laparoscopic cholecystectomies.
We ...conducted a single-blind, randomized, 2-arm trial comparing the efficacy of NIFC (n = 321) versus white light (WL) alone (n = 318) during laparoscopic cholecystectomy. Using the KARL STORZ Image1 S imaging system with OPAL1 technology for NIR/ICG imaging, we evaluated the detection rate for 7 biliary structures-cystic duct (CD), right hepatic duct (RHD), common hepatic duct, common bile duct, cystic common bile duct junction, cystic gallbladder junction (CGJ), and accessory ducts -before and after surgical dissection. Secondary calculations included multivariable analysis for predictors of structure visualization and comparing intergroup biliary duct injury rates.
Predissection detection rates were significantly superior in the NIFC group for all 7 biliary structures, ranging from 9.1% versus 2.9% to 66.6% versus 36.6% for the RHD and CD, respectively, with odds ratios ranging from 2.3 (95% CI 1.6-3.2) for the CGJ to 3.6 (1.6-9.3) for the RHD. After dissection, similar intergroup differences were observed for all structures except CD and CGJ, for which no differences were observed. Significant odds ratios ranged from 2.4 (1.7-3.5) for the common hepatic duct to 3.3 (1.3-10.4) for accessory ducts. Increased body mass index was associated with reduced detection of most structures in both groups, especially before dissection. Only 2 patients, both in the WL group, sustained a biliary duct injury.
In a randomized controlled trial, NIFC was statistically superior to WL alone visualizing extrahepatic biliary structures during laparoscopic cholecystectomy.
NCT02702843.
Minimally invasive spine techniques are becoming increasingly popular owing to their ability to reduce operative morbidity and recovery times. The downside to these new procedures is their need for ...intraoperative radiation guidance.
To establish which technologies provide the lowest radiation exposure to both patient and surgeon.
Systematic review
Average intraoperative radiation exposure (in mSv per screw placed) to surgeon and patient. Average fluoroscopy time per screw placed.
We reviewed the available English medical literature to identify all articles reporting patient and/or surgeon radiation exposure in patients undergoing image-guided thoracolumbar instrumentation. Quantitative meta-analysis was performed for studies providing radiation exposure or fluoroscopy use per screw placed to determine which navigation modality was associated with the lowest intraoperative radiation exposure. Values on meta-analysis were reported as mean ± standard deviation.
We identified 4956 unique articles, of which 85 met inclusion/exclusion criteria. Forty-one articles were included in the meta-analysis. Patient radiation exposure per screw placed for each modality was: conventional fluoroscopy without navigation (0.26±0.38 mSv), conventional fluoroscopy with pre-operative CT-based navigation (0.027±0.010 mSv), intraoperative CT-based navigation (1.20±0.91 mSv), and robot-assisted instrumentation (0.04±0.30 mSv). Values for fluoroscopy used per screw were: conventional fluoroscopy without navigation (11.1±9.0 seconds), conventional fluoroscopy with navigation (7.20±3.93 s), 3D fluoroscopy (16.2±9.6 s), intraoperative CT-based navigation (19.96±17.09 s), and robot-assistance (20.07±17.22 s). Surgeon dose per screw: conventional fluoroscopy without navigation (6.0±7.9 × 10−3 mSv), conventional fluoroscopy with navigation (1.8±2.5 × 10−3 mSv), 3D Fluoroscopy (0.3±1.9 × 10−3 mSv), intraoperative CT-based navigation (0±0 mSv), and robot-assisted instrumentation (2.0±4.0 × 10−3 mSv).
All image guidance modalities are associated with surgeon radiation exposures well below current safety limits. Intraoperative CT-based (iCT) navigation produces the lowest radiation exposure to surgeon albeit at the cost of increased radiation exposure to the patient relative to conventional fluoroscopy-based methods.
Acetabulum positioning affects dislocation rates, component impingement, bearing surface wear rates, and need for revision surgery. Novel techniques purport to improve the accuracy and precision of ...acetabular component position, but may have a significant learning curve. Our aim was to assess whether adopting robotic or fluoroscopic techniques improve acetabulum positioning compared to manual total hip arthroplasty (THA) during the learning curve.
Three types of THAs were compared in this retrospective cohort: (1) the first 100 fluoroscopically guided direct anterior THAs (fluoroscopic anterior FA) done by a surgeon learning the anterior approach, (2) the first 100 robotic-assisted posterior THAs done by a surgeon learning robotic-assisted surgery (robotic posterior RP), and (3) the last 100 manual posterior (MP) THAs done by each surgeon (200 THAs) before adoption of novel techniques. Component position was measured on plain radiographs. Radiographic measurements were taken by 2 blinded observers. The percentage of hips within the surgeons’ “target zone” (inclination, 30°-50°; anteversion, 10°-30°) was calculated, along with the percentage within the “safe zone” of Lewinnek (inclination, 30°-50°; anteversion, 5°-25°) and Callanan (inclination, 30°-45°; anteversion, 5°-25°). Relative risk (RR) and absolute risk reduction (ARR) were calculated. Variances (square of the standard deviations) were used to describe the variability of cup position.
Seventy-six percentage of MP THAs were within the surgeons’ target zone compared with 84% of FA THAs and 97% of RP THAs. This difference was statistically significant, associated with a RR reduction of 87% (RR, 0.13 0.04-0.40; P < .01; ARR, 21%; number needed to treat, 5) for RP compared to MP THAs. Compared to FA THAs, RP THAs were associated with a RR reduction of 81% (RR, 0.19 0.06-0.62; P < .01; ARR, 13%; number needed to treat, 8). Variances were lower for acetabulum inclination and anteversion in RP THAs (14.0 and 19.5) as compared to the MP (37.5 and 56.3) and FA (24.5 and 54.6) groups. These differences were statistically significant (P < .01).
Adoption of robotic techniques delivers significant and immediate improvement in the precision of acetabular component positioning during the learning curve. While fluoroscopy has been shown to be beneficial with experience, a learning curve exists before precision improves significantly.
Retrospective cohort.
To describe our technique for and evaluate the time demand, radiation exposure and outcomes of skin-anchored intraoperative three-dimensional navigation (ION) in minimally ...invasive (MIS) lumbar surgery, and to compare these parameters to 2D fluoroscopy for MI-TLIF.
Limited visualization of anatomic landmarks and narrow access corridor in MIS procedures result in greater reliance on image guidance. Although two-dimensional fluoroscopy has historically been used, ION is gaining traction.
Patients who underwent MIS lumbar microdiscectomy, laminectomy, or MI-TLIF using skin-anchored ION and MI-TLIF by the same surgeon using 2D fluoroscopy were selected. Operative variables, radiation exposure, and short-term outcomes of all procedures were summarized. Time-demand and radiation exposure of fluoroscopy and ION for MI-TLIF were compared.
Of the 326 patients included, 232 were in the ION cohort (92 microdiscectomies, 65 laminectomies, and 75 MI-TLIFs) and 94 in the MI-TLIF using 2D fluoroscopy cohort. Time for ION setup and image acquisition was a median of 22 to 24 minutes. Total fluoroscopy time was a median of 10 seconds for microdiscectomy, 9 for laminectomy, and 26 for MI-TLIF. Radiation dose was a median of 15.2 mGy for microdiscectomy, 16.6 for laminectomy, and 44.6 for MI-TLIF, of this, 93%, 95%, and 37% for microdiscectomy, laminectomy, and MI-TLIF, respectively were for ION image acquisition, with the rest attributable to the procedure. There were no wrong-level surgeries. Compared with fluoroscopy, ION for MI-TLIF resulted in lower operative times (92 vs. 108 min, P < 0.0001), fluoroscopy time (26 vs. 144 s, P < 0.0001), and radiation dose (44.6 vs. 63.1 mGy, P = 0.002), with equivalent time-demand and length of stay. ION lowered the radiation dose by 29% for patients and 55% for operating room personnel.
Skin-anchored ION does not increase time-demand compared with fluoroscopy, is feasible, safe and accurate, and results in low radiation exposure.
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