The Effect of Fluoroscopy Control on Cannulation Rate and Fluoroscopy Time in Endoscopic Retrograde Cholangiopancreatography Training

( Raymond E. Kim ),( Lance T. Uradomo ),( Grace E. Kim ),( John D. Morris ),( Eric M. Goldberg ),( Peter E. Darwin ) 대한췌장담도학회 2021 대한췌담도학회지 Vol.26 No.1

Background/Aim: Endoscopic retrograde cholangiopancreatography (ERCP) training requires varying degrees of staff assistance regarding operation of the fluoroscopy machine via a foot pedal. Efficiency is important to acquire during this training due to radiation risks. In this study, we evaluate the effect of controlling endoscopy and fluoroscopy unit on duct cannulation rates (CRs) and total fluoroscopy time (FT) for fellows in training. Methods: 204 patients undergoing ERCP were randomized to one of two groups: 1) “Endoscopist Driven” group in which the endoscopist controlled the foot pedal for fluoroscopy, and 2) “Assistant Driven” group in which attending or fellow controlled the foot pedal while the other team member controlled the endoscope. Various measures including selective duct CR and total FT were recorded. Results: There was no significant difference in mean procedure duration between the two groups (32 minutes vs. 33 minutes, p=0.70). There was also no statistically significant difference in CR (83.7% vs. 77.4%, p=0.25) or FT (3.27 minutes vs. 3.54 minutes, p=0.48). Conclusions: ERCP is a technically challenging procedure which requires extensive supervision. This study demonstrates that CR and FT are not affected by who controls the fluoroscopy. Korean J Pancreas Biliary Tract 2021;26(1):43-48

Safety and durable patency of tunneled hemodialysis catheter inserted without fluoroscopy

김도형,윤소정,반태현,최범순,김병수,박철휘,양철우,박훈석 대한신장학회 2023 Kidney Research and Clinical Practice Vol.42 No.6

Background: A tunneled hemodialysis (HD) catheter is preferred due to its lower incidence of infection and malfunction than non-tunneled ones. For safer insertion, fluoroscopic guidance is desirable. However, if the patient is unstable, transfer to the fluoroscopy may be impossible or inappropriate. Methods: From June 2019 to September 2022, 81 tunneled HD catheter insertion cases performed under ultrasound guidance without fluoroscopy and 474 cases with fluoroscopy in our institutional HD catheter cohort were retrospectively compared. Results: Immediate complications, later catheter-associated problems, including infections and catheter dysfunction, were comparable between the two groups (p = 0.20 and p = 0.37, respectively). The patency of tunneled catheters inserted without fluoroscopy was comparable to the patency of tunneled catheters inserted with fluoroscopic guidance (p = 0.90). Conclusion: Tunneled HD catheter insertion without fluoroscopy can be performed safely and has durable patency compared to the insertion with fluoroscopy. Therefore, this method can be considered for the selected unstable patients (e.g., ventilator care) in the intensive care unit.

투시와 중재시술의 방사선 피폭과 저감화 방법

정우경 대한의사협회 2011 대한의사협회지 Vol.54 No.12

Radiation exposure during fluoroscopy has been of consistent interest because fluoroscopy is used not only for diagnostic purposes such as upper gastrointestinal series but for many minimally-invasive treatments in various clinical fields. In 2000, the International Commission on Radiological Protection published the important report about the avoidance of radiation injuries from medical interventional procedures, and this report defined harm during fluoroscopic-guided interventional procedure and how to reduce the radiation dose of patients and staff. Two aspects of fluoroscopy exposure differ from other types of medical radiation exposure, including computed tomography. One is that the entrance surface dose during an interventional procedure may be very high, so the deterministic effects of radiation such as skin or corneal injury should be emphasized more than stochastic effects such as cancer risk. The other is that the variation in radiation exposure is great for the same kind of procedure, so it is very difficult to generate a reference level for the radiation dose. Therefore, it is necessary to develop a guideline for the use of fluoroscopy through a nationwide survey about irradiation during fluoroscopic examinations and fluoroscopy-guided intervention procedures. In conclusion, radiation exposure by fluoroscopic guided intervention is not negligible, and the practitioner should always aim to reduce radiation exposure during interventional procedures. Keywords: Radiation dosage; Fluoroscopy; Interventional radiography

Accuracy of Live Fluoroscopy to Detect Intravascular Injection During Lumbar Transforaminal Epidural Injections

Lee, Min-Hye,Yang, Kyung-Seung,Kim, Young-Hoon,Jung, Hyun-Do,Lim, Su-Jin,Moon, Dong-Eon The Korean Pain Society 2010 The Korean Journal of Pain Vol.23 No.1

Background: Complications following lumbar transforaminal epidural injection are frequently related to inadvertent vascular injection of corticosteroids. Several methods have been proposed to reduce the risk of vascular injection. The generally accepted technique during epidural steroid injection is intermittent fluoroscopy. In fact, this technique may miss vascular uptake due to rapid washout. Because of the fleeting appearance of vascular contrast patterns, live fluoroscopy is recommended during contrast injection. However, when vascular contrast patterns are overlapped by expected epidural patterns, it is hard to distinguish them even on live fluoroscopy. Methods: During 87 lumbar transforaminal epidural injections, dynamic contrast flows were observed under live fluoroscopy with using digital subtraction enhancement. Two dynamic fluoroscopy fluoroscopic images were saved from each injection. These injections were performed by five physicians with experience independently. Accuracy of live fluoroscopy was determined by comparing the interpretation of the digital subtraction fluoroscopic images. Results: Using digital subtraction guidance with contrast confirmation, the twenty cases of intravascular injection were found (the rate of incidence was 23%). There was no significant difference in incidence of intravascular injections based either on gender or diagnosis. Only five cases of intravascular injections were predicted with either flash or aspiration of blood (sensitivity = 25%). Under live fluoroscopic guidance with contrast confirmation to predict intravascular injection, twelve cases were predicted (sensitivity = 60%). Conclusions: This finding demonstrate that digital subtraction fluoroscopic imaging is superior to blood aspiration or live fluoroscopy in detecting intravascular injections with lumbar transforaminal epidural injection.

Prediction of successful caudal epidural injection using color Doppler ultrasonography in the paramedian sagittal oblique view of the lumbosacral spine

( Seon Woo Yoo ),( Min-jong Ki ),( A Ram Doo ),( Cheol Jong Woo ),( Ye Sull Kim ),( Ji-seon Son ) 대한통증학회 2021 The Korean Journal of Pain Vol.34 No.3

Background: Ultrasound-guided caudal epidural injection (CEI) is limited in that it cannot confirm drug distribution at the target site without fluoroscopy. We hypothesized that visualization of solution flow through the inter-laminar space of the lumbosacral spine using color Doppler ultrasound alone would allow for confirmation of drug distribution. Therefore, we aimed to prospectively evaluate the usefulness of this method by comparing the color Doppler image in the paramedian sagittal oblique view of the lumbosacral spine (LS-PSOV) with the distribution of the contrast medium observed during fluoroscopy. Methods: Sixty-five patients received a 10-mL CEI of solution containing contrast medium under ultrasound guidance. During injection, flow was observed in the LSPSOV using color Doppler ultrasonography, following which it was confirmed using fluoroscopy. The presence of contrast image at L5-S1 on fluoroscopy was defined as “successful CEI.” We then calculated prediction accuracy for successful CEI using color Doppler ultrasonography in the LS-PSOV. We also investigated the correlation between the distribution levels measured via color Doppler and fluoroscopy. Results: Prediction accuracy with color Doppler ultrasonography was 96.9%. The sensitivity, specificity, positive predictive value, and negative predictive value were 96.7%, 100%, 100%, and 60.0%, respectively. In 52 of 65 patients (80%), the highest level at which contrast image was observed was the same for both color Doppler ultrasonography and fluoroscopy. Conclusions: Our findings demonstrate that color Doppler ultrasonography in the LS-PSOV is a new method for determining whether a drug solution reaches the lumbosacral region (i.e. , the main target level) without the need for fluoroscopy.

Radiation safety for pain physicians: principles and recommendations

( Sewon Park ),( Minjung Kim ),( Jae Hun Kim ) 대한통증학회 2022 The Korean Journal of Pain Vol.35 No.2

C-arm fluoroscopy is a useful tool for interventional pain management. However, with the increasing use of C-arm fluoroscopy, the risk of accumulated radiation exposure is a significant concern for pain physicians. Therefore, efforts are needed to reduce radiation exposure. There are three types of radiation exposure sources: (1) the primary X-ray beam, (2) scattered radiation, and (3) leakage from the X-ray tube. The major radiation exposure risk for most medical staff members is scattered radiation, the amount of which is affected by many factors. Pain physicians can reduce their radiation exposure by use of several effective methods, which utilize the following main principles: reducing the exposure time, increasing the distance from the radiation source, and radiation shielding. Some methods reduce not only the pain physician’s but also the patient’s radiation exposure. Taking images with collimation and minimal use of magnification are ways to reduce the intensity of the primary X-ray beam and the amount of scattered radiation. It is also important to carefully select the C-arm fluoroscopy mode, such as pulsed mode or low-dose mode, for ensuring the physician’s and patient’s radiation safety. Pain physicians should practice these principles and also be aware of the annual permissible radiation dose as well as checking their radiation exposure. This article aimed to review the literature on radiation safety in relation to C-arm fluoroscopy and provide recommendations to pain physicians during C-arm fluoroscopy-guided interventional pain management.

증 례 : 간세포암 환자에서 반복적인 방사선 투시검사로 인한 아급성 방사선 피부염

김보혜 ( Bo Hye Kim ),김희경 ( Hee Kyung Kim ),신재경 ( Jae Kyung Shin ),홍희진 ( Hee Jin Hong ),이주호 ( Joo Ho Lee ),박하나 ( Hana Park ),황성규 ( Seong Gyu Hwang ),임규성 ( Kyu Sung Rim ) 대한소화기학회 2016 대한소화기학회지 Vol.67 No.2

Radiation dermatitis can develop after fluoroscopy-guided interventional procedures. Cases of fluoroscopy-induced radiation dermatitis have been reported since 1996, mostly documented in the fields of radiology, cardiology and dermatology. Since diagnosis and treatment of fluoroscopy-induced radiation dermatitis can be difficult, high grade of suspicion is required. The extent of this reaction is determined by radiation dose, duration of exposure, type of procedure, and host factors and can be aggravated by concomitant use of photosensitizers. Follow-up is important after long and complicated procedures and efforts to minimize radiation exposure time will be necessary to prevent radiation dermatitis. Herein, we report a case of a 58-year-old man with hepatocellular carcinoma presenting with subacute radiation dermatitis after prolonged fluoroscopic exposure during transarterial chemoembolization and chemoport insertion. Physicians should be aware that fluoroscopy is a potential cause of radiation dermatitis.

Fluoroscopy를 이용한 관절강내 약침의 임상적 고찰

김성웅,배은정,이정훈,서정철,임성철,한상원,Kim, Sung-woong,Bae, Eun-jung,Lee, Jung-hoon,Seo, Jung-chul,Lim, Sung-chul,Han, Sang-won 대한침구의학회 2003 대한침구의학회지 Vol.20 No.6

Objective : The aim of this study is to confirm if the intra-articular herbal-acupuncture exactly inserted into the joints by using fluoroscopy. Methods : An Oriental Medicine doctor inserted needle for herbal-acupuncture into intra-articular joint of elbow, wrist, knee and ankle with fluoroscopy or without fluoroscopy. Results : Needle was exactly inserted into elbow, wrist, knee and ankle by using fluorosopy, but it was not exactly inserted into the same point of joints without fluorosopy. Conclusions : Without fluoroscopy, the needle for intra-articular herbal-acupuncture was not exactly inserted into the joints. Further study is needed about intra-articular herbal-acupuncture.

Fluoroscopy-guided intra-articular steroid injection for sternoclavicular joint arthritis secondary to limited cutaneous systemic sclerosis: a case report

( Savas Sencan ),( Emel Guler ),( Isa Cuce ),( Kemal Erol ) 대한통증학회 2017 The Korean Journal of Pain Vol.30 No.1

We report a case of fluoroscopy-guided intraarticular steroid injection for sternoclavicular joint (SCJ) arthritis caused by limited cutaneous systemic sclerosis (SSc). A 50-year-old woman diagnosed with limited cutaneous SSc presented with swelling and pain in the right SCJ. MRI revealed signs of inflammation consistent with right-sided sternoclavicular joint arthritis. After the failure of oral medications, we performed fluoroscopy-guided injection in this region. She reported complete resolution of her symptoms at 4 and 12-week follow-ups. This outcome suggests that a fluoroscopy-guided SCJ injection might be a safe and successful treatment option for sternoclavicular joint arthritis. (Korean J Pain 2017; 30: 59-61)

Radiation Exposure to Physicians During Interventional Pain Procedures

Kim, Tae-Wan,Jung, Jang-Hwan,Jeon, Hyun-Joo,Yoon, Kyung-Bong,Yoon, Duck-Mi The Korean Pain Society 2010 The Korean Journal of Pain Vol.23 No.1

Background: Fluoroscopy has been an integral part of modern interventional pain management. Yet fluoroscopy can be associated with risks for the patients and clinicians unless it is managed with appropriate understanding, skill and vigilance. Therefore, this study was designed to determine the amount of radiation received by a primary operator and an assistant during interventional pain procedures that involve the use of fluoroscopy. Methods: In order to examine the amount of radiation, the physicians were monitored by having them wear three thermoluminescent badges during each single procedure, with one under a lead apron, one under the apron collar and one on the leg during each single procedure. The data obtained from each thermoluminescent badge was reviewed from September 2008 to November 2008 and the annual radiation exposure was subsequently calculated. Results: A total of 505 interventional procedures were performed with C-arm fluoroscopy during three months. The results of this study revealed that the annual radiation exposure was relatively low for both the operator and assistant. Conclusions: With proper precautions, the use of fluoroscopy during interventional pain procedures is a safe practice.