Low-dose pulsed vs standard pulsed fluoroscopy during ERCP to reduce radiation without change in image quality: Prospective randomized study.

Background and study aims Endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of radiation exposure (RE) to patients and staff and increases the risk of adverse biological effects such as cataracts, sterility, and cancer. Newer fluoroscopy equipment (C-Arm) provides options to limit radiation in the form of lower radiation dose and frame rate or time-limited "pulsed" settings. However, the impact of lower settings on image quality has not been assessed, and no standard protocol exists for fluoroscopy settings used during ERCP. Patients and methods This was a single-center, double-blind, prospective randomized study of consecutive adult patients undergoing standard-of-care ERCP at a tertiary academic medical center. Patients were randomized into two groups: 1) standard-dose pulsed and 2) low-dose pulsed. Pulsed mode (8 fps) was defined as x-ray exposure either in the manufacturer standard-dose or low-dose settings limited to 3 seconds each time the foot-operated switch was depressed. Results Seventy-eight patients undergoing ERCP were enrolled and randomized. No difference in age, gender, or body mass index was found between the two groups. No significant difference in image quality was found between standard-dose and low-dose fluoroscopy P = 0.925). The low-dose group was exposed to significantly less radiation when compared with standard-dose P < 0.05). Fluoroscopy time (minutes) was similar in both groups (2.0 vs 1.9), further suggesting that group assignment had no impact on image quality or procedure time. Conclusions Low-dose pulsed fluoroscopy is a reliable method that substantially reduces radiation without compromising image quality or affecting procedure or fluoroscopy times. This underscores the need for standardization in ERCP fluoroscopy settings to limit radiation exposure.

Comparison of the Diagnostic Yield of EUS Needles for Liver Biopsy: Ex Vivo Study.

BACKGROUND AND AIMS: EUS-guided liver biopsy is an emerging method of liver tissue acquisition which is safe and had been shown to produce excellent histological yield. There is limited data comparing the diagnostic yield of different FNA needles. We aimed to compare the diagnostic performance of four commercially available 19-gauge FNA needles. METHODS: Four FNA needles and one percutaneous needle were used to perform liver biopsies on two human cadaveric livers: Cook Echotip Procore™, Olympus EZ Shot 2™, Boston Scientific Expect Slimline™, Covidien SharkCore™, and an 18-gauge percutaneous needle (TruCore™, Argon Medical Devices). Each needle obtained biopsies by three, six, and nine complete back-and-forth motions of the needle ("throw") with a fanning technique. The combined lengths of specimen fragments and the total number of complete portal tracts (CPT) were measured by a blinded pathologist. One-way analysis of variance (ANOVA) and Bonferroni correction were used for statistical analysis. RESULTS: A total of 52 liver biopsies were performed. The Covidien SharkCore needle had significantly greater number of CPT compared to other FNA needles. The number of "throws" did not impact the number of CPT significantly. There was no statistically significant difference in mean total specimen length between each FNA needle type. CONCLUSION: The Covidien SharkCore needle produced superior histological specimen by capturing more CPT, possibly due to its unique needle design.

Evaluation of subepithelial abnormalities of the appendix by endoscopic ultrasound.

Background. The use of through-the-scope (TTS) miniprobe catheter endoscopic ultrasound is a valuable technique for evaluating subepithelial lesions in the proximal colon. Few reports include the evaluation of the appendix by EUS. Objective. To describe endoscopic and endosonographic characteristics of subepithelial lesions of the appendix. Methods. Retrospective case series in a single academic medical center. Adult patients referred for evaluation of subepithelial lesions of the appendix identified by colonoscopy between April 1, 2003 to February 29, 2008. Data were abstracted from an electronic endoscopic database for all patients undergoing miniprobe endoscopic ultrasound examination of the appendix. Medical records were reviewed for patient followup and outcomes. Results. Nine cases were identified. Seven (78%) patients were female. Seven (78%) utilized the 12 MHz miniprobe device and two (22%) used the 20 MHz device. Three mucoceles were described and confirmed by surgical resection. Cases also included one inverted appendix, one gastrointestinal stromal tumor, and one lipoma. In three cases, no abnormality was found. Conclusions. EUS evaluation of the appendix is feasible with standard miniprobe devices and may assist in the selection of patients who may benefit from surgical management.

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

BACKGROUND: Measures should be used to limit radiation exposure of the staff and patients during ERCP. OBJECTIVE: To determine whether "time-limited fluoroscopy" reduces radiation exposure and fluoroscopy time (FT) compared with continuous fluoroscopy. DESIGN: Prospective randomized trial. SETTING: Tertiary academic medical center. PATIENTS: Consecutive adult patients presenting for ERCP. INTERVENTIONS: Subjects were randomized into 2 fluoroscopy setting groups: (1) time-limited, where x-ray exposure is limited to 3 seconds each time the foot-operated switch is depressed; (2) continuous, where x-ray exposure continues for as long as the switch is depressed. MAIN OUTCOMES MEASUREMENTS: FT, patient, and procedure-related data were recorded. Radiation dosimetry badges were used to estimate cumulative exposure. RESULTS: Ninety-nine procedures were performed in the time-limited group and 100 by using continuous fluoroscopy. The mean FT for time-limited fluoroscopy was 284.4 seconds (95% confidence interval [CI] 247.1-321.6) and for continuous fluoroscopy was 314 seconds (95% CI 265.6-362.4; P=.34). Longer FT was associated with moderate or difficult cannulation (P=.008), lithotripsy (P<.001), stent placement (P=.007), sphincterotomy (P<.001), and longer overall procedure length (P<0.001). After controlling for confounding factors and interactions with a multiple linear regression model, time-limited fluoroscopy was associated with a 16.4% lower FT (P=.029). The average radiation dose was not amenable to multivariate analysis, and, therefore, no significant difference between groups was found. LIMITATIONS: Endoscopists were not blinded to the study group assignments. CONCLUSIONS: FT and radiation exposure are dependent upon numerous patient-, operator-, and procedure-related factors. This study found that, after controlling for the impact of confounding factors, time-limited fluoroscopy significantly decreases FTs.

Effect of physician training on fluoroscopy time during ERCP.

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