Effect of post-pyloric Dobhoff tube retention during gastrojejunostomy for reduction of fluoroscopic time and radiation dose.

The purpose of this study was to determine whether retention of a post-pyloric Dobhoff tube (DHT) in position to serve as a visual guide through the pylorus during gastrojejunostomy (GJ) tube placement results in a reduction in fluoroscopy time, procedure time, and estimated radiation dose. A retrospective study evaluated patients who underwent GJ tube placement or gastric to GJ conversion from January 1, 2017, to April 1, 2021. Demographic and procedural data were collected, and results were evaluated using descriptive statistics and hypothesis testing through an unpaired Student's t-test. Of the 71 GJ tube placements included for analysis, 12 patients underwent placement with a post-pyloric DHT in position, and 59 patients underwent placement without a post-pyloric DHT in position. The mean fluoroscopy time and estimated radiation dose were significantly reduced in patients who underwent GJ tube placement with a post-pyloric DHT in position compared with those without (7.08 min vs. 11.02 min, P = 0.004; 123.12 mGy vs. 255.19 mGy, P = 0.015, respectively). The mean total procedure time was also reduced in patients who underwent GJ tube placement with a post-pyloric DHT in position compared with those who had no post-pyloric DHT, but this finding lacked statistical significance (18.55 min vs. 23.15 min; P = 0.09). Post-pyloric DHT retention can be utilized during GJ tube placement to reduce radiation exposure to both the patient and interventionalist.

Fluoroscopy guided percutaneous biopsy in combination with bronchoscopy and endobronchial ultrasound in the diagnosis of suspicious lung lesions - the triple approach.

Flexible bronchoscopy and endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) are the pulmonologists´ basic procedures for the biopsy of suspicious lung lesions. If inconclusive, other guiding-modalities for tissue sampling are needed, computed tomography performed by a radiologist, or - if available - radial EBUS or electromagnetic navigation biopsy. We wanted to investigate if same-day X-ray fluoroscopy-guided transthoracic fine-needle aspiration biopsy (F-TTNAB) performed by the pulmonologist immediately after bronchoscopy and EBUS is a feasible alternative. We retrospectively identified consecutive patients in whom F-TTNAB followed a bronchoscopy and EBUS in the same séance. Patients in whom the suspicion of malignancy was invalidated after complete work up were followed for six months to identify false-negative cases. In total 125 patients underwent triple approach (bronchoscopy, EBUS and F-TTNAB) during the same séance. Malignancy was diagnosed in 86 (69%), and 77 of these (90%) were primary lung cancers. The diagnostic yield of F-TTNAB for malignancy was 77%, and sensitivity was 90%. Pneumothorax occurred in 35 (28%) patients, and was administered with pleural drainage in 22 (18% of all patients). No cases of prolonged haemoptysis were observed. The risk of pneumothorax differed insignificantly with lesion size ≤2.0 cm (27%) versus >2.0 cm (29%). We conclude that it is feasible for pulmonologist to perform F-TTNAB immediately after endoscopy as a combined triple approach in a fast-track workup of suspected lung cancer.

Success Rate of Intra-articular Sacroiliac Joint Injection: Fluoroscopy vs Ultrasound Guidance-A Cadaveric Study.

BACKGROUND: Given the unacceptably high miss rates of non-image-guided injections into the sacroiliac joint, either fluoroscopy or ultrasound is recommended for guidance. The real success rate of both techniques was assessed by cadaver dissection. METHODS: Twenty bodies donated to science (40 joints: 15 female and 5 male) were investigated bilaterally. Fluoroscopy and a lower ultrasound-guided approach were performed in 10 bodies each. Conditions during puncture, the subjective feeling of the needle being intra-articular, and, for fluoroscopic guidance, the intra-articular spread of the contrast were assessed. First, 0.5 cc of Iopamidol was injected, followed by 2 mL of red-colored latex. The spread was investigated by dissection via anterior opening of the sacroiliac joint and the dorsal ligaments. RESULTS: Ultrasound guidance was used in 1/20 (5%, 95% CI = 0.9-23.6%) intra-articular injections. In 19/20 (95%, 95% CI = 0.9-23.6%) cases, latex spread in the interosseous sacroiliac ligament was used. Conditions of structural visibility were classified as good in 11/20 (55%, 95% CI = 34.2-74.2%) cases, puncture condition as good in 16/20 (80%, 95% CI = 58.4-91.9%) cases, and subjective feeling of the needle being intra-articular was present in 10/20 (50%, 95% CI = 34.2-74.2%) cases. Fluoroscopy showed an intra-articular injection in 10/20 (50%, 95% CI = 34.2-74.2%) cases. The structure visibility in fluoroscopy was good in 9/20 (45%, 95% CI = 25.8-65.8%), puncture conditions good in 8/20 (40%, 95% CI = 21.9-61.3%), intra-articular contrast spread visible in 10/20 (50%, 95% CI = 34.2-74.2%), and subjective feeling of being intra-articular was present in 17/20 (85%, 95% CI = 64.0-94.8%) cases. CONCLUSIONS: Fluoroscopy clearly showed a higher success rate of intra-articular sacroiliac joint injection.

Fluoroscopy-free ultrasonography-guided percutaneous nephrolithotomy in pediatric patients: a single-center experience.

OBJECTIVES: To present the safety and efficacy of fluoroscopy-free ultrasound-guided PCNL for the treatment of renal calculi in pediatric patients of all ages. METHODS: 30 children with mean age of 5 years (6 months-12 years) underwent totally ultrasound-guided PCNL from March 2013 to August 2016. The pyelocalyceal system was punctured in prone position using only ultrasonography guidance, and the tract was dilated using a single shot dilation technique. No fluoroscopy was used during any of the stages of renal access. The procedure was performed using adult-sized instruments. RESULTS: The mean stone size was 27.1 ± 8.7 mm. Mean access time was 4.3 ± 2 min. Mean nephroscopic time was 34.6 ± 15.2 min. Mean hospital stay of patients was 3 days (range 2-5). 21 patients were stone-free after the procedure (70% success rate). Only four patients out of 30 experienced postoperative complications. CONCLUSIONS: The results of this study showed that fluoroscopic-free ultrasound-guided PCNL in pediatric patients of all ages is safe, highly efficient, and minimizes potential radiation exposure risks associated with the procedure.

Accuracy and repeatability of quantitative fluoroscopy for the measurement of sagittal plane translation and finite centre of rotation in the lumbar spine.

Quantitative fluoroscopy (QF) was developed to measure intervertebral mechanics in vivo and has been found to have high repeatability and accuracy for the measurement of intervertebral rotations. However, sagittal plane translation and finite centre of rotation (FCR) are potential measures of stability but have not yet been fully validated for current QF. This study investigated the repeatability and accuracy of QF for measuring these variables. Repeatability was assessed from L2-S1 in 20 human volunteers. Accuracy was investigated using 10 consecutive measurements from each of two pairs of linked and instrumented dry human vertebrae as reference; one which tilted without translation and one which translated without tilt. The results found intra- and inter-observer repeatability for translation to be 1.1mm or less (SEM) with fair to substantial reliability (ICC 0.533-0.998). Intra-observer repeatability of FCR location for inter-vertebral rotations of 5° and above ranged from 1.5mm to 1.8mm (SEM) with moderate to substantial reliability (ICC 0.626-0.988). Inter-observer repeatability for FCR ranged from 1.2mm to 5.7mm, also with moderate to substantial reliability (ICC 0.621-0.878). Reliability was substantial (ICC>0.81) for 10/16 measures for translation and 5/8 for FCR location. Accuracy for translation was 0.1mm (fixed centre) and 2.2mm (moveable centre), with an FCR error of 0.3mm(x) and 0.4mm(y) (fixed centre). This technology was found to have a high level of accuracy and with a few exceptions, moderate to substantial repeatability for the measurement of translation and FCR from fluoroscopic motion sequences.

Pediatric patient radiation dosage during endomyocardial biopsies and right heart catheterization using a standard "ALARA" radiation reduction protocol in the modern fluoroscopic era.

BACKGROUND: Surveillance endomyocardial biopsy (EMB) with right heart catheterization (RHC) is the standard of care for the assessment of post cardiac transplantation rejection. This procedure has traditionally relied upon fluoroscopy, which exposes both patient and staff to the risks of ionizing radiation. These risks may be of particular concern in the transplant patient who must undergo many such procedures lifelong. We present data on a new "ALARA - As Low As Reasonably Achievable" protocol to reduce radiation exposure during the performance of RHC with EMB. METHODS: All cardiac transplantation patients < 21 years of age who underwent RHC with EMB at The Children's Hospital at Montefiore from 6/11-12/11 were included. EMB was performed after all right heart pressures including wedge pressure and thermodilution cardiac output were measured. A novel ALARA protocol consisting of multiple features including ultra-low frame rates (2-3 fps), low fluoro dose/frame (10-18 nGy/frame), use of the "air-gap" technique for patients < 20 kg, and multiple other techniques aimed at minimizing use of fluoroscopy were employed in all cases. Demographics, procedural data and patient radiation exposure levels were collected and analyzed. RESULTS: 18 patients underwent 45 surveillance RHC with EMB in the study period and were the subject of this analysis. The mean age was 5.9 ± 6.1 years, weight was 20.4 kg ± 16.6 kg, and BSA was 0.75 ± 45 m(2) . PA fluoroscopy was used exclusively in 45/45. Vascular access was RFV (21/45; 47%), RIJV (17/45; 38%), LFV (4/45; 9%) and LIJV (3/45; 7%). The median number of EMB specimens obtained was 5 (range, 4-7). The median fluoroscopy time was 3.7 min (range, 1.2-9). The median air Kerma product (K) was 1.4 mGy (range, 0.4-14), and dose area product (DAP) was 15.8 uGym(2) (range, 3.5-144.5). The K and DAP are substantially lower than any prior published data for RHC/EMB in this patient group. There were no procedural complications. CONCLUSIONS: The use of a novel ALARA protocol for RHC and EMB in pediatric cardiac transplantation patients markedly reduced radiation exposure to levels far below any previously reported values without negatively affecting the safety or efficacy of these procedures.