Korean J Gastroenterol.  2024 Dec;84(6):251-264. 10.4166/kjg.2024.074.

Guideline for Minimizing Radiation Exposure of Interventionalists during Fluoroscopy-guided Interventional Procedures

• Shin IS
• Lee YN
• Lee JK
• Kim JS
• Kim SB
• Keum J
• Oh CH
• Lee KW
• Chung J
• Kwon LM
• Kim NH
• Lee SS
• Son BK
• Choi M

• KMID: 2563342
• DOI: http://doi.org/10.4166/kjg.2024.074

Abstract

As fluoroscopy-guided interventional procedures gain popularity, the associated health threats from radiation exposure to interventionalists during these procedures are increasing. Therefore, an understanding of the potential risks of radiation and careful consideration on minimizing exposure to radiation during the procedures are of paramount importance. The Korean Pancreatobiliary Association has developed a clinical practice guideline to minimize radiation exposure during fluoroscopy-guided interventional procedures. This guideline provides recommendations to deal with the risk of radiation exposure to interventionalists who perform fluoroscopy-guided procedures, and emphasizes the importance of proper and practical approaches to avoid unnecessary radiation exposure.

Keyword

Radiation exposure; Radiation protection; Fluoroscopy; Endoscopic retrograde cholangiopancreatography

Figure

• 

  Fig. 1 Proper wearing of radiation protection equipments including protective wrap-around apron, collar, and glasses.

• 

  Fig. 2 Various types of protection shielding devices ([A] a free-standing shield, [B] a shield hanging from ceiling, and [C] a shield suspended from patient table).

• 

  Fig. 3 Different stationary fluoroscopy systems with X-ray tubes located under ([A] under-couch system) or above ([B] over-couch system) the patient table (adapted from Oh and Son).

• 

  Fig. 4 (A) Balloon-occluded cholangiogram obtained using the last-image-hold method. (B) Taking a radiograph does not provide any additional information. (C) Taking a radiograph with image enlargement gives no additional information with the most radiation exposure compared to last-image-hold method.

• 

  Fig. 5 Schematic diagram of Diagnostic Reference Level (DRL). (A) DRL is established using the 75th percentile of radiation dose measurements collected from various institutions. (B) New 75th percentile value can be set as a new DRL to further reduce overall radiation doses.

• 

  Fig. 6 (A) A schema showing proper wearing sites for dosimeters. Dosimeters are attached on the outside of the protective apron at neck level (B), and under the protective apron at thoracic level (C).

Reference

1. Oh CH, Son BK. 2022; Minimizing radiation exposure in endoscopic retrograde cholangiopancreatography: a review for medical personnel. Korean J Intern Med. 37:1111–1119. DOI: 10.3904/kjim.2022.093. PMID: 36217814. PMCID: PMC9666259.

2. Huang RJ, Thosani NC, Barakat MT, et al. 2017; Evolution in the utilization of biliary interventions in the United States: results of a nationwide longitudinal study from 1998 to 2013. Gastrointest Endosc. 86:319–326.e5. DOI: 10.1016/j.gie.2016.12.021. PMID: 28062313. PMCID: PMC5496794.

3. Itoi T, Kasuya K, Sofuni A, et al. 2013; Endoscopic ultrasonographyguided pancreatic duct access: techniques and literature review of pancreatography, transmural drainage and rendezvous techniques. Dig Endosc. 25:241–252. DOI: 10.1111/den.12048. PMID: 23490022.

4. Tsuchiya T, Itoi T, Sofuni A, Tonozuka R, Mukai S. 2016; Endoscopic ultrasonography-guided rendezvous technique. Dig Endosc. 28 Suppl 1:96–101. DOI: 10.1111/den.12611. PMID: 26786389.

5. Teoh AYB, Bapaye A, Lakhtakia S, et al. 2020; Prospective multicenter international study on the outcomes of a newly developed self-approximating lumen-apposing metallic stent for drainage of pancreatic fluid collections and endoscopic necrosectomy. Dig Endosc. 32:391–398. DOI: 10.1111/den.13494. PMID: 31343773.

6. Katanuma A, Hayashi T, Kin T, et al. 2020; Interventional endoscopic ultrasonography in patients with surgically altered anatomy: Techniques and literature review. Dig Endosc. 32:263–274. DOI: 10.1111/den.13567. PMID: 31643105.

7. Schünemann HJ, Oxman AD, Brozek J, et al. 2008; Grading quality of evidence and strength of recommendations for diagnostic tests and strategies. BMJ. 336:1106–1110. DOI: 10.1136/bmj.39500.677199.AE. PMID: 18483053. PMCID: PMC2386626.

8. Maeder M, Brunner-La Rocca HP, Wolber T, et al. 2006; Impact of a lead glass screen on scatter radiation to eyes and hands in interventional cardiologists. Catheter Cardiovasc Interv. 67:18–23. DOI: 10.1002/ccd.20457. PMID: 16273590.

9. McGinley PH, Miner MS. 1995; A history of radiation shielding of x-ray therapy rooms. Health Phys. 69:759–765. DOI: 10.1097/00004032-199511000-00010. PMID: 7558866.

10. Archer BR, Gray JE. 2005; Important changes in medical x-ray imaging facility shielding design methodology. A brief summary of recommendations in NCRP Report No. 147. Med Phys. 32:3599–3601. DOI: 10.1118/1.2124587. PMID: 16475758.

11. Campbell N, Sparrow K, Fortier M, Ponich T. 2002; Practical radiation safety and protection for the endoscopist during ERCP. Gastrointest Endosc. 55:552–557. DOI: 10.1067/mge.2002.122578. PMID: 11923771.

12. Pedrosa MC, Farraye FA, Shergill AK, et al. 2010; Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc. 72:227–235. DOI: 10.1016/j.gie.2010.01.071. PMID: 20537638.

13. Yaffe MJ, Mawdsley GE, Lilley M, Servant R, Reh G. 1991; Composite materials for x-ray protection. Health Phys. 60:661–664. DOI: 10.1097/00004032-199105000-00004. PMID: 2019497.

14. Rehani MM, Ciraj-Bjelac O, Vañó E, et al. 2010; ICRP Publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department. Ann ICRP. 40:1–102. DOI: 10.1016/j.icrp.2012.03.001. PMID: 22732420.

15. Vano E, Kleiman NJ, Duran A, Rehani MM, Echeverri D, Cabrera M. 2010; Radiation cataract risk in interventional cardiology personnel. Radiat Res. 174:490–495. DOI: 10.1667/RR2207.1. PMID: 20726724.

16. Sethi S, Barakat MT, Friedland S, Banerjee S. 2019; Radiation training, radiation protection, and fluoroscopy utilization practices among US therapeutic endoscopists. Dig Dis Sci. 64:2455–2466. DOI: 10.1007/s10620-019-05564-z. PMID: 30911863. PMCID: PMC7313385.

17. Wagner LK, Mulhern OR. 1996; Radiation-attenuating surgical gloves: effects of scatter and secondary electron production. Radiology. 200:45–48. DOI: 10.1148/radiology.200.1.8657942. PMID: 8657942.

18. Son B, Lee S, Lee K, Kim JS. 2009; Prevention of ERCP-related radiation hazard. Korean J Pancreas Biliary Tract. 14:35–44.

19. Chen MY, Van Swearingen FL, Mitchell R, Ott DJ. 1996; Radiation exposure during ERCP: effect of a protective shield. Gastrointest Endosc. 43:1–5. DOI: 10.1016/S0016-5107(96)70250-X. PMID: 8903808.

20. Johlin FC, Pelsang RE, Greenleaf M. 2002; Phantom study to determine radiation exposure to medical personnel involved in ERCP fluoroscopy and its reduction through equipment and behavior modifications. Am J Gastroenterol. 97:893–897. DOI: 10.1111/j.1572-0241.2002.05605.x. PMID: 12003424.

21. Morishima Y, Chida K, Meguro T. 2018; Effectiveness of additional lead shielding to protect staff from scattering radiation during endoscopic retrograde cholangiopancreatography procedures. J Radiat Res. 59:225–232. DOI: 10.1093/jrr/rrx039. PMID: 29409055. PMCID: PMC5951079.

22. Chung KH, Park YS, Ahn SB, Son BK. 2019; Radiation protection effect of mobile shield barrier for the medical personnel during endoscopic retrograde cholangiopancreatography: a quasi-experimental prospective study. BMJ Open. 9:e027729. DOI: 10.1136/bmjopen-2018-027729. PMID: 30898834. PMCID: PMC6527993.

23. Badawy MK, Henely-Smith E, Hasmat S. 2023; Radiation exposure to staff during fluoroscopic endoscopic procedures. DEN Open. 3:e234. DOI: 10.1002/deo2.234. PMID: 37035033. PMCID: PMC10076694.

24. Kurihara T, Itoi T, Sofuni A, et al. 2012; Novel protective lead shield and pulse fluoroscopy can reduce radiation exposure during the ERCP procedure. Hepatogastroenterology. 59:709–712.

25. Yamada R, Saimyo Y, Tanaka K, et al. 2020; Usefulness of an additional lead shielding device in reducing occupational radiation exposure during interventional endoscopic procedures: An observational study. Medicine (Baltimore). 99:e21831. DOI: 10.1097/MD.0000000000021831. PMID: 32846829. PMCID: PMC7447393.

26. Muniraj T, Aslanian HR, Laine L, et al. 2015; A double-blind, randomized, sham-controlled trial of the effect of a radiation-attenuating drape on radiation exposure to endoscopy staff during ERCP. Am J Gastroenterol. 110:690–696. DOI: 10.1038/ajg.2015.85. PMID: 25823765.

27. Harris AM. 2018; radiation exposure to the urologist using an overcouch radiation source compared with an undercouch radiation source in contemporary urology practice. Urology. 114:45–48. DOI: 10.1016/j.urology.2017.12.011. PMID: 29305204.

28. Bowsher WG, Blott P, Whitfield HN. 1992; Radiation protection in percutaneous renal surgery. Br J Urol. 69:231–233. DOI: 10.1111/j.1464-410X.1992.tb15518.x. PMID: 1568094.

29. Vañó E, González L, Beneytez F, Moreno F. 1998; Lens injuries induced by occupational exposure in non-optimized interventional radiology laboratories. Br J Radiol. 71:728–733. DOI: 10.1259/bjr.71.847.9771383. PMID: 9771383.

30. Churrango G, Deutsch JK, Dinneen HS, Churrango J, Samiullah S, Ahlawat SK. 2015; Minimizing radiation exposure during ERCP by avoiding live or continuous fluoroscopy. J Clin Gastroenterol. 49:e96–100. DOI: 10.1097/MCG.0000000000000385. PMID: 26191644.

31. Seo D, Kim KH, Kim JS, Han S, Park K, Kim J. 2016; Evaluation of radiation doses in patient and medical staff during endoscopic retrograde cholangiopancreatography procedures. Radiat Prot Dosimetry. 168:516–522. DOI: 10.1093/rpd/ncv373. PMID: 26269518.

32. Jorgensen JE, Rubenstein JH, Goodsitt MM, Elta GH. 2010; Radiation doses to ERCP patients are significantly lower with experienced endoscopists. Gastrointest Endosc. 72:58–65. DOI: 10.1016/j.gie.2009.12.060. PMID: 20421102. PMCID: PMC2906113.

33. Damilakis J, Perisinakis K, Theocharopoulos N, et al. 2005; Anticipation of radiation dose to the conceptus from occupational exposure of pregnant staff during fluoroscopically guided electrophysiological procedures. J Cardiovasc Electrophysiol. 16:773–780. DOI: 10.1111/j.1540-8167.2005.40727.x. PMID: 16050837.

34. Uradomo LT, Lustberg ME, Darwin PE. 2006; Effect of physician training on fluoroscopy time during ERCP. Dig Dis Sci. 51:909–914. DOI: 10.1007/s10620-005-9007-y. PMID: 16718536.

35. López PO, Dauer LT, Loose R, et al. 2018; ICRP Publication 139: Occupational radiological protection in interventional procedures. Ann ICRP. 47:1–118. DOI: 10.1177/0146645317750356. PMID: 29532669.

36. Larkin CJ, Workman A, Wright RE, Tham TC. 2001; Radiation doses to patients during ERCP. Gastrointest Endosc. 53:161–164. DOI: 10.1067/mge.2001.111389. PMID: 11174284.

37. Stueve D. 2006; Management of pediatric radiation dose using Philips fluoroscopy systems DoseWise: perfect image, perfect sense. Pediatr Radiol. 36 Suppl 2:216–220. DOI: 10.1007/s00247-006-0216-0. PMID: 16862406. PMCID: PMC2663644.

38. Chaffins JA. 2008; Radiation protection and procedures in the OR. Radiol Technol. 79:415–428. quiz 429–31.

39. Miller DL, Balter S, Schueler BA, Wagner LK, Strauss KJ, Vañó E. 2010; Clinical radiation management for fluoroscopically guided interventional procedures. Radiology. 257:321–332. DOI: 10.1148/radiol.10091269. PMID: 20959547.

40. Rauch P, Lin PJ, Balter S, et al. 2012; Functionality and operation of fluoroscopic automatic brightness control/automatic dose rate control logic in modern cardiovascular and interventional angiography systems: a report of Task Group 125 Radiography/Fluoroscopy Subcommittee, Imaging Physics Committee, Science Council. Med Phys. 39:2826–2828. DOI: 10.1118/1.4704524. PMID: 22559654.

41. Meisinger QC, Stahl CM, Andre MP, Kinney TB, Newton IG. 2016; Radiation protection for the fluoroscopy operator and staff. AJR Am J Roentgenol. 207:745–754. DOI: 10.2214/AJR.16.16556. PMID: 27440524.

42. Buls N, Pages J, Mana F, Osteaux M. 2002; Patient and staff exposure during endoscopic retrograde cholangiopancreatography. Br J Radiol. 75:435–443. DOI: 10.1259/bjr.75.893.750435. PMID: 12036837.

43. Schueler BA. 2000; The AAPM/RSNA physics tutorial for residents: general overview of fluoroscopic imaging. Radiographics. 20:1115–1126. DOI: 10.1148/radiographics.20.4.g00jl301115. PMID: 10903700.

44. Ho IK, Cash BD, Cohen H, et al. 2014; Radiation exposure in gastroenterology: improving patient and staff protection. Am J Gastroenterol. 109:1180–1194. DOI: 10.1038/ajg.2014.122. PMID: 24842339.

45. Kwok K, Hasan N, Duloy A, Murad F, Nieto J, Day LW. 2021; American Society for Gastrointestinal Endoscopy radiation and fluoroscopy safety in GI endoscopy. Gastrointest Endosc. 94:685–697.e4. DOI: 10.1016/j.gie.2021.05.042. PMID: 34399965.

46. Boix J, Lorenzo-Zúñiga V. 2011; Radiation dose to patients during endoscopic retrograde cholangiopancreatography. World J Gastrointest Endosc. 3:140–144. DOI: 10.4253/wjge.v3.i7.140. PMID: 21860683. PMCID: PMC3159502.

47. The 2007 Recommendations of the International Commission on Radiological Protection. ICRP publication 103. Ann ICRP. 2007; 37:1–332. DOI: 10.1016/j.icrp.2008.07.001.

48. Dumonceau JM, Garcia-Fernandez FJ, Verdun FR, et al. 2012; Radiation protection in digestive endoscopy: European Society of Digestive Endoscopy (ESGE) guideline. Endoscopy. 44:408–421. DOI: 10.1055/s-0031-1291791. PMID: 22438152.

49. Olgar T, Bor D, Berkmen G, Yazar T. 2009; Patient and staff doses for some complex x-ray examinations. J Radiol Prot. 29:393–407. DOI: 10.1088/0952-4746/29/3/004. PMID: 19690354.

50. Menon S, Mathew R, Kumar M. 2019; Ocular radiation exposure during endoscopic retrograde cholangiopancreatography: a meta-analysis of studies. Eur J Gastroenterol Hepatol. 31:463–470. DOI: 10.1097/MEG.0000000000001341. PMID: 30830881.

51. O'Connor U, Gallagher A, Malone L, O'Reilly G. 2013; Occupational radiation dose to eyes from endoscopic retrograde cholangiopancreatography procedures in light of the revised eye lens dose limit from the International Commission on Radiological Protection. Br J Radiol. 86:20120289. DOI: 10.1259/bjr.20120289. PMID: 23385992. PMCID: PMC3608047.

52. Radiological protection and safety in medicine. A report of the International Commission on Radiological Protection. Ann ICRP. 1996; 26:1–47. DOI: 10.1016/S0146-6453(00)89195-2.

53. Takenaka M, Hosono M, Hayashi S, Nishida T, Kudo M. 2022; How should radiation exposure be handled in fluoroscopy-guided endoscopic procedures in the field of gastroenterology? Dig Endosc. 34:890–900. DOI: 10.1111/den.14208. PMID: 34850457. PMCID: PMC9543255.

54. Lopes J, Baudin C, Feuardent J, et al. 2023; Cohort profile: ORICAMs, a French cohort of medical workers exposed to low-dose ionizing radiation. PLoS One. 18:e0286910. DOI: 10.1371/journal.pone.0286910. PMID: 37289793. PMCID: PMC10249798.

55. Geise RA, O'Dea TJ. 1999; Radiation dose in interventional fluoroscopic procedures. Appl Radiat Isot. 50:173–184. DOI: 10.1016/S0969-8043(98)00046-3. PMID: 10028636.

56. Moreira AC, da Silva Branco AJ, Khoury HJ, Pires SR, Pereira Barbosa AH, Bitelli Medeiros R. 2023; Cardiologist's exposure to radiation in cath lab measured with Instadose^TM dosimeter. J Radiol Prot. 43:011512. DOI: 10.1088/1361-6498/acb82b. PMID: 36731124.

57. Krueger KJ, Hoffman BJ. 1992; Radiation exposure during gastroenterologic fluoroscopy: risk assessment for pregnant workers. Am J Gastroenterol. 87:429–431.

58. Ratnapalan S, Bona N, Chandra K, Koren G. 2004; Physicians' perceptions of teratogenic risk associated with radiography and CT during early pregnancy. AJR Am J Roentgenol. 182:1107–1109. DOI: 10.2214/ajr.182.5.1821107. PMID: 15100102.

59. International Commission on Radiological Protection. Pregnancy and medical radiation. Ann ICRP. 2000; 30:iii–viii. 1–43.

60. Mainprize JG, Yaffe MJ, Chawla T, Glanc P. 2023; Effects of ionizing radiation exposure during pregnancy. Abdom Radiol (NY). 48:1564–1578. DOI: 10.1007/s00261-023-03861-w. PMID: 36933026. PMCID: PMC10024285.

61. Vu CT, Elder DH. 2013; Pregnancy and the working interventional radiologist. Semin Intervent Radiol. 30:403–407. DOI: 10.1055/s-0033-1359735. PMID: 24436568. PMCID: PMC3835582.

62. Marx MV, Niklason L, Mauger EA. 1992; Occupational radiation exposure to interventional radiologists: a prospective study. J Vasc Interv Radiol. 3:597–606. DOI: 10.1016/S1051-0443(92)72903-0. PMID: 1446120.