A simple ergonomic measure reduces fluoroscopy time during ERCP: A multivariate analysis

Abstract

Background and study aims Endoscopic retrograde cholangiopancreatgraphy (ERCP) carries a radiation risk to patients undergoing the procedure and the team performing it. Fluoroscopy time (FT) has been shown to have a linear relationship with radiation exposure during ERCP. Recent modifications to our ERCP suite design were felt to impact fluoroscopy time and ergonomics. This multivariate analysis was therefore undertaken to investigate these effects, and to identify and validate various clinical, procedural and ergonomic factors influencing the total fluoroscopy time during ERCP. This would better assist clinicians with predicting prolonged fluoroscopic durations and to undertake relevant precautions accordingly.

Patients and methods A retrospective analysis of 299 ERCPs performed by 4 endoscopists over an 18-month period, at a single tertiary care center was conducted. All inpatients/outpatients (121 males, 178 females) undergoing ERCP for any clinical indication from January 2012 to June 2013 in the chosen ERCP suite were included in the study. Various predetermined clinical, procedural and ergonomic factors were obtained via chart review. Univariate analyses identified factors to be included in the multivariate regression model with FT as the dependent variable.

Results Bringing the endoscopy and fluoroscopy screens next to each other was associated with a significantly lesser FT than when the screens were separated further (–1.4 min, P = 0.026). Other significant factors associated with a prolonged FT included having a prior ERCP (+ 1.4 min, P = 0.031), and more difficult procedures (+ 4.2 min for each level of difficulty, P < 0.001). ERCPs performed by high-volume endoscopists used lesser FT vs. low-volume endoscopists (–1.82, P = 0.015).

Conclusions Our study has identified and validated various factors that affect the total fluoroscopy time during ERCP. This is the first study to show that decreasing the distance between the endoscopy and fluoroscopy screens in the ERCP suite significantly reduces the total fluoroscopy time, and therefore radiation exposure to patients and staff involved in the procedure.

• References

• 1 Larkin C, Workman A, Wright R. et al. Radiation doses to patients during ERCP. Gastrointest Endosc 2001; 53: 161-164
• 2 Naidu LS, Singhal S, Preece DE. et al. Radiation exposure to personnel performing endoscopic retrograde cholangiopancreatography. Postgrad Med J 2005; 81: 660-662
• 3 de Revision E, Uradomo L, Cohen H. et al. World Gastroenterology Organization Practice Guideline: Radiation protection in the endoscopy suite-Minimizing radiation exposure for patients and staff in endoscopy: a joint ASGE/IAEA/WGO guideline [Official Spanish translation of the WGO]. Gastroenterologia Latinoamerican 2012; 36: 202
• 4 Rehani M, Vano E, Ciraj-Bjelac O. et al. Radiation and cataract. Radiat Protection Dosimetry 2011; 147: 300-304
• 5 Kleinerman RA. Cancer risks following diagnostic and therapeutic radiation exposure in children. Pediatr Radiol 2006; 36 (Suppl. 02) 121-125
• 6 Campbell N, Sparrow K, Fortier M. et al. Practical radiation safety and protection for the endoscopist during ERCP. Gastrointest Endosc 2002; 55: 552-557
• 7 Romagnuolo J, Cotton PB. Recording ERCP fluoroscopy metrics using a multinational quality network: establishing benchmarks and examining time-related improvements. Am J Gastroenterol 2013; 108: 1224-1230
• 8 Ho IK, Cash BD, Cohen H. et al. Radiation exposure in gastroenterology: improving patient and staff protection. Am J Gastroenterol 2014; 109: 1180-1194
• 9 Shergill AK, McQuaid KR, Rempe lD. Ergonomics and GI endoscopy. Gastrointest. Endosc 2009; 70: 145-153
• 10 Pedrosa MC, Farraye FA, Shergill AK. et al. Minimizing occupational hazards in endoscopy: personal protective equipment, radiation safety, and ergonomics. Gastrointest Endosc 2010; 72: 227-235
• 11 Buls N, Pages J, Mana F. et al. Patient and staff exposure during ERCP. Br J Radiol 2002; 75: 435-443
• 12 Johlin FC, Pelsang RE, Greenleaf M. Phantom study to determine radiation exposure to medical personnel involved in ERCP fluoroscopy and its reduction through equipment and behavior modifications. Am J Gastroenterol 2002; 97: 893-897
• 13 Chen MY, Van swearingen FL, Mitchell R. et al. Radiation exposure during ERCP: effect of a protective shield. Gastrointest Endosc 1996; 43: 1-5
• 14 Cohen RV, Aldred MA, Paes WS. et al. How safe is ERCP to the endoscopist?. Surg Endosc 1997; 11: 615-617
• 15 Hernandez RJ, Goodsitt MM. Reduction of radiation dose in pediatric patients using pulsed fluoroscopy. AJR Am J Roentgenol 1996; 167: 1247-1253
• 16 Scanavacca M, D'avila A, Velarde JL. et al. Reduction of radiation exposure time during catheter ablation with the use of pulsed fluoroscopy. Int J Cardiol 1998; 63: 71-74
• 17 Uradomo LT, Goldberg EM, Darwin PE. Time-limited fluoroscopy to reduce radiation exposure during ERCP: a prospective randomized trial. Gastrointest Endosc 2007; 66: 84-89
• 18 Jorgensen J, Rubenstein J, Goodsitt M. et al. Radiation doses to ERCP patients are significantly lower with experienced endoscopists. Gastrointest Endosc 2011; 72: 58-65
• 19 Uradomo LT, Lustberg ME, Darwin PE. Effect of physician training on fluoroscopy time during ERCP. Dig Dis Sci 2006; 51: 909-914
• 20 Kim E, Mcloughlin M, Lam EC. et al. Prospective analysis of fluoroscopy duration during ERCP: critical determinants. Gastrointest Endosc 2010; 72: 50-57
• 21 Katsinelos P, Gatopoulou A, Gkagkalis S. et al. A prospective analysis of factors influencing fluoroscopy time during therapeutic ERCP. Ann Gastroenterol 2012; 25: 338-344
• 22 Cotton PB, Eisen G, Romagnuolo J. et al. Grading the complexity of endoscopic procedures: results of an ASGE working party. Gastrointest Endosc 2011; 73: 868-874
• 23 Adler DG, Lieb II JG, Cohen J. et al. Quality indicators for ERCP. Am J Gastroenterol 2015; 110: 91-101