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 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.

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.

슬관절강 내 주사시 투시 유도의 유용성

명재성,이준우,이지연,최자영,김성현,전우선,김나라,김주형,정희선,홍성환,전용환,한헌,강흥식 대한영상의학회 2007 대한영상의학회지 Vol.56 No.6

Purpose: To determine the accuracy of the intra-articular location of hyaluroinc acid injection using a blind approach and to establish the usefulness of fluoroscopy-guided intra-articular injection. Materials and Methods: A fluoroscopy unit was used for 368 intra-articular injections of hyaluronic acid to 93 knees in 65 patients. Initially, blind needle positioning was conducted on the fluoroscopy table. The failure rate of the blind approach among the 368 injections was evaluated, and a relationship between the Kellgren-Lawrence grade (K-L grade) and the incidence of repeated failures using the blind approach was determined for injections to 52 knees in 37 patients who received a complete cycle of injections (five consecutive injections with a one-week interval between injections). Results: Using a blind approach, 298 of 368 trials (81.2%) resulted in a needle tip being placed in an intra-articular location, while 70 of 368 trials resulted in an extra-articular placement of the needle tip. Among 52 knees to which a complete cycle of injections (five consecutive injections with a one-week interval between injections) was administered, repeated failure of intra-articular placement using the blind approach was seen for 18 knees (34.6%); a more severe K-L grade assigned was associated with a higher rate of repeated failure. However, the trend was not statistically significant based on the Chi-squared test (p value = 0.14). Conclusion: Fluoroscopy-guided needle placement may be helpful to ensure therapeutic intra-articular injection of the knee. 목적: 투시 유도 없이 시행하는 슬관절강내 히알루론산 주사의 정확성을 조사하고 투시 유도의 유용성을 알아보고자 한다 대상과 방법: 퇴행성 관절염 진단하에 히알루론산 주사를 의뢰받은 65명 환자의 93 슬관절에 대해 368회의 관절강 내 주사를 시행하였다. 투시장치 계기대위에서 투시 유도 없이 천자를 하고 시험적 조영제(OmnipaqueTM, Amersham Health, Carrigtohill, Ireland)를 주입하여 천자 침 끝이 관절강 내 위치하는지를 확인하였다. 관절강 내 위치 후 2 mL의 히알루론산 주사를 시행하였다. 투시 유도 없이 시행한 관절강 내 주사의 실패율, 1주 간격으로 5회 주사를 시행 받은 37 환자의 52 슬관절에 대하여 Kellgren-Lawrence grade(K-L grade)와 2번 이상의 반복적인 실패확률의 상관관계를 비교하였다. 결과는 Chi-square 검사를 이용하여 통계 처리하였고, 유의 수준 p=0.05를 사용하였다. 결과: 투시 유도 없이 시행한 슬관절강 내 주사 368예 중 298예(81.2%)에서 성공하였고 70예에서 실패하였다. 1주 간격으로 5회 주사를 시행 받은 52 슬관절 중 18(34.6%) 슬관절이 2번 이상의 반복적인 실패를 보였다. K-L grade 가 높을수록 반복적 실패를 보이는 경향이 있었으나 통계적 유의성은 없었다(p value = 0.14). 결론: 슬관절강내 주사시 투시 유도는 치료 효과를 위한 위치 확보에 도움이 된다.

A case report : Fluoroscopy-guided pudendal nerve block and pulsed radiofrequency treatment

Sang Hyun Lee,Chul Joong Lee,Jin Young Lee,Tae Hyeong Kim,Woo Seok Sim,Suk Young Lee,Hee Youn Hwang 대한마취과학회 2009 Korean Journal of Anesthesiology Vol.56 No.5

Pudendal nerve block (PNB) is performed for differential diagnosis and treatment of chronic pelvic and perineal pain. Several block methods, such as transvaginal, transperineal, computerized tomography-, ultrasound- and fluoroscopy-guided approach are currently under practice. Compared to others, a fluoroscopy-guided approach has several advantages, such as its relatively low cost, facility and ease of landmark recognition. We depicted a fluoroscopy-guided PNB technique to selectively block and elaborate a pulsed radiofrequency treatment in a 51-year-old man with chronic pelvic and perineal pain. The patient had undergone a ganglion of impar block with a limited pain relief. Thereafter, a PNB was performed and the pain was relieved significantly for 2 weeks. Further PNB with a pulsed radiofrequency treatment reduced the pain for more than 8 weeks. The pain relief sustained up to the time of this report. The fluoroscopy-guided PNB and pulsed radiofrequency treatment allowed simplicity in manipulation and precision in performing the procedures with a favorable outcome. (Korean J Anesthesiol 2009;56:605~8)

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.