This article expresses the current view of the European Society of Gastrointestinal Endoscopy (ESGE) about radiation protection for endoscopic procedures, in particular endoscopic retrograde cholangiopancreatography (ERCP). Particular cases, including pregnant women and pediatric patients, are also discussed. This Guideline was developed by a group of endoscopists and medical physicists to ensure that all aspects of radiation protection are adequately dealt with. A two-page executive summary of evidence statements and recommendations is provided. The target readership for this Guideline mostly includes endoscopists, anesthesiologists, and endoscopy assistants who may be exposed to X-rays during endoscopic procedures.
This article describes the European DIMOND approach to defining reference levels (RLs) for radiation doses delivered to patients during two types of invasive cardiology procedures, namely coronary angiography (CA) and percutaneous transluminal coronary angioplasty (PTCA). Representative centres of six European countries recorded patients' doses in terms of dose-area product (DAP), fluoroscopy time and number of radiographic exposures, using X-ray equipment that has been subject to constancy testing. In addition, a DAP trigger level for cardiac procedures which should alert the operator to possible skin injury, was set to 300 Gyxcm2. The estimation of maximum skin dose was recommended in the event that a DAP trigger level was likely to be exceeded. The proposed RLs for CA and PTCA were for DAP 45 Gyxcm2 and 75 Gyxcm2, for fluoroscopy time 7.5 min and 17 min and for number of frames 1250 and 1300, respectively. The proposed RLs should be considered as a first approach to help in the optimisation of these procedures. More studies are required to establish certain "tolerances" from the proposed levels taking into account the complexity of the procedure and the patient's size.
Comparison of CT results with diagnostic reference levels revealed the need for revisions, partly because the newer scanners have improved technology that facilitates lower patient doses.
In interventional cardiology, a wide variation in patient dose for the same type of procedure has been recognised by different studies. Variation is almost due to procedure complexity, equipment performance, procedure protocol and operator skill. The SENTINEL consortium has performed a survey in nine european centres collecting information on near 2000 procedures, and a new set of reference levels (RLs) for coronary angiography and angioplasty and diagnostic electrophysiology has been assessed for air kerma-area product: 45, 85 and 35 Gy cm2, effective dose: 8, 15 and 6 mSv, cumulative dose at interventional reference point: 650 and 1500 mGy, fluoroscopy time: 6.5, 15.5 and 21 min and cine frames: 700 and 1000 images, respectively. Because equipment performance and set-up are the factors contributing to patient dose variability, entrance surface air kerma for fluoroscopy, 13 mGy min(-1), and image acquisition, 0.10 mGy per frame, have also been proposed in the set of RLs.
In this study, a mathematical method was used to estimate the entrance surface dose (ESD) to the patient and the scattered dose (Ds) to the operating surgeon during various fluoroscopically guided surgical orthopaedic procedures. For 204 patients, the procedure type, the fluoroscopy time and the highest tube potential and current values observed during fluoroscopy were recorded. For the most often performed procedures (intramedullary nailing of peritrochanteric fractures, open reduction and internal fixation of malleolar fractures and intramedullary nailing of diaphyseal fractures of the femur), the respective mean fluoroscopy times were 3.2, 1.5 and 6.3 min while the estimated mean ESDs were 183, 21 and 331 mGy, respectively. The estimated Ds rates for the hands, chest, thyroid, eyes, gonads and legs of the operating surgeon were on average to 0.103, 0.023, 0.013, 0.012, 0.066 and 0.045 mGy min(-1), respectively, and compare well with the literature. The mathematical estimation of doses cannot replace actual measurements; however, it can be used for a preliminary assessment of the radiation dose levels during various surgical procedures, so that the operator, the surgeon and the rest of the medical staff involved could be aware of the associated radiation risk and the radiation protection measures required.
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