Low-dose Pulsed Vs Standard Pulsed Fluoroscopy During ERCP to Reduce Radiation Without Change in Image Quality: Prospective Randomized Study.

Background: Endoscopic retrograde cholangiopancreatography (ERCP) poses the risk of radiation exposure (RE) to patients and staff, and increases the risk of adverse biological effects such as cataracts, sterility, and cancer. Newer fluoroscopy equipment (C-Arm) provides options to limit radiation in the form of lower radiation dose and frame rate or time-limited “pulsed” settings. However, the impact of lower settings on image quality has not been assessed, and no standard protocol for fluoroscopy settings used during ERCP exist. Methods: A single-center, double-blind, prospective randomized study of consecutive adult patients undergoing standard-of-care ERCP at a tertiary academic medical center. Patients were randomized into two groups: 1) standard-dose pulsed; 2) low-dose pulsed. Pulsed mode (8 fps) was defined as x-ray exposure either in the manufacturer standard-dose or low-dose settings limited to 3 seconds each time the foot-operated switch is depressed. Results: Seventy-eight patients undergoing ERCP were enrolled and randomized. No difference in age, gender, and BMI was found between the two groups. No significant difference in image quality was found between standard-dose and low-dose fluoroscopy (p=0.925). The low-dose group was exposed to significantly less radiation when compared to standard-dose (p < 0.05). Fluoroscopy time (minutes) was similar in both groups (2.0 vs 1.9), further suggesting that group assignment had no impact on image quality or procedure time. Conclusions: Low-dose pulsed fluoroscopy is a reliable method that substantially reduces radiation without compromising image quality or affecting procedural or fluoroscopy times. This highlights the need for standardization in ERCP fluoroscopy settings to limit radiation exposure.