Assessment of effective doses for fluoroscopy-guided balloon dilatation of benign esophageal strictures in pediatric medicine

Interventional examinations are associated with high levels of patient exposure per examination, which makes it particularly important to monitor individual patient doses and to assess radiation risks. The aim of this study was the assessment of effective doses for fluoroscopy-guided balloon dilatation of benign esophageal strictures, whichwasperformedonpediatricpatientsaged 1 to 2 yearsatthe Departmentof Radiosurgical Methodsof Diagnosis and Treatment of St. Petersburg State Pediatric Medical University. Patient exposure patterns were basedonourowndatacollection.    Thecalculationofeffectiveandorgandosesofpatientsnormalizedbythevalue of the dose area product measured during the study was carried out using PCXMC 2.0 software. The conversion coefficients from the dose area product to the effective dose were calculated using tissue weighting coefficients from the ICRP Publications 60 and 103 their values were 10.7 and 11.7 µSv/cGy cm2, respectively. The results of verification of the method indicated that the use of inappropriate conversion coefficients leads to an almost double underestimation of children’s effective doses. Differences in the values of conversion coefficients are significant and are explained by differences in voltage, source to image distance, and irradiation field size. A simplified model of patient exposure was proposed, which is described by a single irradiation field. The assessment of effective doses using multi-field and single-field irradiation model shows comparable results, which allows using the differentiated approach to the assessment of radiation doses of patients.

1. ICRP Publication 117. Radiological protection in fluoroscopically guided procedures performed outside the imaging department. Ann ICRP. 2010 Dec;40(6): 1-102.

2. Scientific annex A: Evaluation of medical exposure to ionizing radiation The UNSCEAR 2020/2021 Report Volume I to the General Assembly (A/76/46). Official site UN SCEAR. Available from: https://css.unscear.org/unscear/uploads/documents/publications/UNSCEAR_2020_21_Annex-A.pdf (Accessed: 15.06.2023).

3. ISO/IEC 17025:2017(E) General requirements for the competence of testing and calibration laboratories; 2017.

4. EC. Radiation Protection no 180 Medical radiation exposure of the European population, Part , EU; 2014.

5. Ubeda C, Vano E, Miranda P, Figueroa X. Organ and effective doses detriment to paediatric patients undergoing multiple interventional cardiology procedures. Medical Physics. 2019;60: 182-187. doi: 10.1016/j.ejmp.2019.03.020.

6. Schegerer A, Loose R, Heuser LJ, Brix G. Diagnostic Reference Levels for Diagnostic and Interventional X-Ray Procedures in Germany: Update and Handling. Rofo. 2019;191(8): 739751 (English, German) doi: 10.1055/a-0824-7603.

7. Barnaoui S, Rehel JL, Baysson H, Boudjemline Y, Girodon B, Bernier MO, et al. Local reference levels and organ doses from pediatric cardiac interventional procedures. Pediatric Cardiology. 2014;35(6): 1037-45. doi: 10.1007/s00246-014-0895-5.

8. Walsh MA, Noga M, Rutledge J. Cumulative radiation exposure in pediatric patients with congenital heart disease. Pediatric Cardiology. 2015;36(2): 289-94. doi: 10.1007/ s00246-014-0999-y.

9. Karambatsakidou A, Omar A, Fransson A, Poludniowski G. Calculating organ and effective doses in paediatric interventional cardiac radiology based on DICOM structured reports – Is detailed examination data critical to dose estimates? Medical Physics. 2019;57: 17-24. doi: 10.1016/j.ejmp.2018.12.008.

10. Lai P, McNeil SM, Gordon CL, Connolly BL. Effective doses in children: association with common complex imaging techniques used during interventional radiology procedures. American Journal of Roentgenology. 2014;203(6): 1336-44. doi: 10.2214/AJR.13.11445.

11. Orbach DB, Stamoulis C, Strauss KJ, Manchester J, Smith ER, Scott RM, Lin N. Neurointerventions in children: radiation exposure and its import. American Journal of Neuroradiology. 2014;35(4): 650-6. doi: 10.3174/ajnr.A3758.

12. Ploussi A, Brountzos E, Rammos S, Apostolopoulou S, Efstathopoulos EP. Radiation Exposure in Pediatric Interventional Procedures. Cardiovascular and Interventional Radiology. 2021;44(6): 857-865. doi: 10.1007/s00270-020-02752-7.

13. Rizk C, Fares G, Vanhavere F, Saliba Z, Farah J. Diagnostic Reference Levels, Deterministic and Stochastic Risks in Pediatric Interventional Cardiology Procedures. Health Physics. 2020;118(1): 85-95. doi: 10.1097/HP.0000000000001114.

14. Ubeda C, Miranda P, Vano E, Nocetti D, Manterola C. Organ and effective doses from paediatric interventional cardiology procedures in Chile. Medical Physics. 2017;40: 95-103. doi: 10.1016/j.ejmp.2017.07.015.

15. Lee C, Yeom YS, Shin J, Streitmatter SW, Kitahara CM. NCIRF: an organ dose calculator for patients undergoing radiography and fluoroscopy. Biomedical Physics and Engineering Express. 2023;9(4). doi: 10.1088/2057-1976/acd2de.

16. Omar A, Bujila R, Fransson A, Andreo P, Poludniowski GG. A framework for organ dose estimation in x-ray angiography and interventional radiology based on dose-related data in DICOM structured reports. Physics in Medicine & Biology. 2016;61: 3063 – 3083.

17. Wildgruber M, Müller-Wille R, Goessmann H, Uller W, Wohlgemuth WA. Direct Effective Dose Calculations in Pediatric Fluoroscopy-Guided Abdominal Interventions with Rando-Alderson Phantoms – Optimization of Preset Parameter Settings. PLoS One. 2016;11(8): e0161806. doi: 10.1371/journal.pone.0161806.

18. Vodovatov AV, Golikov VYu, Kamyshanskaya IG, Zinkevich KV, Bernhardsson C. Estimation of the conversion coefficients from dose-area product to effective dose for barium meal examinations for adult patients. Radiatsionnaya Gygiena = Radiation Hygiene. 2018;11(1): 93-100. (In Russian).

19. Vodovatov A, Golikov V, Kamyshanskaya I, Cheremysin V, Zinkevich K, Bernhardsson C. Estimation of the effective doses from typical fluoroscopic examinations with barium contrast. Radiation Protection Dosimetry. 2021;195(3-4): 264-272. doi: 10.1093/rpd/ncab059.

20. Tupylenko AV, Oldakovsky VI, Lokhmatov MM, Budkina TN. Pat. № 2768600 C1 Russian Federation, МПК A61B 17/94. Method for balloon dilatation of esophageal strictures in children with dystrophic form of congenital epidermolysis bullosa. Published 24.03.2022. (In Russian).

21. Dmitriev EG, Mikhailova NV. Benign strictures of the esophagus and gastric outlet: interventional management (review based on foreign press materials). Khirurgicheskaya praktika = Surgical practice. 2011;4: 28-34. (In Russian).

22. Boyko VV, Avdosiev YuV, Sizyy MYu. Therapeutic and diagnostic balloon dilatation of extended post-burn strictures of the esophagus. Vestnik KhNU im. V.N. Karazina. Seriya Meditsina = Vestnik KhNU im. V.N. Karazin. Medicine Series. 2005;10(658). Available from: https://cyberleninka.ru/article/n/lechebno-diagnosticheskaya-ballonnaya-dilatatsiya-protyazhennyh-posleozhogovyh-striktur-pischevoda (Accessed: 06.08.2023). (In Russian).

23. Kim KY, Tsauo J, Song HY, Park HJ, Kang WS, Park JH, et al. Fluoroscopy-guided balloon dilation in patients with Eustachian tube dysfunction. European Radiology. 2018;28(3): 910-919. doi: 10.1007/s00330-017-5040-4.

24. Fan Y, Song HY, Kim JH, Park JH, Ponnuswamy I, Jung HY, et al. Fluoroscopically guided balloon dilation of benign esophageal strictures: incidence of esophageal rupture and its management in 589 patients. American Journal of Roentgenology. 2011;197(6): 1481-6. doi: 10.2214/AJR.11.6591.

25. Tapiovaara M, Siiskonen T. PCXMC: A Monte Carlo program for calculating patient doses in medical x-ray examinations. 2nd Ed. STUK, Finalnd; 2008.