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Exposure to ionizing radiation remains a hazard for patients and healthcare providers. We evaluated the utility of an artificial intelligence (AI)-enabled fluoroscopy system to minimize radiation exposure during image-guided endoscopic procedures. We conducted a prospective study of 100 consecutive patients who underwent fluoroscopy-guided endoscopic procedures. Patients underwent interventions using either conventional or AI-equipped fluoroscopy system that uses ultrafast collimation to limit radiation exposure to the region of interest. The main outcome measure was to compare radiation exposure with patients, which was measured by dose area product. Secondary outcome was radiation scatter to endoscopy personnel measured using dosimeter. Of 100 patients who underwent procedures using traditional (n = 50) or AI-enabled (n = 50) fluoroscopy systems, there was no significant difference in demographics, body mass index, procedural type, and procedural or fluoroscopy time between the conventional and the AI-enabled fluoroscopy systems. Radiation exposure to patients was lower (median dose area product 2,178 vs 5,708 mGym, P = 0.001) and scatter effect to endoscopy personnel was less (total deep dose equivalent 0.28 vs 0.69 mSv; difference of 59.4%) for AI-enabled fluoroscopy as compared to conventional system. On multivariate linear regression analysis, after adjusting for patient characteristics, procedural/fluoroscopy duration, and type of fluoroscopy system, only AI-equipped fluoroscopy system (coefficient 3,331.9 [95% confidence interval: 1,926.8-4,737.1, P < 0.001) and fluoroscopy duration (coefficient 813.2 [95% confidence interval: 640.5-985.9], P < 0.001) were associated with radiation exposure. The AI-enabled fluoroscopy system significantly reduces radiation exposure to patients and scatter effect to endoscopy personnel (see Graphical abstract, Supplementary Digital Content, http://links.lww.com/AJG/B461).

Purpose To prospectively evaluate the efficacy and safety of RIRS, SWL and PCNL for lower calyceal stones sized 1–2 cm. Materials and methods Patients with a single lower calyceal stone with an evidence of a CT diameter between 1 and 2 cm were enrolled in this multicenter, randomized, unblinded, clinical trial study. Patients were randomized into three groups: group A: SWL (194 pts); group B: RIRS (207 pts); group C: PCNL (181 pts). Patients were evaluated with KUB radiography (US for uric acid stones) at day 10 and a CT scan after 3 months. The CONSORT 2010 statement was adhered to where possible. The collected data were analyzed. Results The mean stone size was 13.78 mm in group A, 14.82 mm in group B and 15.23 mm in group C ( p  = 0.34). Group C compared to group B showed longer operative time [72.3 vs. 55.8 min ( p  = 0.082)], fluoroscopic time [175.6 vs. 31.8 min ( p  = 0.004)] and hospital stay [3.7 vs. 1.3 days ( p  = 0.039)]. The overall stone-free rate (SFR) was 61.8% for group A, 82.1% for group B and 87.3% for group C. The re-treatment rate was significantly higher in group A compared to the other two groups, 61.3% ( p  < 0.05). The auxiliary procedure rate was comparable for groups A and B and lower for group C ( p  < 0.05). The complication rate was 6.7, 14.5 and 19.3% for groups A, B and C, respectively. Conclusions RIRS and PCNL were more effective than SWL to obtain a better SFR and less auxiliary and re-treatment rate in single lower calyceal stone with a CT diameter between 1 and 2 cm. RIRS compared to PCNL offers the best outcome in terms of procedure length, radiation exposure and hospital stay. ISRCTN 55546280.

To evaluate the clinical efficacy of ZhuZheng robot-assisted versus C-arm fluoroscopy-guided percutaneous pedicle screw fixation (PPSF) in the treatment of thoracolumbar burst fractures. A retrospective analysis was conducted on 86 patients with thoracolumbar burst fractures treated at our institution between March 2022 and August 2023. The cohort included 46 males and 40 females, aged 27 to 69 years. Patients were assigned to either the robot-assisted group ( n  = 41) or the conventional C-arm fluoroscopy group ( n  = 45) according to intraoperative navigation method. Baseline characteristics, including gender ratio and body mass index (BMI), were comparable between the two groups ( P  > 0.05). All patients underwent segmental fixation. Intraoperative parameters such as fluoroscopy frequency, operative time, and estimated blood loss were recorded. The accuracy of screw placement was assessed using postoperative CT at day 3 and graded according to the Gertzbein-Robbins scale. Pain was evaluated using the Visual Analogue Scale (VAS) preoperatively and at 1 day, 3 days, and 1 month postoperatively. Radiological assessments included Cobb angle and anterior vertebral height ratio at baseline, 3 days, 1 month, and 6 months postoperatively. Statistical analyses were performed using the t-test and Mann-Whitney U test. The robot-assisted group had significantly shorter operative time, reduced intraoperative blood loss, lower radiation dose, and fewer fluoroscopy exposures compared to the conventional group (all P  < 0.05). No perioperative complications occurred in either group during follow-up. The screw placement accuracy (grades A + B) was significantly higher in the robot-assisted group (98.4%, 242/246) than in the conventional group (90.4%, 244/270; P  < 0.05). VAS pain scores at postoperative day 1 and day 3 were significantly lower in the robot-assisted group; no significant difference was observed at 1 month. There were no significant intergroup differences in the postoperative Cobb angle or anterior vertebral height ratio at any time point ( P  > 0.05). Robot-assisted orthopedic surgery demonstrates significant advantages in improving screw placement accuracy, reducing intraoperative blood loss, shortening operative time, and minimizing radiation exposure and fluoroscopy frequency, thereby offering improved clinical outcomes in the management of thoracolumbar burst fractures.

Objective To compare the safety and accuracy of cortical bone trajectory screw placement between the robot-assisted and fluoroscopy-assisted approaches. Methods This retrospective study was conducted between November 2018 and June 2020, including 81 patients who underwent cortical bone trajectory (CBT) surgery for degenerative lumbar spine disease. CBT was performed by the same team of experienced surgeons. The patients were randomly divided into two groups—the fluoroscopy-assisted group (FA, 44 patients) and the robot-assisted group (RA, 37 patients). Robots for orthopedic surgery were used in the robot-assisted group , whereas conventional fluoroscopy-guided screw placement was used in the fluoroscopy-assisted group. The accuracy of screw placement and rate of superior facet joint violation were assessed using postoperative computed tomography (CT). The time of single screw placement, intraoperative blood loss, and radiation exposure to the surgical team were also recorded. The χ 2 test and Student’s t-test were used to analyze the significance of the variables ( P  < 0.05). Results A total of 376 screws were inserted in 81 patients, including 172 screws in the robot-assisted group and 204 pedicle screws in the fluoroscopy-assisted group. Screw placement accuracy was higher in the RA group (160, 93%) than in the FA group (169, 83%) ( P  = 0.003). The RA group had a lower violation of the superior facet joint than the FA group. The number of screws reaching grade 0 in the RA group (58, 78%) was more than that in the FA group (56, 64%) ( P  = 0.041). Screw placement time was longer in the FA group (7.25 ± 0.84 min) than in the RA group (5.58 ± 1.22 min, P  < 0.001). The FA group had more intraoperative bleeding (273.41 ± 118.20 ml) than the RA group (248.65 ± 97.53 ml, P  = 0.313). The radiation time of the FA group (0.43 ± 0.07 min) was longer than the RA group (0.37 ± 0.10 min, P  = 0.001). Furthermore, the overall learning curve tended to decrease. Conclusions Robot-assisted screw placement improves screw placement accuracy, shortens screw placement time, effectively improves surgical safety and efficiency, and reduces radiation exposure to the surgical team. In addition, the learning curve of robot-assisted screw placement is smooth and easy to operate.

This study introduces a new fluoroscopy-guided intradiscal radiopaque gelified ethanol injection technique using the antero-posterior view and compare it to conventional oblique view. Intradiscal procedures, are minimally invasive techniques that aim to reduce pain associated with lumbar disc herniation by modifying the disc material and decreasing pressure on surrounding nerves. This study introduces a new fluoroscopy-guided intradiscal radiopaque gelified ethanol injection technique using an anteroposterior view compared to the conventional oblique view. This is a double blind, randomized trial. A tertiary care center. Patients with radicular leg pain were randomly assigned to receive a radiopaque gelified ethanol injection via an anteroposterior view or oblique view.. The primary outcomes were procedure time, complication rates, and radiation exposure. A total of 70 patients were randomized to each group (35 for each group). There were no serious complications in either group. Radiation exposure was significantly lower in the anteroposterior view group (36.92 vs 50.46 µGray/m2 [µGy/m2; P = 0.007). The procedure time was also significantly lower in the anteroposterior  group (171 vs 287 seconds; P = 0.001). Limitations of our trial include the relatively small sample size, the single-center nature of the study, and the short follow-up period. We were also limited in only including patients with moderate body habitus, and patients with only L3 or L4 disc herniation, which might restrict the generalizability of the findings. An anteroposterior view radiopaque gelified ethanol injection is a promising alternative to the conventional oblique view technique for radicular leg pain management. This novel approach offers a safer and more efficient treatment option, reducing radiation exposure and procedure time without compromising clinical outcomes. Its potential to minimize patient discomfort and enhance overall management of radicular leg pain warrants further investigation and widespread adoption.

Background and ObjectivesThoracic epidural analgesia can reduce postoperative pain and cardiopulmonary morbidity, but it is associated with a high rate of clinical failure. Up to 50% of clinical failure is thought to be related to technical insertion. In this study, patients undergoing thoracic surgery were randomized to one of two catheter insertion techniques: fluoroscopically guided or conventional loss of resistance with saline/air. Our primary aim was to examine whether fluoroscopic guidance could increase the incidence of correct catheter placement and improve postoperative analgesia. Our secondary aim was to assess the potential impact of correct epidural catheter positioning on length of stay in the postanesthesia care unit and total hospital length of stay.MethodsThis randomized clinical trial was conducted at Dartmouth-Hitchcock Medical Center over 25 months (January 2012 to February 2014). Patients (N = 100) undergoing thoracic surgery were randomized to fluoroscopic guidance (n = 47) or to loss of resistance with saline/air (n = 53). Patients were followed for the primary outcomes of 24-hour morphine use, 24-hour numeric pain scores, and the incidence of epidural catheter positioning within the epidural space. Postanesthesia care unit and total hospital lengths of stay were evaluated as secondary outcome measurements and compared for patients with correct epidural catheter positioning and those without correct epidural catheter positioning.ResultsOne hundred patients were included in an intention-to-treat analysis. Numeric pain scores and 24-hour morphine consumption were no different between groups. Fluoroscopic guidance was associated with an increased incidence of epidural catheter placement within the epidural space compared with loss of resistance with air/saline [fluoroscopic guidance, epidural in 98% (46/47) versus loss of resistance with saline/air, epidural in 74% (39/53)]. There was a significant increase in correct catheter positioning with (odds ratio, 21.07; 95% confidence interval, 2.07-214.38; P = 0.010) or without (odds ratio, 16.15; 95% confidence interval, 2.03-128.47; P = 0.009) adjustment for potentially confounding variables. In an adjusted analysis, correctly positioned thoracic epidural catheters were associated with shorter postanesthesia care unit (5.87 ± 5.39 hours vs 4.30 ± 1.171 hours; P = 0.044) and total hospital length of stay (5.77 ± 4.94 days vs 4.93 ± 2.79 days; P = 0.031).ConclusionsFluoroscopic guidance increases the incidence of epidural catheter positioning within the epidural space and may reduce postanesthesia care unit and hospital lengths of stay. Future work should validate the effectiveness of this approach.This clinical trial is registered with ClinicalTrials.gov (NCT02678039).

The Eating Assessment Tool-10 (EAT-10) represents a validated, easy to administer patient report dysphagia severity scale. Although its ability to detect swallowing impairment has been investigated in other patient populations, the utility of this instrument in individuals with head and neck cancer (HNC) has not been studied. The aim of the current investigation was to determine the relationship between patient ratings of swallowing impairment (EAT-10) and objective clinical ratings of swallow physiology in individuals with HNC. Forty-four HNC participants completed the EAT-10 and a standardized videofluoroscopy swallow study. Blinded raters determined airway safety using the penetration–aspiration scale (PAS) and swallowing function using the modified barium swallow impairment profile (MBSImP™©). Participants were stratified into three groups (pre-treatment through 1 year post-treatment, 1–5 years post-treatment, and >5 years post-treatment). Independent t tests, Pearson’s and Spearman’s Rho correlations, and a Bonferroni correction for multiple comparisons were performed. EAT-10 scores were significantly higher in HNC patients with unsafe swallowing (M 24.45, SD 8.32) compared to those with safe swallowing (M 16.20, SD 12.14), t (21) = −2.36, p  < 0.04. Significant correlations were revealed between EAT-10 scores and the MBSImP™© (pharyngeal composite), and PAS scores ( p  < 0.05) for the pre-treatment to within 1 year post-treatment group. No associations, however, were observed for HNC patients in the time groups representing greater than 1-year post cancer treatment.

This study was designed to evaluate the non-inferiority of ultrasound puncture followed by endoscopically guided tract dilatation compared to the standard fluoroscopy-guided PCNL. Forty patients with non-opaque kidney stones eligible for PCNL were randomly divided into two groups. The standard fluoroscopy-guided PCNL using the Amplatz dilator was performed in the XRAY group. In the SONO group, the Kidney was punctured under an ultrasound guide followed by tract dilatation using a combination of the Amplatz dilator based on the tract length and an endoscopically guided tract dilatation using a bi-prong forceps in cases of short-advancement. The primary outcome was successful access. In 90% of cases in the XRAY and 95% in the SONO group access dilatation process was performed uneventfully at the first attempt (p = 0.5). In 45% of cases in the SONO group, bi-prong forceps were used as salvage for short-advancement. In one case in the X-ray group over-advancement occurred. One month after surgery, the stone-free rate on the CT-scan was 75% for the X-ray group and 85% for the SONO group (p = 0.4). There were no significant differences in operation time, hospitalization duration, transfusion, or complication rates between the two groups. We conclude that ultrasound-guided renal puncture, followed by endoscopically guided tract dilatation can achieve a high success rate similar to X-ray-guided PCNL while avoiding the harmful effects of radiation exposure and the risk of over-advancement.

Objective There is no pharmacological treatment for oropharyngeal dysphagia (OD). The aim of this study was to compare the therapeutic effect of stimulation of oropharyngeal transient receptor potential vanilloid type 1 (TRPV1) with that of thickeners in older patients with OD. Design A clinical videofluoroscopic non-randomised study was performed to assess the signs of safety and efficacy of swallow and the swallow response in (1) 33 patients with OD (75.94±1.88 years) while swallowing 5, 10 and 20 ml of liquid (20.4 mPa.s), nectar (274.4 mPa.s), and pudding (3930 mPa.s) boluses; (2) 33 patients with OD (73.94±2.23 years) while swallowing 5, 10 and 20 ml nectar boluses, and two series of nectar boluses with 150 μM capsaicinoids and (3) 8 older controls (76.88±1.51 years) while swallowing 5, 10 and 20 ml nectar boluses. Results Increasing bolus viscosity reduced the prevalence of laryngeal penetrations by 72.03% (p<0.05), increased pharyngeal residue by 41.37% (p<0.05), delayed the upper esophageal sphincter opening time and the larynx movement and did not affect the laryngeal vestibule closure time and maximal hyoid displacement. Treatment with capsaicinoids reduced both, penetrations by 50.% (p<0.05) and pharyngeal residue by 50.% (p<0.05), and shortened the time of laryngeal vestibule closure (p<0.001), upper esophageal sphincter opening (p<0.05) and maximal hyoid and laryngeal displacement. Conclusion Stimulation of TRPV1 by capsaicinoids strongly improved safety and efficacy of swallow and shortened the swallow response in older patients with OD. Stimulation of TRPV1 might become a pharmacologic strategy to treat OD.

Background Implanting leadless pacemakers in the right ventricular (RV) apex is prone to causing pericardial tamponade and myocardial perforation. Objective To investigate the feasibility and safety of right ventriculography-guided implantation of Micra™ leadless pacemaker (Micra™, Medtronic, Minneapolis, MN, USA) in the RV mid-septum. Methods One hundred eight consecutive patients who underwent Micra™ implantation intended in the mid-septum were enrolled and randomized (3:1) into the radiography group ( n  = 81) with assistance of right ventriculography to illustrate the RV septum and the non-radiography group ( n  = 27). All subjects underwent a postoperative computed tomography (CT) scan to determine the Micra™ location. The Micra™ location assessed by CT image was compared between the two groups to confirm the accuracy of the intended pacing site. The duration of the procedure, X-ray radiation dose, and time were also compared between the two groups. Results Reconstructed CT 3-D cardiac images found the Micra™ location in the intended mid-septum in 13 patients (48.1%, 13/27) in the non-radiography group and 76 patients (93.8%, 76/81) in the radiography group ( P  < 0.0001 between two groups). There was no significant difference in procedure interval between the two groups while the X-ray radiation dose (564.86 ± 112.44 vs. 825.85 ± 156.12 mGy, P  < 0.0001), X-ray exposure time (7.79 ± 1.43 vs. 12.03 ± 2.86 min, P  < 0.0001), and the number of fluoroscopy re-positioning (2.79 ± 1.03 vs. 6.41 ± 1.82, P  < 0.0001) were significantly less in the radiography group than in the non-radiography group. No implantation-related complications were observed in both groups. Conclusion Right ventriculography increases the accuracy of Micra™ implantation in the mid-septum and reduces X-ray exposure. Trial registration The trial registration number (ChiCTR2100051374) and date (09/22/2021).