Less risky than traditional surgery, with shorter hospital stays and faster recovery, image-guided minimally invasive procedures are used more and more frequently worldwide. In 2020, the last year for which data is available, 24 million such procedures were performed – a six-fold increase over a dozen years. But there can be a catch: without the proper precautions, both patients and medical staff can be exposed to unnecessary radiation from the X-ray fluoroscopy used so doctors can “see” what they are doing inside the body.
与传统手术相比，图像引导的微创手术风险更小、住院时间更短、恢复时间更快，现在全世界范围内被越来越多地使用。2020年，总共进行了2400万例此类程序，自2008年以来增加了六倍多。然而，可能会有一个问题：如果没有适当的预防措施，患者和医务人员都可能受到不必要的X射线照射，这些射线是透视检查时医生用来“查看”体内情况的。
原子能机构辐射防护专家Jenia Vassileva说：“由于这些程序的技术发展和复杂性增加，以及在改善患者和工作人员辐射防护的导则和培训方面可能存在的差距，我们已发现辐射防护的新挑战。”
X 线透视显示连续X 线图像，由穿过身体的光束产生，显示在监视器上。
在最近的一次原子能机构会议上，作为对医疗界支持的一部分，来自42个国家和18个国际组织和专业机构的100多名专家讨论了在X线透视引导下介入程序中取得的进展和面临的挑战。他们重点讨论了在应用这些程序时如何加强对患者和医务人员的辐射防护，因为这些程序可能导致患者的皮肤损伤和执行介入程序的医务人员的辐射诱发白内障。
通常情况下，组织反应只涉及皮肤发红或脱发，但在少数情况下，会出现更严重的反应，如溃疡或皮肤坏死，有时是几周、几个月甚至几年后。
会议主席、美国哥伦比亚大学临床放射学和医学教授Stephen Balter说：“与高剂量有关的因素是患者的体型和程序的医学复杂性，这需要长时间的透视；然而，在大多数情况下，由于操作者缺乏知识和认识，会发生意外的严重组织反应。”
Hal Workman，一位14年前因心脏介入手术而遭受严重皮肤损伤的患者说：“过了一年多，才有人能确定是我长时间的透视手术造成了我的伤害，在超过15个月的时间里，我每次的睡眠时间都不超过两个小时。这是你能想象的最糟糕的痛苦。”
与会者还了解了透视技术的最新发展，包括一种具有彩色或灰度的辐射剂量视觉分布的皮肤剂量图。这为操作者提供了剂量监测信息，以便更好地调整程序的设置，避免伤害患者的皮肤。
“经过20年的努力，发生皮肤损伤案例已大幅减少。”Balter说，“主要原因是透视设备和这些手术医疗器械得到改进。”他强调，重要的是要做好计划，特别是对肥胖患者和接受多种手术的患者，当需要在复杂手术中使用大量辐射时，要不断监测所提供的剂量，并主动跟进可能的皮肤反应。
此外，监测医务人员的剂量在许多国家仍是一项挑战。加强辐射防护工作包括，例如，使用实时电子剂量计、自动跟踪工作人员的视频系统，以及虚拟模拟器。
Vassileva说，提高医务人员对辐射防护的认识也将对减少工作人员和患者的照射量有很大帮助。与会者表示，在这方面，通过视频方式开展以实践为导向的培训，例如原子能机构关于介入手术中辐射防护的新实践教程，十分有效。
为了弥补患者组织反应数据方面的现有差距，并对国际上的实践进行比较，原子能机构已启动一项关于透视引导下介入手术的患者剂量和组织反应的国际研究。
Vassileva说：“我们的目标是在全球范围内收集数据，这将有助于我们更新用于启动有皮肤反应风险的患者的随防程序的剂量值。”
Often tissue reactions are skin reddening or loss of hair only, but, in a few cases, particularly when higher doses are applied, more severe reactions such as ulceration or dermal necrosis can arise, sometimes weeks, months of even years later.
“Factors associated with such high doses are patient size and the medical complexity of the procedure, which require prolonged fluoroscopy; but in most cases unintended severe tissue reactions occur as a result of the lack of knowledge and awareness of the operator,” said the meeting’s Chair Stephen Balter, a Professor of Clinical Radiology (Physics) and Medicine at Columbia University in New York, USA.
Hal Workman, a patient who had suffered from dire skin injury as a result of a cardiac intervention 14 years ago, said: “It took more than a year before anyone could identify that my prolonged fluoroscopy procedure caused my injury, and for over 15 months I had no more than two hours of sleep at any one time. This was the worst pain you can imagine.”
Participants also learned about the latest developments in fluoroscopy technology such as a type of skin dose map with a colour or a grey-scale visual distribution of radiation dose to the patient skin. This provides operators information on dose monitoring in order to better adjust the procedure’s settings and avoid skin injury to the patient.
“Twenty years of effort has resulted in a dramatic reduction of cases of skin injuries,” said Balter. “Improvements in fluoroscopic equipment and in the medical devices used for these procedures are major contributors. In our lab, we pay attention to the skills and competence of the medical staff, as well as to our protocols.” He emphasised that it is important to plan, especially for patients with obesity and those undergoing multiple procedures, and to constantly monitor the dose delivered and proactively follow-up for possible skin reactions when a substantial amount of radiation needs to be used in a complex procedure.
Monitoring doses to medical staff is still a challenge in many countries as well. Efforts to increase radiation protection involve, for example, the use of real time electronic dosimeters, video systems for automatic tracking of staff and virtual simulators. “Doses to the medical staff can also be recorded in the IAEA’s international database ISEMIR-IC to benchmark and optimize practice,” Vassileva said.
Raising awareness among medical staff about radiation protection would already go a long way towards decreasing exposure of staff and patients, she added. Meeting participants said that practice oriented trainings using videos, such as the new IAEA practical tutorials on Radiation protection in interventional procedures, are effective in this regard.
To bridge the existing gaps in data on tissue reactions in patients, and to compare practices internationally, the IAEA has launched an international study of patient doses and tissue reactions from fluoroscopy guided interventional procedures.
“This project will study the frequency of appearance of tissue reactions and the relationship between them and associated factors such as, for example, dose parameters from interventional procedures,” said Vassileva. “Our goal is to collect data globally, which will help to update dose values used to initiate follow up procedures of a patient at risk for skin reactions. This will also help the IAEA to make necessary development of the IAEA voluntary reporting system SAFRAD (Safety in Radiological Procedures).”
To participate in this year-long study, medical facilities need to complete this online feedback form by the end of April. Existing local, national or regional organizations that are interested to submit data from their registries can contact the IAEA through patient-protection.contact-point@iaea.org