TY - JOUR
AU - Kairaluoma,, Matti
AB - Abstract This study aimed to determine the exposure to radiation delivered to the patient during routine intraoperative cholangiography (IOC) in cholecystectomy and examine the factors affecting radiation dose and fluoroscopy time (FT). From January 2016 to December 2017, 598 IOC examinations were performed. This study included 324 intraoperative cholangiographies performed with c-arm equipment not exceeding 10 years of age. When residents performed the procedures, the mean kerma area product (KAP) was 0.36 (standard deviation [SD] 0.70) Gycm 2 and in specialist surgeons group 0.36 (SD 0.47) Gycm2, P = 0.47. In residents group, the mean FT was 11.4 (SD 10.1) seconds and in specialist surgeons group, 9.2 (SD 11.9) seconds, P < 0.01. Linear regression analysis showed association between increased KAP-values and the presence of common bile duct (CBD) stones and body mass index (BMI). Age, BMI, laparoscopic surgery, acute cholecystitis, presence of CBD stones, resident surgeon performing IOC and ASA III–IV were associated with higher FT. National diagnostic reference level for IOC has not been introduced in Finland so far. Our mean KAP values (0.36 Gycm2) were 3–4 times lower and FT (10.1 seconds) were 3–5 times lower than the few reported in the literature. Routine use of IOC during cholecystectomy results in relatively low-radiation dose performed either by residents or specialist surgeons, irrespective of whether CBD stones were visualized or not. INTRODUCTION The benefits of intraoperative cholangiography (IOC) performed during cholecystectomy are twofold: to detect common bile duct (CBD) stones and to reveal the bile duct anatomy and thus to reduce the incidence of inadvertent bile duct injury(1,2). IOC is performed under fluoroscopic image guidance. Laparoscopic clearance of CBD stones in patients with concomitant gallbladder stones can be performed by a single-stage procedure during laparoscopic cholecystectomy (LC). Another option is to perform a two-stage procedure, which consists of preoperative endoscopic clearance of CBD stones followed by laparoscopic removal of gallbladder. Single-stage procedure results in shorter hospital-stay provided that expertise and adequate instrumentation are available(3). When considering intraoperative management of CBD stones, the presence of intraductal bile calculi is confirmed in most cases by intraoperative c-arm cholangiography. Preoperative diagnostic magnetic resonance cholangiopancreatography (MRCP) does not exclude the presence of CBD stones at the time of surgery as gallstones may migrate from the gallbladder to CBD during the interval between the investigation and cholecystectomy(2). Another option for detecting CBD stones is intraoperatively performed laparoscopic ultrasound, which offers similar diagnostic accuracy as IOC without radiation exposure(4). However, the disadvantage is the long learning curve needed(5). Although near-infrared imaging provides radiation-free real-time imaging of the biliary tract, it cannot distinguish CBD stones. In this technique, the biliary structures are fluorescently highlighted after intravenous administration of indocyanine green (ICG), which is secreted into the bile(6). The as-low-as reasonably achievable principle of reducing the patient dose to minimal while maintaining the quality of imaging is the main goal for proper use of all radiological examinations(7). Although ionizing radiation is a concern in IOC, only few studies have examined the degree of exposure to radiation of IOC(8,9). The aim of the present study was to examine the factors affecting the exposure to radiation of routine use of IOC in cholecystectomy with special aim in comparison between residents and specialist surgeons. MATERIALS AND METHODS Study design From January 2016 to December 2017, consecutive 598 IOC examinations were performed at the Central Finland Central Hospital. In this single center retrospective cohort study, we included 353 cholangiographies, which were performed with c-arm equipment not exceeding 10 years of age in the beginning of 2016. The main measures of outcome were the recorded radiation dose data of c-arm systems from our manual database (Prosessium). The data were cross-checked with the radiation dose information from our Picture Archiving and Communication System (PACS, Sectra Commit, Espoo, Finland), where it is transferred automatically from the c-arm equipment. Another 25 cases were excluded because it was not possible to cross-check the manually recorded radiation dose data from the PACS system. Additional four patients who underwent intraoperative endoscopic retrograde cholangiopancreatography (ERCP) were removed from the exposure to radiation analysis because IOC and ERCP were performed consequently with the same c-arm and the exposure to radiation of IOC could not be separated from the registered total kerma-area product (KAP) and fluoroscopy time (FT). Thus the final analysis consisted of 324 IOCs. Data were collected retrospectively from hospital records. In our hospital, cholecystectomies were operated in three operating theatre units situated remote from another. Due to this, we had seven different movable c- arm systems available. Five of them were Philips BV Pulsera image intensifier equipment (Philips Healthcare, Vantaa, Finland), and two were Ziehm R and RDF c-arms (Ziehm Imaging Oy, Porvoo, Finland), one with image intensifier and the other with digital detector. KAP is the product of the air kerma incident on the patient and the area of the X-ray beam at the skin surface. For simplicity we have unified varying units received from different c-arms and will only use Gray multiplied by square centimeters (Gycm2). KAP values were measured using inbuilt ionization chambers in c-arms. For this study, we collected the KAP values from exposure and pulsed fluoroscopy. We also recorded the FT(s). During the procedure, with Philips c-arms, the number of pulses per second has typically been 12 p s−1. With Ziehm c-arms, this has varied from 12.5 to 25 p s−1. We have a dose adjustment made with the manufacturer for Ziehm 25 p s−1 dose rate, making it possible for surgeon to record moving image (cine) with fluoroscopy dose. The c-arms are under regular maintenance and quality assurance, and all of them have last-image-hold feature. IOC IOC was performed in our institution routinely during cholecystectomy. In our hospital, laparoscopic cholecystectomies were performed both by residents and specialist surgeons. Residents were trained in a special teaching program for LC, which includes a workshop on how to perform IOC. Residents were allowed to operate independently after they had passed a five-step training program for LC including simulator training (LapSim) and supervised operations. C-arms were available in the corridor of operating theatre and easily brought up into the operating room during the preliminary preparations of cholecystectomy. A technical assistant or attending nurse handled the c-arm under the operating surgeon’s guidance. The fluoroscopy images were interpreted immediately by the operating surgeon. If the operating surgeon was resident and a second opinion was needed, a senior surgeon was always available for consultation. Reasons for deferral of IOC were documented in operative details. In laparoscopic cholangiography, the cystic duct was isolated and cannulated with a catheter (LAP-13, Avon, Massachusetts, USA). In open cholecystectomies, also a 5-Fr infant feeding tube (Unomedical, New South Wales, Australia) was used alternatively. The cholangiogram was obtained by injecting Omnipaque 140 mg per ml (GE Healthcare AS, Oslo, Norway) contrast medium with simultaneous c-arm imaging until the biliary tree was visualized. Hyoscine butylbromide (Buscopan) was used to relax the papilla of Vater if needed. If CBD stones were detected or suspected during IOC the decision to proceed to intraoperative CBD stone clearance, postoperative ERCP or follow-up was done by senior consultant. All intraoperative CBD clearances were performed by senior consultants. Statistical procedures The data are presented as means with standard deviations (SD), medians with interquartile range (IQR) or counts with percentages. Results were analyzed by the chi-square test, Mann–Whitney U test and by Fisher’s exact test. P values less than 0.05 were considered to be statistically significant. Univariable logistic regression analysis with beta coefficient and 95% confidence intervals (95% CIs) was used to assess risk factors for high-radiation dose and FT. A logarithmic transformation was performed with the KAP and FT due to asymmetrical distribution. Statistical analyses were carried out using SPSS statistical software, version 24 (SPSS, Inc., Chicago, IL, USA). ETHICAL ASPECTS The study was approved by the hospital administration. No ethical approval or written informed consent was needed because the study was retrospective in nature. RESULTS Altogether 324 out of 598 cholecystectomies with IOC were analyzed in this study to determine the patient dose and factors affecting radiation dose of IOC. Baseline and procedural characteristics are presented in Table 1. Preoperative MRCP was performed in 96 patients (29.6%). Of these, preoperative suspicion of CBD stones was made in 44 patients (45.8%). Preoperative ERCP for CBD stone removal was performed in 10 patients (3.1%). Table 1 Baseline and procedural characteristics of 324 patients. Resident (n = 135) Specialist surgeon (n = 189) P value Age, mean (SD) (years) 55.0 (17.0) 57.9 (16.1) 0.10 Female sex, n (%) 96 (71.1) 113 (59.8) 0.04 Male, n (%) 39 (28.9) 76 (40.2) BMI (kg m−2),mean (SD) 28.8 (5.2) 29.5 (5.9) 0.38 ASA I–II, n (%) 105 (77.8) 137 (72.5) 0.28 ASA III–IV, n (%) 30 (22.2) 52 (27.5) Operation time, min, median (IQR) 100 (74–130) 72 (57–99) <0.01 LC, n (%) 129 (95.6) 166 (87.8) 0.05 Conversion to open surgery, n (%) 3 (2.2) 8 (4.2) Open cholecystectomy, n (%) 3 (2.2) 15 (7.9) Operation type 0.68 Elective, n (%) 81 (60.0) 10 (57.7) Emergency, n (%) 54 (40.0) 80 (42.3) CBD stones in IOC 18 (13.3) 30 (15.9) 0.53 Resident (n = 135) Specialist surgeon (n = 189) P value Age, mean (SD) (years) 55.0 (17.0) 57.9 (16.1) 0.10 Female sex, n (%) 96 (71.1) 113 (59.8) 0.04 Male, n (%) 39 (28.9) 76 (40.2) BMI (kg m−2),mean (SD) 28.8 (5.2) 29.5 (5.9) 0.38 ASA I–II, n (%) 105 (77.8) 137 (72.5) 0.28 ASA III–IV, n (%) 30 (22.2) 52 (27.5) Operation time, min, median (IQR) 100 (74–130) 72 (57–99) <0.01 LC, n (%) 129 (95.6) 166 (87.8) 0.05 Conversion to open surgery, n (%) 3 (2.2) 8 (4.2) Open cholecystectomy, n (%) 3 (2.2) 15 (7.9) Operation type 0.68 Elective, n (%) 81 (60.0) 10 (57.7) Emergency, n (%) 54 (40.0) 80 (42.3) CBD stones in IOC 18 (13.3) 30 (15.9) 0.53 ASA, American Society of Anesthesiologists. Open in new tab Table 1 Baseline and procedural characteristics of 324 patients. Resident (n = 135) Specialist surgeon (n = 189) P value Age, mean (SD) (years) 55.0 (17.0) 57.9 (16.1) 0.10 Female sex, n (%) 96 (71.1) 113 (59.8) 0.04 Male, n (%) 39 (28.9) 76 (40.2) BMI (kg m−2),mean (SD) 28.8 (5.2) 29.5 (5.9) 0.38 ASA I–II, n (%) 105 (77.8) 137 (72.5) 0.28 ASA III–IV, n (%) 30 (22.2) 52 (27.5) Operation time, min, median (IQR) 100 (74–130) 72 (57–99) <0.01 LC, n (%) 129 (95.6) 166 (87.8) 0.05 Conversion to open surgery, n (%) 3 (2.2) 8 (4.2) Open cholecystectomy, n (%) 3 (2.2) 15 (7.9) Operation type 0.68 Elective, n (%) 81 (60.0) 10 (57.7) Emergency, n (%) 54 (40.0) 80 (42.3) CBD stones in IOC 18 (13.3) 30 (15.9) 0.53 Resident (n = 135) Specialist surgeon (n = 189) P value Age, mean (SD) (years) 55.0 (17.0) 57.9 (16.1) 0.10 Female sex, n (%) 96 (71.1) 113 (59.8) 0.04 Male, n (%) 39 (28.9) 76 (40.2) BMI (kg m−2),mean (SD) 28.8 (5.2) 29.5 (5.9) 0.38 ASA I–II, n (%) 105 (77.8) 137 (72.5) 0.28 ASA III–IV, n (%) 30 (22.2) 52 (27.5) Operation time, min, median (IQR) 100 (74–130) 72 (57–99) <0.01 LC, n (%) 129 (95.6) 166 (87.8) 0.05 Conversion to open surgery, n (%) 3 (2.2) 8 (4.2) Open cholecystectomy, n (%) 3 (2.2) 15 (7.9) Operation type 0.68 Elective, n (%) 81 (60.0) 10 (57.7) Emergency, n (%) 54 (40.0) 80 (42.3) CBD stones in IOC 18 (13.3) 30 (15.9) 0.53 ASA, American Society of Anesthesiologists. Open in new tab Table 2 Mean KAP values and FT during IOC. Total (n = 324) Resident (n = 135) Specialist surgeon (n = 189) P value KAP (Gycm2), mean (SD) 0.36 (0.58) 0.36 (0.70) 0.36 (0.47) 0.47 FT (seconds), mean (SD) 10.1 (11.20) 11.4 (10.10) 9.2 (11.90) <0.01 Total (n = 324) Resident (n = 135) Specialist surgeon (n = 189) P value KAP (Gycm2), mean (SD) 0.36 (0.58) 0.36 (0.70) 0.36 (0.47) 0.47 FT (seconds), mean (SD) 10.1 (11.20) 11.4 (10.10) 9.2 (11.90) <0.01 Open in new tab Table 2 Mean KAP values and FT during IOC. Total (n = 324) Resident (n = 135) Specialist surgeon (n = 189) P value KAP (Gycm2), mean (SD) 0.36 (0.58) 0.36 (0.70) 0.36 (0.47) 0.47 FT (seconds), mean (SD) 10.1 (11.20) 11.4 (10.10) 9.2 (11.90) <0.01 Total (n = 324) Resident (n = 135) Specialist surgeon (n = 189) P value KAP (Gycm2), mean (SD) 0.36 (0.58) 0.36 (0.70) 0.36 (0.47) 0.47 FT (seconds), mean (SD) 10.1 (11.20) 11.4 (10.10) 9.2 (11.90) <0.01 Open in new tab IOC was interpreted to be normal in 274 patients (84.6%). CBD stones were visualized or highly suspected in 48 patients (14.8%), CBD stricture after biliary pancreatitis was visualized in one patient (0.3%) and in one patient (0.3%), the contrast flow to duodenum was so abundant that the filling of intrahepatic ducts was insufficient. No bile duct injuries were observed in IOC. Management of CBD stones was performed successfully transcystically in 30 patients (9.3%). Transcystic failure occurred due to technical issues in five patients (1.5%) followed by postoperative MRCP with normal findings, transcystic attempt of stone removal followed by normal ERCP in three patients (0.9%), transcystic removal followed by postoperative ERCP and residual stone removal in two patients (0.6%). Postoperative ERCP for stone removal was performed in five patients (1.5%) and postoperative ERCP with normal findings in one patient (0.3%). Transductal removal was performed in one patient (0.3%) and follow-up without any further investigations was programmed in one patient (0.3%). From all 324 patients, pulsed fluoroscopy was used in 283 patients, pulsed exposure in 40 cases and exposure was needed in 1 instance. Mean KAP values and screening time during IOC are presented in Table 2. Mean KAP values were low with no significant difference between residents and specialist surgeons (0.36 Gycm2 SD (0.70) versus 0.36 Gycm2 SD (0.47), P = 0.47]. The mean FT in residents was 11.4 (SD 10.10) seconds and in specialist surgeons 9.2 (SD 11.90) seconds, P < 0.01. The mean KAP was 0.56 Gycm2 SD (1.01) in presence of CBD stones and 0.32 Gycm2 SD (0.44) when CBD stones were not visualized in cholangiography. In 30 patients with transcystic clearance of CBD stones, the mean KAP was 0.33 Gycm2 (SD 0.41). The set of nine predictors were analyzed in linear regression model after logarithmic transformation of KAP and FT due to asymmetric distribution. The results are presented in Table 3. Presence of CBD stones and body mass index (BMI) were associated with increased KAP values. Higher FT was associated with age, BMI, laparoscopic surgery, acute cholecystitis, presence of CBD stones, resident surgeon performing IOC and ASA III–IV. In multivariable model, 12.6% of the variability of KAP and 15.2% of the variability of FT was explained by the variation in the nine variables in the model. Table 3 Univariable linear regression analysis of factors influencing KAP and FT. β 95% CI P-value KAP Gender (male) 0.065 −0.050 to 0.180 0.265 Age (continuous) 0.002 −0.001 to 0.006 0.229 BMI (continuous) 0.032 0.022 to 0.041 < 0.01 ASA III–IV −0.320 −0.166 to 0.101 0.632 Acute cholecystitis −0.140 −0.133 to 0.105 0.818 Previous biliary pancreatitis 0.105 −0.088 to 0.299 0.284 Resident surgeon 0.012 −0.098 to 0.117 0.316 LC −0.760 −0.248 to 0.097 0.390 CBD stones in IOC 0.169 0.022 to 0.316 0.024 FT Gender (male) 0.045 −0.046 to 0.137 0.328 Age (continuous) 0.004 0.001 to 0.007 0.005 BMI (continuous) 0.011 0.003 to 0.018 0.004 ASA III–IV −0.110 −0.216 to −0.004 0.039 Acute cholecystitis 0.139 0.044 to 0.233 0.004 Previous biliary pancreatitis −0.910 −0.246 to 0.065 0.252 Resident surgeon 0.205 0.122 to 0.288 <0.01 LC −0.142 −0.277 to −0.007 0.039 CBD stones in IOC 0.163 0.049 to 0.278 0.005 β 95% CI P-value KAP Gender (male) 0.065 −0.050 to 0.180 0.265 Age (continuous) 0.002 −0.001 to 0.006 0.229 BMI (continuous) 0.032 0.022 to 0.041 < 0.01 ASA III–IV −0.320 −0.166 to 0.101 0.632 Acute cholecystitis −0.140 −0.133 to 0.105 0.818 Previous biliary pancreatitis 0.105 −0.088 to 0.299 0.284 Resident surgeon 0.012 −0.098 to 0.117 0.316 LC −0.760 −0.248 to 0.097 0.390 CBD stones in IOC 0.169 0.022 to 0.316 0.024 FT Gender (male) 0.045 −0.046 to 0.137 0.328 Age (continuous) 0.004 0.001 to 0.007 0.005 BMI (continuous) 0.011 0.003 to 0.018 0.004 ASA III–IV −0.110 −0.216 to −0.004 0.039 Acute cholecystitis 0.139 0.044 to 0.233 0.004 Previous biliary pancreatitis −0.910 −0.246 to 0.065 0.252 Resident surgeon 0.205 0.122 to 0.288 <0.01 LC −0.142 −0.277 to −0.007 0.039 CBD stones in IOC 0.163 0.049 to 0.278 0.005 β = beta coefficient. Open in new tab Table 3 Univariable linear regression analysis of factors influencing KAP and FT. β 95% CI P-value KAP Gender (male) 0.065 −0.050 to 0.180 0.265 Age (continuous) 0.002 −0.001 to 0.006 0.229 BMI (continuous) 0.032 0.022 to 0.041 < 0.01 ASA III–IV −0.320 −0.166 to 0.101 0.632 Acute cholecystitis −0.140 −0.133 to 0.105 0.818 Previous biliary pancreatitis 0.105 −0.088 to 0.299 0.284 Resident surgeon 0.012 −0.098 to 0.117 0.316 LC −0.760 −0.248 to 0.097 0.390 CBD stones in IOC 0.169 0.022 to 0.316 0.024 FT Gender (male) 0.045 −0.046 to 0.137 0.328 Age (continuous) 0.004 0.001 to 0.007 0.005 BMI (continuous) 0.011 0.003 to 0.018 0.004 ASA III–IV −0.110 −0.216 to −0.004 0.039 Acute cholecystitis 0.139 0.044 to 0.233 0.004 Previous biliary pancreatitis −0.910 −0.246 to 0.065 0.252 Resident surgeon 0.205 0.122 to 0.288 <0.01 LC −0.142 −0.277 to −0.007 0.039 CBD stones in IOC 0.163 0.049 to 0.278 0.005 β 95% CI P-value KAP Gender (male) 0.065 −0.050 to 0.180 0.265 Age (continuous) 0.002 −0.001 to 0.006 0.229 BMI (continuous) 0.032 0.022 to 0.041 < 0.01 ASA III–IV −0.320 −0.166 to 0.101 0.632 Acute cholecystitis −0.140 −0.133 to 0.105 0.818 Previous biliary pancreatitis 0.105 −0.088 to 0.299 0.284 Resident surgeon 0.012 −0.098 to 0.117 0.316 LC −0.760 −0.248 to 0.097 0.390 CBD stones in IOC 0.169 0.022 to 0.316 0.024 FT Gender (male) 0.045 −0.046 to 0.137 0.328 Age (continuous) 0.004 0.001 to 0.007 0.005 BMI (continuous) 0.011 0.003 to 0.018 0.004 ASA III–IV −0.110 −0.216 to −0.004 0.039 Acute cholecystitis 0.139 0.044 to 0.233 0.004 Previous biliary pancreatitis −0.910 −0.246 to 0.065 0.252 Resident surgeon 0.205 0.122 to 0.288 <0.01 LC −0.142 −0.277 to −0.007 0.039 CBD stones in IOC 0.163 0.049 to 0.278 0.005 β = beta coefficient. Open in new tab DISCUSSION The value of IOC is well noticeable when expertise and equipment to treat CBD stones in a single-session procedure are available. Use of IOC is crucial when diagnosing CBD stones before performing intraoperative CBD stone removal(3,10). The advantages of one-stage laparoscopic CBD clearance, when compared with the two-stage preoperative endoscopic clearance followed by LC, are the lower number of procedures, technical success and shorter hospital stay(3). The frequency of intraoperatively found CBD stones has been reported to be around 11% of the cholecystectomy patients(11,12). In line with that, our incidence was 14.8%. Nassar et al. have showed that routine IOC can be performed with high success rate and without any delay when the logistic set-up is well standardized(13). Similar observations of only 3–10-min increase in the operation time have been reported(14,15). With this in mind, IOC offers clear advantages as CBD stones can be visualized with high accuracy(12). When IOC is routine, the whole surgical team is familiar with the procedure. The navigation of the c-arm to the right imaging position is then easier and obviously leads to less exposure to radiation. Due to the retrospective character of our study, we could not register separately the total procedural time spent when performing the IOC. Alternative methods of intraoperative biliary imaging without ionizing radiation are also available. ICG can help in visualization of the bile ducts, although CBD stones are not visualized by this method. Excess amount of adipose tissue can also result in decreased visualization of the biliary tract structures when using ICG imaging method(6). There is a lack of international reference levels for radiation dose of IOC. Only a few studies have reported patient dose of IOC during cholecystectomy. A study from UK showed mean dose area product values of 1.67 Gy cm−2 and FT time of 0.53 min(9) and a national survey from France showed mean Kerma area product (KAP) values of 1.2 Gy cm−2 and FT of 0.9 min in LC(8). Our mean KAP values (0.36 Gycm2) were 3–4 times lower and FT (10.1 seconds) were 3–5 times lower than the few reported in the literature. As a comparison from all the values measured in the study in only 13 (4%) procedures, the total KAP exceeded 1.6 Gycm2, which is the Finnish national dose reference level for abdominal plain radiography(19). The explanation for our results might be the routine policy of performing IOC and the newer c-arm equipment we used. For some years, we have arranged in our hospital radiation safety lessons with hands-on training for personnel using c-arms. There have also been feedback sessions with ERCP-nurses, where the possible methods to save the dose and use different automatic protocols in c-arm systems have been discussed. In our study, CBD stones and higher BMI were associated with significantly higher KAP values during IOC. However, in this series, successful transcystic removal of CBD stones was associated with low mean KAP values. These figures are lower than previously reported after endoscopic removal of CBD stones(16). This model of factors influencing the exposure to radiation is instructive, as it reveals that FT is dependent on much more multiple variables than KAP (Table 3). BMI and the visualization of CBD stones intraoperatively were associated with increased KAP and FT. Age, presence of acute cholecystitis and resident as operating surgeon were highly associated with FT, as laparoscopy and ASA grade II–IV had a negative association with FT. Although the coefficient of determination (R2) in regression model was relatively low, statistically significant predictors still highlight reasons for variability of exposure between patients. In our study, the longer FT in the residents group may reflect the more intense and time-consuming interpretation process of what you see in the fluoroscopic image. However, the mean KAP values between residents and specialist surgeons were similar. This indicates that residents are well trained for the nuances of performing imaging of the bile ducts. Surgical simulation-based training has been shown to result in skill transfer to real operative environment(17). Resident impact on LC was shown also in a recent study revealing that resident involvement in LC may lengthen the operative time without compromising the clinical outcome(18). This study has several limitations. Because of the retrospective nature of the study, we could not evaluate the sensitivity and specificity of IOC in CBD stones. Our database included only those IOCs with registered radiation dose in the hospital data. The attempted cholangiography cannulations without any exposure to radiation were not collected. Thus, we could not calculate the real success of cholangiographies. Furthermore, we did not examine the learning curve effect of IOC in the resident group. Despite these limitations, this is the first study to examine the differences of radiation use and patient doses between residents and specialist surgeons performing IOC. CONCLUSION In summary, the routine use of IOC results in relatively low-radiation dose performed either by residents or specialist surgeons, irrespective of whether CBD stones were visualized or not. Factors associated with higher KAP and FT were BMI and the presence of CBD stones in cholangiography. Conflict of Interest statement The author(s) declared no potential conflict of interests with respect to the research, authorship and/or publication of this article. Funding This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Trial registry number NCT 03817723. References 1. Buddingh , K. 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TI - INTRAOPERATIVE CHOLANGIOGRAPHY DURING CHOLECYSTECTOMY RESULTS IN LOW EXPOSURE TO RADIATION: A RETROSPECTIVE COHORT STUDY
JF - Radiation Protection Dosimetry
DO - 10.1093/rpd/ncz262
DA - 2020-06-12
UR - https://www.deepdyve.com/lp/oxford-university-press/intraoperative-cholangiography-during-cholecystectomy-results-in-low-0KSkmjZtkv
SP - 1
VL - Advance Article
IS - 
DP - DeepDyve
ER -