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• W3203787467 abstract "HomeRadioGraphicsVol. 41, No. 6 PreviousNext Education CornerFree AccessRG TEAM21st-Century Fluoroscopy: What Will We Be Doing? A Trainee’s PerspectiveDavid H. Ballard , David E. Sweet, Tushar Garg, David J. DiSantisDavid H. Ballard , David E. Sweet, Tushar Garg, David J. DiSantisAuthor AffiliationsFrom the Mallinckrodt Institute of Radiology, Washington University School of Medicine, 510 S Kingshighway Blvd, Campus Box 8131, St Louis, MO 63110 (D.H.B.); Imaging Institute, Cleveland Clinic, Cleveland, Ohio (D.E.S.); Department of Radiology, Seth GS Medical College & KEM Hospital, Mumbai, India (T.G.); and Department of Radiology, Mayo Clinic, Jacksonville, Fla (D.J.D.).Address correspondence to D.H.B. (e-mail: [email protected]).David H. Ballard David E. SweetTushar GargDavid J. DiSantisPublished Online:Oct 1 2021https://doi.org/10.1148/rg.2021210189MoreSectionsPDF ToolsImage ViewerAdd to favoritesCiteTrack CitationsPermissionsReprints ShareShare onFacebookTwitterLinked In IntroductionGastrointestinal/genitourinary (GI/GU) fluoroscopy as a “dinosaur” and a “dying art” has been a long-standing narrative (1–3). Radiologists with expertise in GI/GU fluoroscopy are the most senior members of every radiology department. Most faculty at academic centers are the next generation, who trained when advanced cross-sectional imaging was readily available and had replaced fluoroscopy for many clinical situations.As the number of skilled fluoroscopy practitioners dwindles year by year, trainees have begun to view fluoroscopy as an interesting but irrelevant anachronism, like pneumoencephalography or x-ray pelvimetry. The volume of fluoroscopic examinations has dropped sharply in recent decades, with some previously common examinations now very rarely performed (1–3). With that backdrop, some will be astonished that in 2019 (the most recent numbers available) nearly 3 million GI fluoroscopic procedures were performed just in the United States (Figure). A closer look at this number provides a guide for matching fluoroscopic training with the future practice needs of our residents and fellows.Figure. Graph shows data from the U.S. Centers for Medicare & Medicaid Services comparing the number of gastrointestinal fluoroscopic studies performed in the United States in the year 2000 versus in 2019. (Data provided by Rebecca Hemingway, MS, Harvey L. Neiman Health Policy Institute, American College of Radiology.)Figure.Download as PowerPointOpen in Image Viewer Fluoroscopy is a very different experience for current radiology trainees, abdominal imaging fellows, and early career radiologists when compared with radiologists who practiced in the 1980s and 1990s (3). Then, fluoroscopy was the prime diagnostic imaging modality for many indications, and so the fluoroscopist was the first to suggest an initial diagnosis. Cross-sectional imaging and endoscopy usurped much of that initial diagnostic role. Consequently, for trainees and young radiologists, barium depictions of gastric ulcers, small bowel fluoroscopic disease, and “apple core” lesions are pictures in textbooks or just something to know while cramming for examinations.That outcome could be predicted by the plummeting nationwide fluoroscopic examination volume over a 2-decade span from 2000 to 2019 (U.S. Centers for Medicare & Medicaid Services data; provided by Rebecca Hemingway, MS, Harvey L. Neiman Health Policy Institute, American College of Radiology). Virtually moribund double-contrast barium enemas endured a 95% drop in volume, with the single-contrast barium enema only slightly ahead at 89%. Upper GI examinations fared a bit better, with the double-contrast study falling 77% and the single-contrast upper GI examination down 65% (Figure).Because fluoroscopy requires a skilled operator and depends on the ability to see things in real time, trainees must perform many examinations to become proficient in both proper image acquisition and interpretation. This poses a unique challenge for any radiologists who trained with such reduced fluoroscopy caseloads and case complexity. Of note, esophagrams decreased by just 2% and modified barium swallows actually increased by 26% in 2019 as compared with in 2000. The stark variation in procedure volume trends likely can be ascribed to the esophagram and swallowing study’s ability to depict both structure and function. No wonder, then, that those two examinations accounted for about 69% of procedure volume in 2019 (Figure).But one problem not addressed in a simple numbers assessment is the shift in case mix. Anecdotal experience suggests that in many academic department fluoroscopic services, much of the day’s schedule now comprises postoperative “leak checks,” modified barium swallows performed in conjunction with speech pathologists, and the occasional contrast enema before ostomy reversal. Trainees come to see these as monotonous tasks offering little diagnostic challenge. Indeed, some departments have moved such studies outside of the fluoroscopy suites, administering contrast material on inpatient floors for small bowel obstruction “Gastrografin challenges” (diatrizoate meglumine; Bracco) or therapeutic contrast enemas for patients with profound constipation.Two points deserve mention regarding the maintenance of fluoroscopic skills. The first is that, outside of academic institutions, indications for fluoroscopic studies can be broader—an esophagram for dysphagia might be the first test to reveal esophageal carcinoma. The second is that access to higher-level medical care is nonuniform. Patients in less affluent locales (or indeed less affluent nations) are unlikely to undergo manometry, endoscopy, a pH probe, capsule endoscopy, or CT colonography. Retaining diagnostic skills in fluoroscopy is proportionately more important in settings such as these.Current procedure volumes confirm that fluoroscopy remains a standard part of contemporary radiology practice. While the referral patterns of individual practices differ, the applicability of fluoroscopic procedures is supported by the American College of Radiology (ACR) Appropriateness Criteria in the “usually appropriate” category (4).Examples include obtaining a double-contrast barium esophagram in the initial workup of dysphagia; a fluoroscopic hysterosalpingogram for female infertility with suspected tubal occlusion; a cystogram for traumatic suspected lower urinary tract injury; and, for patients who do not undergo esophagogastroduodenoscopy, a double-contrast esophagram or upper GI series to evaluate epigastric pain, clinical suspicion for acid reflux, esophagitis, gastritis, or ulcer disease (4).One fluoroscopic staple—a single-contrast esophagram for postesophageal surgery dysphagia—shares the ACR Appropriateness Criteria “usually appropriate” category with contrast-enhanced chest and/or neck CT (4). Although some studies militate against routine single-contrast esophagography after esophagectomy (5), others argue for routine leak checks with an esophagram (6), and the ACR still considers it the study of choice (4). Estimated cost savings of early identification of an anastomotic leak are over $80 000 when compared with costs in patients with anastomotic leaks who presented symptomatically (6).Since at least the mid 1980s, studies have highlighted decreasing utilization of GI fluoroscopic examinations (7), and narratives on the future of barium radiology have speculated on how advances in endoscopy and cross-sectional imaging will impact fluoroscopy’s viability. A 1997 narrative by Ott and Gelfand (3) expressed pessimism about the future of barium radiology, acknowledging that its survival into the 21st century would be a challenge. They correctly predicted that interpretive skills could suffer as fewer and fewer of these studies are performed, with “practicing radiology [being drawn toward] newer technologies and those studies with higher reimbursements.” Further, they stressed the particular importance of continuing to train radiology residents to perform these fluoroscopic examinations.The utilization numbers indicate that fluoroscopy, while no longer the pinnacle of imaging technology, will be a part of our trainees’ practice life for years to come. Inevitably, fluoroscopic training will continue to get short shrift as compared with the ever-increasing emphasis on cross-sectional imaging—a reasonable circumstance, given the trends. But young radiologists must keep in mind as they step into practice that 2.9 million patients will depend on their fluoroscopic technical and interpretive skills to arrive at the correct diagnosis. These are studies that we still do, and we should do them right.Disclosures of Conflicts of Interest.— D.H.B. Activities related to the present article: editorial board member of RadioGraphics. Activities not related to the present article: disclosed no relevant relationships. Other activities: disclosed no relevant relationships. D.J.S. Activities related to the present article: editorial board member of RadioGraphics. Activities not related to the present article: payment from University of Texas for visiting professorship; course fees and travel support from University of California San Francisco. Other activities: disclosed no relevant relationships.D.H.B. and D.J.S. have provided disclosures (see end of article).References1. DiSantis DJ. Esophagography and gastroesophageal reflux disease: utilization and utility. Abdom Radiol (NY) 2018;43(6):1306–1307. Crossref, Medline, Google Scholar2. DiSantis DJ. Gastrointestinal fluoroscopy: what are we still doing? AJR Am J Roentgenol 2008;191(5):1480–1482. Crossref, Medline, Google Scholar3. Ott DJ, Gelfand DW. The future of barium radiology. Br J Radiol 1997;70(Spec No):S171–S176. Crossref, Medline, Google Scholar4. American College of Radiology. ACR Appropriateness Criteria. https://acsearch.acr.org/list. Accessed June 20, 2021. Google Scholar5. Cools-Lartigue J, Andalib A, Abo-Alsaud A, et al. Routine contrast esophagram has minimal impact on the postoperative management of patients undergoing esophagectomy for esophageal cancer. Ann Surg Oncol 2014;21(8):2573–2579. Crossref, Medline, Google Scholar6. Haisley KR, DeSouza ML, Dewey EN, et al. Assessment of Routine Esophagram for Detecting Anastomotic Leak After Esophagectomy. JAMA Surg 2019;154(9):879–881. Crossref, Medline, Google Scholar7. Gelfand DW, Ott DJ, Chen YM. Decreasing numbers of gastrointestinal studies: report of data from 69 radiologic practices. AJR Am J Roentgenol 1987;148(6):1133–1136. Crossref, Medline, Google ScholarArticle HistoryReceived: July 02 2021Accepted: July 07 2021Published online: Oct 01 2021Published in print: Oct 2021 FiguresReferencesRelatedDetailsRecommended Articles Esophagectomy and Gastric Pull-through Procedures: Surgical Techniques, Imaging Features, and Potential ComplicationsRadioGraphics2016Volume: 36Issue: 1pp. 107-121CT Esophagography for Evaluation of Esophageal PerforationRadioGraphics2021Volume: 41Issue: 2pp. 447-461Imaging Review of Gastrointestinal Motility DisordersRadioGraphics2022Volume: 42Issue: 7pp. 2014-2036Role of Multimodality Imaging in Gastroesophageal Reflux Disease and Its Complications, with Clinical and Pathologic CorrelationRadioGraphics2020Volume: 40Issue: 1pp. 44-71Imaging Tips for Performing a Perfect Barium SwallowRadioGraphics2019Volume: 39Issue: 5pp. 1325-1326See More RSNA Education Exhibits Resident Primer in Fluoroscopic Imaging of the Upper Gastrointestinal Tract: Overview of Technique, Pearls and PitfallsDigital Posters2020Are Gastrointestinal (GI) Series a Thing From the Past? The Importance of Fluoroscopy in the Diagnosis of Gastric Pathology: A Pictorial Review of GI Series with a 2020 VisionDigital Posters2020Weighing In: Fluoroscopy of Anatomy and Complications After Weight Loss SurgeryDigital Posters2019 RSNA Case Collection Candida EsophagitisRSNA Case Collection2022Chagas diseaseRSNA Case Collection2021Gastric Antral Vascular EctasiaRSNA Case Collection2021 Vol. 41, No. 6 Abbreviations Abbreviations: GI gastrointestinal GU genitourinary Metrics Altmetric Score PDF download" @default.
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