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Endoscopy 2023; 55(01): 4-11
DOI: 10.1055/a-1850-6717
Original article

An artificial intelligence difficulty scoring system for stone removal during ERCP: a prospective validation

Li Huang‡   *
1   Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
2   Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
3   Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
,
Youming Xu‡   *
1   Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
2   Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
3   Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
,
Jie Chen
4   Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
,
Feng Liu
5   Digestive Endoscopy Center, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
,
Deqing Wu
5   Digestive Endoscopy Center, Shanghai Tenth People’s Hospital, Tongji University School of Medicine, Shanghai, China
,
Wei Zhou
1   Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
2   Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
3   Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
,
Lianlian Wu
1   Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
2   Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
3   Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
,
Tingting Pang
4   Department of Gastroenterology, Changhai Hospital, Naval Medical University, Shanghai, China
,
Xu Huang
1   Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
2   Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
3   Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
,
Kuo Zhang
6   Wuhan ENDOANGEL Medical Technology Company, Wuhan, China
,
Honggang Yu 
1   Department of Gastroenterology, Renmin Hospital of Wuhan University, Wuhan, China
2   Hubei Provincial Clinical Research Center for Digestive Disease Minimally Invasive Incision, Renmin Hospital of Wuhan University, Wuhan, China
3   Key Laboratory of Hubei Province for Digestive System Disease, Renmin Hospital of Wuhan University, Wuhan, China
› Author AffiliationsTrial Registration: ClinicalTrials.gov Registration number (trial ID): NCT04719117 Type of study: Prospective observation Trial
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Make the entrance wider and the depth deeperEndoscopy 2023; 55(01): 12-13
DOI: 10.1055/a-1929-1564

Abstract

Background A computer-assisted (CAD) system was developed to assess, score, and classify the technical difficulty of common bile duct (CBD) stone removal during endoscopic retrograde cholangiopancreatography (ERCP). The efficacy of the CAD system was subsequently assessed through a multicenter, prospective, observational study.

Method All patients who met the inclusion criteria were included. Based on cholangiogram images, the CAD system analyzed the level of difficulty of stone removal and classified it into “difficult” and “easy” groups. Subsequently, differences in clinical endpoints, including attempts at stone extraction, stone extraction time, total operation time, and stone clearance rates were compared between the two groups.

Results 173 patients with CBD stones from three hospitals were included in the study. The group classified as difficult by CAD had more extraction attempts (7.20 vs. 4.20, P < 0.001), more frequent machine lithotripsy (30.4 % vs. 7.1 %, P < 0.001), longer stone extraction time (16.59 vs. 7.69 minutes, P < 0.001), lower single-session stone clearance rate (73.9 % vs. 94.5 %, P < 0.001), and lower total stone clearance rate (89.1 % vs. 97.6 %, P = 0.019) compared with the group classified as easy by CAD.

Conclusion The CAD system effectively assessed and classified the degree of technical difficulty in endoscopic stone extraction during ERCP. In addition, it automatically provided a quantitative evaluation of CBD and stones, which in turn could help endoscopists to apply suitable procedures and interventional methods to minimize the possible risks associated with endoscopic stone removal.

* These authors contributed equally.


Tables 1 s–3 s



Publication History

Received: 25 November 2021

Accepted after revision: 12 May 2022

Accepted Manuscript online:
12 May 2022

Article published online:
12 July 2022

© 2022. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • References

  • 1 Tazuma S. Gallstone disease: epidemiology, pathogenesis, and classification of biliary stones (common bile duct and intrahepatic). Best Pract Res Clin Gastroenterol 2006; 20: 1075-1083
    CrossrefPubMedGoogle Scholar
  • 2 Schutz SM, Abbott RM. Grading ERCPs by degree of difficulty: a new concept to produce more meaningful outcome data. Gastrointest Endosc 2000; 51: 535-539
    CrossrefPubMedGoogle Scholar
  • 3 Kim HJ, Choi HS, Park JH. et al. Factors influencing the technical difficulty of endoscopic clearance of bile duct stones. Gastrointest Endosc 2007; 66: 1154-1160
    CrossrefPubMedGoogle Scholar
  • 4 Huang L, Lu X, Huang X. et al. Intelligent difficulty scoring and assistance system for endoscopic extraction of common bile duct stones based on deep learning: multicenter study. Endoscopy 2021; 53: 491-498
    Article in Thieme ConnectPubMedGoogle Scholar
  • 5 Manes G, Paspatis G, Aabakken L. et al. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2019; 51: 472-491
    Article in Thieme ConnectPubMedGoogle Scholar
  • 6 Buxbaum JL, Abbas Fehmi SM. ASGE Standards of Practice Committee. et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc 2019; 89: 1075-1105
    CrossrefPubMedGoogle Scholar
  • 7 Wu L, Zhang J, Zhou W. et al. Randomised controlled trial of WISENSE, a real-time quality improving system for monitoring blind spots during esophagogastroduodenoscopy. Gut 2019; 68: 2161-2169
    CrossrefPubMedGoogle Scholar
  • 8 Gong D, Wu L, Zhang J. et al. Detection of colorectal adenomas with a real-time computer-aided system (ENDOANGEL): a randomised controlled study. Lancet Gastroenterol Hepatol 2020; 5: 352-361
    CrossrefPubMedGoogle Scholar
  • 9 Zhang J, Zhu L, Yao L. et al. Deep learning-based pancreas segmentation and station recognition system in EUS: development and validation of a useful training tool (with video). Gastrointest Endosc 2020; 92: 874-885
    CrossrefPubMedGoogle Scholar
  • 10 Carr-Locke DL. Difficult bile-duct stones: cut, dilate, or both?. Gastrointest Endosc 2008; 67: 1053-1055
    CrossrefPubMedGoogle Scholar
  • 11 Cotton PB. Income and outcome metrics for the objective evaluation of ERCP and alternative methods. Gastrointest Endosc 2002; 56: S283-S290
    CrossrefPubMedGoogle Scholar
  • 12 Cotton PB, Eisen G, Romagnuolo J. et al. Grading the complexity of endoscopic procedures: results of an ASGE working party. Gastrointest Endosc 2011; 73: 868-874
    Google Scholar
  • 13 Schutz SM. Grading the degree of difficulty of ERCP procedures. Gastroenterol Hepatol (N Y) 2011; 7: 674-676
    PubMedGoogle Scholar
  • 14 Zhou XD, Chen QF, Zhang YY. et al. Outcomes of endoscopic sphincterotomy vs open choledochotomy for common bile duct stones. World J Gastroenterol 2019; 25: 485-497
    CrossrefPubMedGoogle Scholar
  • 15 Jeon J, Lim SU, Park CH. et al. Restoration of common bile duct diameter within 2 weeks after endoscopic stone retraction is a preventive factor for stone recurrence. Hepatobiliary Pancreat Dis Int 2018; 17: 251-256
    CrossrefPubMedGoogle Scholar
  • 16 Ryu S, Jo IH, Kim S. et al. Clinical impact of common bile duct angulation on the recurrence of common bile duct stone: a meta-analysis and review. Korean J Gastroenterol 2020; 76: 199-205
    CrossrefPubMedGoogle Scholar
  • 17 Ekkelenkamp VE, de Man RA, Ter Borg F. et al. Prospective evaluation of ERCP performance: results of a nationwide quality registry. Endoscopy 2015; 47: 503-507
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Rodrigues-Pinto E, Macedo G, Baron TH. ERCP competence assessment: miles to go before standardization. Endosc Int Open 2017; 5: e718-e721
    Article in Thieme ConnectPubMedGoogle Scholar
  • 19 Williams EJ, Ogollah R, Thomas P. et al. What predicts failed cannulation and therapy at ERCP? Results of a large-scale multicenter analysis. Endoscopy 2012; 44: 674-683
    Article in Thieme ConnectPubMedGoogle Scholar
  • 20 Rutter MD, Senore C, Bisschops R. et al. The European Society of Gastrointestinal Endoscopy Quality Improvement Initiative: developing performance measures. Endoscopy 2016; 48: 81-89
    PubMedGoogle Scholar
  • 21 Nzenza TC, Al-Habbal Y, Guerra GR. et al. Recurrent common bile duct stones as a late complication of endoscopic sphincterotomy. BMC Gastroenterol 2018; 18: 39
    CrossrefPubMedGoogle Scholar
  • 22 Park SY, Hong TH, Lee SK. et al. Recurrence of common bile duct stones following laparoscopic common bile duct exploration: a multicenter study. J Hepatobiliary Pancreat Sci 2019; 26: 578-582
    CrossrefPubMedGoogle Scholar
  • 23 Chang JH, Kim TH, Kim CW. et al. Size of recurrent symptomatic common bile duct stones and factors related to recurrence. Turk J Gastroenterol 2014; 25: 518-523
    CrossrefPubMedGoogle Scholar
  • 24 Brägelmann J, Barahona Ponce C, Marcelain K. et al. Epigenome‐wide analysis of methylation changes in the sequence of gallstone disease, dysplasia, and gallbladder cancer. Hepatology 2021; 73: 2293-2310
    CrossrefPubMedGoogle Scholar
  • 25 Zheng R, Chen M, Wang X. et al. Development and validation of a risk prediction model and scoring system for post-endoscopic retrograde cholangiopancreatography pancreatitis. Ann Transl Med 2020; 8: 1299
    CrossrefPubMedGoogle Scholar
  • 26 Chiba M, Kato M, Kinoshita Y. et al. The milestone for preventing post-ERCP pancreatitis using novel simplified predictive scoring system: a propensity score analysis. Surg Endosc 2020; 35: 6696-6707
    CrossrefPubMedGoogle Scholar
  • 27 Fujita K, Yazumi S, Uza N. et al. New practical scoring system to predict post-endoscopic retrograde cholangiopancreatography pancreatitis: development and validation. JGH Open 2021; 5: 1078-1084
    CrossrefPubMedGoogle Scholar
  • 28 Dumonceau JM, Kapral C, Aabakken L. et al. ERCP-related adverse events: European Society of Gastrointestinal Endoscopy (ESGE) Guideline. Endoscopy 2020; 52: 127-149
    Google Scholar
  • 29 Talukdar R. Complications of ERCP. Best Pract Res Clin Gastroenterol 2016; 30: 793-805
    CrossrefPubMedGoogle Scholar
  • 30 Zhou W, Li Y, Zhang Q. et al. Risk factors for postendoscopic retrograde cholangiopancreatography pancreatitis: a retrospective analysis of 7,168 cases. Pancreatology 2011; 11: 399-405
    CrossrefPubMedGoogle Scholar
  • 31 Masci E, Minoli G, Rossi M. et al. Prospective multicenter quality assessment of endotherapy of biliary stones: does center volume matter?. Endoscopy 2007; 39: 1076-1081
    Article in Thieme ConnectPubMedGoogle Scholar