Digital Cholangioscopic Interpretation: When North Meets the South

Michel Kahaleh*, Isaac Raijman, Monica Gaidhane, Amy Tyberg, Amrita Sethi, Adam Slivka, Douglas G. Adler, Divyesh Sejpal, Haroon Shahid, Avik Sarkar, Fernanda Martins, Christine Boumitri, Samuel Burton, Helga Bertani, Paul Tarnasky, Frank Gress, Ian Gan, Jose C. Ardengh, Prashant Kedia, Urban ArneloPriya Jamidar, Raj J. Shah, Carlos Robles-Medranda

*Corresponding author for this work

Research output: Contribution to journalArticlepeer-review

3 Scopus citations


Background: Digital single‐operator cholangioscopy (DSOC) (SpyGlass DS™, Boston Scientific, MA, USA) allows for high‐definition imaging of the biliary tree. The superior visualization has led to the development of two different sets of criteria to evaluate and classify indeterminate biliary strictures: the Monaco criteria and the criteria in Carlos Robles–Medranda’s publication (CRM). Our objective was to assess the interrater agreement (IA) of DSOC interpretation for indeterminate biliary strictures using the two newly published criteria. Methods: Forty de‐identified DSOC video recordings were sent to 15 interventional endoscopists with experience in cholangioscopy. They were asked to score the videos based on the presence of Monaco Classification criteria: stricture, lesion, mucosal changes, papillary projections, ulceration, white linear bands or rings, and vessels. Next, they scored the videos using CRM criteria: villous pattern, polypoid pattern, inflammatory pattern, flat pattern, ulcerate pattern and honeycomb pattern. The endoscopists then diagnosed the recordings as neoplastic or non-neoplastic based on the criteria. Intraclass correlation (ICC) analysis was done to evaluate interrater agreement for both criteria set and final diagnosis. Results: Recordings of 26 malignant lesions and 14 benign lesions were scored. The IA using both the Monaco criteria and CRM criteria ranged from poor to excellent (range 0.1–0.76) and (range 0.1–0.62), respectively. Within the Monaco criteria, IA was excellent for lesion (0.75) and fingerlike papillary projections (0.74); good for tortuous vessels (0.7), mucosal features (0.62), uniform papillary projections (0.53), and ulceration (0.58); and fair for white linear bands (0.4). Within the CRM criteria, the IA was good for villous pattern (0.62), flat pattern (0.62), and honeycomb pattern; fair for ulcerated pattern (0.56), polypoid pattern (0.52) and inflammatory pattern (0.54). The diagnostic IA using Monaco criteria was good (0.65), while the diagnostic IA using CRM was fair (0.58). The overall diagnostic accuracy using the Monaco classification was 61% and CRM criteria were 57%. Conclusion: The IOA and accuracy rate of DSOC using visual criteria from both Monaco Criteria and CRM are similar. However, some criteria from both sets suffer from poor IA, thus affecting the overall diagnostic accuracy. More formal training and refinements in visual criteria with additional validation are needed to improve diagnostic accuracy. Trial Registration: Identifier: NCT02166099.

Original languageEnglish (US)
Pages (from-to)1345-1351
Number of pages7
JournalDigestive diseases and sciences
Issue number4
StatePublished - Apr 2022


  • Cholangioscopy
  • Indeterminate biliary stricture
  • Monaco criteria
  • Single-operator digital cholangioscopy
  • Video cholangioscopy

ASJC Scopus subject areas

  • Physiology
  • Gastroenterology


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