Abstract
Background
Single-use gastrointestinal endoscopes eliminate the need for post-procedure reprocessing and have become an area of interest in endoscopic device development and quality management. However, clinical data on their use in routine gastrointestinal endoscopy remain limited. This prospective, two-center, single-arm study evaluated the feasibility and short-term safety of single-use gastroscopy performed with ENDOANGEL, an artificial intelligence (AI)-based real-time quality monitoring system, and single-use colonoscopy in routine gastrointestinal endoscopy. Formal AI-based quality scoring was applied to gastroscopy, whereas ENDOANGEL-related colonoscopy indicators were recorded descriptively.
Results
A total of 120 participants were enrolled, including 60 who underwent gastroscopy and 60 who underwent colonoscopy. Imaging of predefined anatomical sites was successful in all participants in both groups (60/60 in each group; 95% CI 94.0–100.0%). All procedures were completed without conversion to reusable endoscopes. The overall image quality scores were 39.2 ± 0.8/40 for gastroscopy and 31.3 ± 0.8/32 for colonoscopy. Mean total procedure times were 9.3 ± 2.7 min and 12.6 ± 3.1 min, respectively. No device malfunction, device defect, or procedure-related adverse event was observed during the procedure or within 24 h after endoscopy. In gastroscopy, all ENDOANGEL-assisted examinations achieved the maximum procedural score, and ENDOANGEL-based assessment agreed with manual assessment of imaging success and procedure completion. In colonoscopy, ENDOANGEL-related cecal intubation reminders agreed with manual assessment in all procedures, and withdrawal-speed alerts were recorded in 4 of 60 procedures.
Conclusion
Single-use gastroscopy with real-time AI-based quality monitoring and single-use colonoscopy were feasible in routine gastrointestinal endoscopy and showed a favorable short-term safety profile within 24 h. AI-related findings should be interpreted as feasibility and agreement data for gastroscopy and as descriptive process-monitoring observations for colonoscopy. Further controlled studies are needed to compare single-use and reusable systems and to clarify the clinical role of AI-based process monitoring in single-use endoscopy.
Trial registration: Chinese Clinical Trial Registry, ChiCTR2100045101. Retrospectively registered on April 6, 2021.
Supplementary Information
The online version contains supplementary material available at https://doi.org/10.1186/s12938-026-01595-6.
Keywords: Single-use gastrointestinal endoscopy, Artificial intelligence, Quality monitoring, Gastroscopy, Colonoscopy, Technical performance
Background
Gastrointestinal endoscopy is central to the diagnosis and treatment of gastrointestinal diseases and is widely used in both diagnostic and therapeutic practice. Reusable endoscopes require a multistep reprocessing workflow that includes bedside pre-cleaning, manual cleaning, high-level disinfection, drying, and storage to reduce procedure-related infection risk [1, 2]. Despite established guidelines and standardized protocols, residual contamination has been reported after reprocessing, raising concerns about exogenous contamination and occupational exposure in endoscopy units [3–6].
Single-use endoscopic systems have been introduced as an alternative platform by removing the need for post-procedure reprocessing [7–12]. This feature provides a rationale for evaluating their use in routine endoscopic practice, particularly from the perspective of device management and quality control. However, their comparative clinical performance, infection-related outcomes, cost, workflow implications, and environmental impact require direct evaluation in controlled studies. Previous studies have suggested that single-use gastroscopes can achieve acceptable imaging and operational performance; however, routine clinical data remain limited, particularly regarding examination completeness, standardized image-quality assessment, clinical operability, and short-term safety within a structured quality-management framework [7, 8, 13, 14]. Evidence for single-use colonoscopy remains more limited, although earlier human studies have demonstrated the technical feasibility of single-use colonoscopic platforms [15].
Artificial intelligence (AI)-based quality monitoring systems have been applied in endoscopy to support real-time process monitoring and more complete visualization of key anatomical sites [16, 17]. In colonoscopy, quality assessment has traditionally relied on indicators such as cecal intubation and withdrawal time, and emerging AI-based process-monitoring systems may provide additional real-time information during withdrawal [18–20]. To date, clinical data on AI-assisted quality monitoring in single-use gastroscopy remain scarce, and data on AI-based process monitoring during single-use colonoscopy are limited. In this prospective, two-center study, we evaluated the feasibility and short-term safety of single-use gastroscopy with ENDOANGEL-assisted real-time quality monitoring and single-use colonoscopy. Formal ENDOANGEL quality scoring was applied to gastroscopy, whereas ENDOANGEL-related colonoscopy indicators were recorded descriptively.
Methods
Study design and setting
This prospective, two-center, single-arm study was conducted at Shenzhen Hospital of Southern Medical University (Shenzhen, China; Center A) and Shenzhen University General Hospital (Shenzhen, China; Center B) between February 2021 and May 2022. The protocol was approved by the Ethics Committee of Shenzhen Hospital of Southern Medical University (approval Nos. NYSZYYEC20200036 and NYSZYYEC20200042) and the Ethics Committee of Shenzhen University General Hospital (approval No. 2020-003-002). Written informed consent was obtained from all participants before endoscopy. This study was registered with the Chinese Clinical Trial Registry (ChiCTR2100045101) on April 6, 2021. At Center A, all participants were enrolled after trial registration. At Center B, enrollment was conducted between February 24, 2021 and September 4, 2021; therefore, some participants at Center B had been enrolled before trial registration. The exact number of participants enrolled at Center B before registration could not be reliably determined from the available site-level records.
Participants
Consecutive adults aged 18–75 years who were scheduled to undergo upper gastrointestinal endoscopy or colonoscopy for symptoms or screening were eligible for enrollment. The main exclusion criteria were contraindications to upper or lower gastrointestinal endoscopy, pregnancy or lactation, previous upper or lower gastrointestinal surgery, participation in another clinical trial within the previous month, known allergy to anesthetic agents, and any other condition that, in the investigator’s judgment, made the patient unsuitable for inclusion.
Endoscopic devices and procedures
All examinations were performed using single-use gastroscopes (XZING-W200B) or single-use colonoscopes (XZING-C200B) together with the corresponding imaging processor (XZING-S2; serial numbers S22003001 and S22003002), developed by Huizhou Xzing Technology Co., Ltd. (Huizhou, China). Single-use gastroscopy was performed with ENDOANGEL (ENDOANGEL Medical Technology Co., Ltd., Wuhan, China), an AI-based system for real-time quality monitoring. During single-use colonoscopy, ENDOANGEL-related process-monitoring indicators, including the cecal intubation reminder and withdrawal-speed alert, were recorded descriptively. These colonoscopy indicators were not treated as formal AI quality-scoring endpoints. Detailed device specifications are provided in Online Resources 1 and 2.
Participants fasted for at least 6 h before endoscopy. All procedures were performed under intravenous anesthesia with propofol administered by anesthesiologists. For colonoscopy, bowel preparation was performed using polyethylene glycol, and bowel preparation quality was assessed using the Boston Bowel Preparation Scale (BBPS). Adequate bowel preparation was defined as a total BBPS score of at least 6, with each segment score of at least 2. Each center had one participating endoscopist, and all examinations at a given center were performed by the corresponding endoscopist. Both endoscopists had more than 5 years of endoscopic experience and performed the procedures according to standardized inspection protocols. Representative images of predefined anatomical sites were obtained, and the entire procedure was recorded. Biopsy and minor endoscopic interventions were permitted when clinically indicated. Vital signs were monitored throughout the procedure, and all participants were followed for 24 h after endoscopy to assess adverse events.
Outcome measures
Primary endpoint
The primary endpoint was the imaging success rate at predefined anatomical sites (10 sites for gastroscopy and 8 sites for colonoscopy; Online Resource 3). Imaging success was defined as acquisition of at least one representative image from each predefined site. The success rate was calculated as the proportion of participants who met this criterion. Representative images of these predefined sites are also provided in Online Resource 3.
Secondary endpoints
Image quality score
Image quality at each predefined site was independently assessed by two assessors using a 5-point scale ranging from 0 to 4, where 0 indicated a missed or non-assessable image and 4 indicated a very clear image. The assessors were not involved in the index procedures and were blinded to patient information and endoscopist identity. They were aware of the study center, and complete blinding to device or procedure information was not feasible because this information could potentially be inferred from the characteristics of endoscopic images or videos. Site-specific scores were summed for each participant, with maximum total scores of 40 for gastroscopy and 32 for colonoscopy. Scores of 3 or 4 were considered acceptable. Disagreements were resolved by a third assessor. Detailed scoring criteria are provided in Online Resource 4. Interobserver agreement was assessed separately for each center using linear weighted kappa.
Procedure completion
Procedure completion was defined as successful intubation to the second portion of the duodenum for gastroscopy and cecal intubation for colonoscopy.
Clinical operability
Endoscopists evaluated predefined items related to device operability and image-related performance using a three-grade scale: A, good; B, fair; and C, poor. Overall operability was considered acceptable if all items were rated A or B. Detailed evaluation criteria are provided in Online Resource 5.
Device malfunction or defect
Device malfunction or defect was defined as any interruption or loss of device function during the procedure.
Procedure time
Insertion time, withdrawal time, and total procedure time were recorded.
ENDOANGEL score and agreement (gastroscopy only)
The ENDOANGEL score was recorded for each gastroscopy. Agreement between the ENDOANGEL-based assessment and manual assessment of imaging success and procedure completion was evaluated. Detailed site-specific scoring criteria are provided in Online Resource 6.
Additional ENDOANGEL process-monitoring indicators (colonoscopy only)
During colonoscopy, ENDOANGEL-related cecal intubation reminders and withdrawal-speed alerts were recorded descriptively. Withdrawal speed was displayed dynamically using numeric values and color changes. According to the predefined thresholds used in this study, values of ≤ 40 were considered normal, values of 41–44 were considered warning values, and values of > 44 were considered high-speed alert values. Because these indicators differed methodologically from the ENDOANGEL quality-scoring measures used in gastroscopy, they were summarized descriptively and were not analyzed as formal AI quality-scoring endpoints.
Safety endpoints
Periprocedural hemodynamic stability was assessed by monitoring blood pressure and heart rate at predefined time points: before the procedure, during scope insertion, and at 10 and 60 min after the procedure. Procedure-related adverse events within 24 h included nausea, vomiting, hypotension, respiratory depression, myocardial infarction, gastrointestinal bleeding, perforation, and other complications.
Sample size calculation
According to the original study protocol, sample size was estimated separately for gastroscopy and colonoscopy in this single-arm feasibility study using key procedural success indicators. Assuming a target value of 90%, an expected success rate of 100%, a one-sided α of 0.025, and a dropout rate of 10%, the minimum required sample size was 29 participants for each procedure group. Given the two-center design and with reference to previous feasibility studies of single-use endoscopy using similar devices, 60 participants were planned for each group.
Statistical analysis
Categorical variables are presented as n (%), and continuous variables are presented as mean ± standard deviation (SD) or median (interquartile range [IQR]), as appropriate. Imaging success and other proportion outcomes were reported with two-sided 95% confidence intervals calculated using the Clopper–Pearson exact method. Interobserver agreement for ordinal image-quality scores was assessed using linear weighted kappa and reported separately for each center. ENDOANGEL-related process-monitoring indicators recorded during colonoscopy were summarized descriptively and were not treated as formal AI quality-scoring endpoints. All analyses were performed using SPSS version 26.0 (IBM Corp., Armonk, NY, USA).
Results
Participants
A total of 120 participants were enrolled, including 60 who underwent single-use gastroscopy and 60 who underwent single-use colonoscopy (Fig. 1). Baseline characteristics are summarized in Table 1. All participants completed the 24-h follow-up.
Fig. 1.
Participant flow diagram. A total of 120 participants were enrolled, including 60 who underwent single-use gastroscopy and 60 who underwent single-use colonoscopy. All participants completed the 24-h follow-up and were included in the analysis
Table 1.
Baseline characteristics of participants
| Single-use gastroscopy (n = 60) | Single-use colonoscopy (n = 60) | |
|---|---|---|
| Sex, n (%) | ||
| Male | 25 (41.7) | 27 (45.0) |
| Female | 35 (58.3) | 33 (55.0) |
| Age, years, median (IQR) | 41.5 (32.0–53.3) | 42.5 (35.0–52.3) |
| Comorbidities, n (%) | ||
| Yes | 12 (20.0) | 11 (18.3) |
| No | 48 (80.0) | 49 (81.7) |
| Systolic blood pressure, mmHg, median (IQR) | 111.0 (101.5–120.0) | 109.0 (102.8–116.3) |
| Diastolic blood pressure, mmHg, median (IQR) | 70.0 (65.0–76.0) | 73.5 (66.0–78.0) |
| Heart rate, beats/min, median (IQR) | 72.0 (68.0–78.5) | 72.0 (68.8–79.3) |
Data are presented as n (%) or median (IQR). IQR interquartile range
Primary endpoint
Imaging success at predefined anatomical sites
Imaging success at predefined anatomical sites was achieved in all gastroscopies (60/60) and all colonoscopies (60/60), corresponding to a success rate of 100.0% for both procedures (95% CI 94.0–100.0% for each group) (Table 2). No procedure required conversion to a reusable endoscope.
Table 2.
Imaging success for predefined anatomical sites
| Outcome | Single-use gastroscopy (n = 60) | Single-use colonoscopy (n = 60) |
|---|---|---|
| Imaging success for predefined anatomical sites, n/N (%) | 60/60 (100.0) | 60/60 (100.0) |
| 95% CI | 94.0–100.0% | 94.0–100.0% |
Data are presented as n/N (%) unless otherwise indicated. Imaging success was defined as successful imaging of all predefined anatomical sites in each participant. CI confidence interval
Secondary endpoints
Image quality
The overall image quality scores were 39.2 ± 0.8 out of 40 for gastroscopy and 31.3 ± 0.8 out of 32 for colonoscopy (Table 3). Image quality was rated as acceptable at all predefined anatomical sites. Site-level score distributions are provided in Online Resources 7 and 8. Interobserver agreement for ordinal site-level ratings is reported separately for each center in Online Resource 9.
Table 3.
Image quality outcomes
| Outcome | Single-use gastroscopy (n = 60) | Single-use colonoscopy (n = 60) |
|---|---|---|
| Overall image quality score, mean ± SD | 39.2 ± 0.8 | 31.3 ± 0.8 |
| Acceptable image-quality rate*, % | 100.0 | 100.0 |
*Acceptable image quality was defined as a site-specific score of 3–4 after adjudication
Procedure completion, bowel preparation quality, procedural details, clinical operability, and procedure time
Procedure completion was achieved in all cases, including all gastroscopies (60/60) and all colonoscopies (60/60), corresponding to a completion rate of 100.0% for both procedures (95% CI 94.0–100.0% for each group). In the colonoscopy group, bowel preparation quality was generally high, with a mean total BBPS score of 8.6 ± 0.7, and all colonoscopies met the criteria for adequate bowel preparation. Detailed segmental BBPS scores are presented in Online Resource 10. The evaluated procedures consisted mainly of routine diagnostic examinations with clinically indicated biopsy or minor intervention. Additional procedural details were summarized descriptively. Biopsy was performed in 10 gastroscopies and 4 colonoscopies. Gastric polyps were identified in 18 gastroscopies and colonic polyps in 13 colonoscopies, including some polyps that were not removed during the index procedure. Across both procedure groups, minor interventions were performed in 28 procedures: cold forceps polypectomy in 21, cold snare polypectomy in 1, endoscopic mucosal resection (EMR) in 4, and argon plasma coagulation (APC) in 2. No complex therapeutic procedures beyond these clinically indicated minor interventions were performed. Clinical operability was rated as acceptable for both single-use gastroscopy and single-use colonoscopy, with all predefined items rated A or B (Table 4). Item-level distributions of clinical operability ratings are provided in Online Resource 11. Mean total procedure time was 9.3 ± 2.7 min for gastroscopy and 12.6 ± 3.1 min for colonoscopy. Insertion and withdrawal times are summarized in Table 4, and categorized time distributions are provided in Online Resource 12.
Table 4.
Procedure performance and ENDOANGEL-related findings
| Outcome | Single-use gastroscopy (n = 60) | Single-use colonoscopy (n = 60) |
|---|---|---|
| Procedure completion*, n/N (%) | 60/60 (100.0) | 60/60 (100.0) |
| Conversion to reusable endoscope, n (%) | 0 (0.0) | 0 (0.0) |
| Acceptable clinical operability, n (%) | 60 (100.0) | 60 (100.0) |
| Total procedure time, mean ± SD, min | 9.3 ± 2.7 | 12.6 ± 3.1 |
| Insertion time, mean ± SD, min | 3.7 ± 1.3 | 5.4 ± 2.5 |
| Withdrawal time, mean ± SD, min | 5.6 ± 2.2 | 7.2 ± 1.5 |
| ENDOANGEL-related findings | ||
| Full ENDOANGEL score, n (%) | 60 (100.0) | – |
| Concordance with manual imaging success assessment, n (%) | 60 (100.0) | – |
| Concordance with manual procedure completion assessment, n (%) | 60 (100.0) | – |
| Cecal intubation reminder, n/N (%) | – | 60/60 (100.0) |
| Withdrawal-speed alert, n/N (%) | – | 4/60 (6.7) |
Data are presented as n/N (%), n (%), or mean ± SD, as appropriate. – not applicable
*For procedure completion in each procedure group, the two-sided 95% confidence interval was 94.0–100.0%
Safety outcomes
No device malfunction or device defect occurred in either group, and no procedure-related adverse event was observed during the procedure or within 24 h after endoscopy (0/60 in each group for each outcome; 95% CI 0.0–6.0%). In the single-use gastroscopy group, the rates of hemodynamic stability across the predefined time points ranged from 90.0 to 91.7% for systolic blood pressure, 86.7–96.7% for diastolic blood pressure, and 86.7–93.3% for heart rate. The corresponding ranges in the single-use colonoscopy group were 86.7–96.7%, 91.7–96.7%, and 93.3–100.0%, respectively. Detailed values by procedure type and time point are provided in Online Resource 13.
ENDOANGEL-related findings
In single-use gastroscopy, all examinations achieved the maximum ENDOANGEL procedural score according to the predefined site-specific scoring system (Table 4 and Online Resource 6). ENDOANGEL-based assessment was concordant with manual assessment of imaging success and procedure completion in all gastroscopies. In single-use colonoscopy, AI-related cecal intubation reminders recorded by ENDOANGEL were concordant with manual assessment in all procedures (60/60), and withdrawal-speed alerts were recorded in 4 of 60 colonoscopies (6.7%) (Table 4). These colonoscopy-related AI indicators were summarized descriptively, and no formal colonoscopy AI quality score was calculated.
Discussion
In this prospective two-center single-arm study, single-use gastroscopy with ENDOANGEL-assisted real-time quality monitoring and single-use colonoscopy were feasible in routine endoscopic practice and showed a favorable short-term safety profile within 24 h. Imaging of predefined anatomical sites and procedure completion were achieved in all enrolled participants. Image quality scores were high, clinical operability was acceptable, and no device malfunction, device defect, or procedure-related adverse event was observed during the procedure or within 24 h after endoscopy. These findings provide preliminary evidence on the feasibility of single-use gastroscopy and colonoscopy in routine practice.
Our findings are consistent with growing evidence that single-use gastroscopes can achieve acceptable technical and operational performance in routine diagnostic settings [7, 8]. Our study extends this evidence by assessing both single-use gastroscopy and single-use colonoscopy within the same prospective framework. In addition to procedure completion, predefined anatomical-site imaging was used as a structured measure of examination completeness and was combined with image-quality assessment and clinical operability evaluation. This approach allowed feasibility to be assessed beyond procedural completion alone and is aligned with quality-oriented endoscopic practice [20–22]. Evidence on single-use colonoscopy remains more limited, although earlier human studies have demonstrated the technical feasibility of single-use colonoscopic platforms [15].
We also explored AI-related monitoring during single-use endoscopy. In upper gastrointestinal endoscopy, blind spots remain an important quality concern, and real-time monitoring systems have been used to support more complete inspection of key anatomical sites [16, 17]. In the present study, all ENDOANGEL-assisted gastroscopies achieved the maximum procedural score, and ENDOANGEL-based assessment agreed with manual assessment of imaging success and procedure completion. These observations suggest that real-time quality monitoring could be incorporated into single-use gastroscopy in routine practice. However, because the study did not include a non-AI comparator, it cannot determine whether ENDOANGEL improved examination quality or clinical outcomes. For colonoscopy, AI-related cecal intubation reminders and withdrawal-speed alerts generated by ENDOANGEL were recorded and summarized as descriptive process-monitoring indicators. The agreement between cecal intubation reminders and manual assessment provides preliminary information on system behavior during single-use colonoscopy, but these data should not be interpreted as formal AI quality scoring or evidence of improved clinical outcomes.
Regarding safety, no device malfunction or defect occurred, and no procedure-related adverse events were observed during the procedure or within 24 h after endoscopy. Periprocedural hemodynamic stability was also evaluated using a prespecified criterion of no more than 20% deviation from baseline at multiple time points. Although the corresponding stability rates did not reach 100% under this definition, the observed fluctuations were within the range expected during endoscopy performed under intravenous anesthesia and were not suggestive of device-related harm [23, 24]. Similar findings have been reported in previous studies of single-use endoscopy using comparable hemodynamic monitoring time points and indicators [8, 25]. However, these findings should be interpreted as short-term safety data, as delayed adverse events, particularly after biopsy or minor intervention, could not be assessed beyond the 24 h follow-up period.
Several limitations of this study should be considered. First, this was a single-arm feasibility study without reusable-endoscope or non-AI comparators. The findings should therefore be interpreted as feasibility and short-term safety data, rather than evidence of comparative performance between single-use and reusable systems or evidence that AI improved examination quality. Outcomes relevant to broader implementation, including infection-related outcomes, workflow efficiency, costs, resource use, waste disposal, and environmental sustainability, were not evaluated. Second, the sample size was modest and follow-up was limited to 24 h; therefore, rare device-related events, uncommon adverse events, and delayed complications, particularly after biopsy or minor intervention, could not be fully assessed. Third, the study mainly comprised routine diagnostic examinations, with only minor interventions performed when clinically indicated. No complex therapeutic procedures beyond these minor interventions were performed; therefore, the findings on clinical operability should not be generalized to complex therapeutic procedures, which require dedicated prospective evaluation. Fourth, complete blinding of image-quality assessment was not feasible because the assessors were aware of the study center, and device or procedure information could potentially be inferred from the images or videos. Finally, formal lesion, polyp, and adenoma detection outcomes and patient-reported outcomes were not prespecified. The gastric and colonic polyp findings reported in this study were descriptive procedural findings only. Future controlled studies with larger sample sizes, longer follow-up, and appropriate reusable-endoscope and non-AI comparators are needed to evaluate comparative performance, longer-term safety, and broader implementation outcomes.
Conclusions
Single-use gastroscopy with real-time AI-based quality monitoring and single-use colonoscopy were feasible in routine gastrointestinal endoscopy and showed a favorable short-term safety profile within 24 h. Complete imaging of predefined anatomical sites was achieved in all cases, and no procedure required conversion to a reusable endoscope. The ENDOANGEL results suggest that AI-based quality monitoring could be incorporated into single-use gastroscopy, whereas colonoscopy-related AI indicators should be regarded as descriptive process-monitoring data. Further controlled studies are needed to compare single-use and reusable systems and to clarify the clinical role of AI-based process monitoring in single-use endoscopy.
Supplementary Information
Acknowledgements
The authors thank Huizhou Xzing Technology Co., Ltd. and ENDOANGEL Medical Technology Co., Ltd. for providing the single-use endoscopic devices, the ENDOANGEL system, and necessary technical support related to device operation. The authors also thank American Journal Experts (AJE) for English language editing.
Trial registration
The study was registered with the Chinese Clinical Trial Registry (registration number: ChiCTR2100045101) on April 6, 2021. The registration was retrospective for one participating center, where enrolment had started before registration, as described in the Methods section.
Author contributions
W.G. and F.Z. contributed to the study conception and design. Material preparation was performed by G.X. and Z.Z. Data collection was performed by Y.Z. and L.X. Data analysis was performed by W.X. The first draft of the manuscript was written by Y.L. All authors commented on previous versions of the manuscript. All authors read and approved the final manuscript.
Funding
This study was supported by the Bao’an District Medical and Health Research Project of Shenzhen, China (Grant Number 2022JD024).
Data availability
The datasets generated and/or analyzed during the current study are not publicly available because they contain clinical data from individual participants and are subject to institutional and ethical restrictions. The data are available from the corresponding author on reasonable request.
Code availability
Not applicable.
Declarations
Ethics approval and consent to participate
The study was approved by the Ethics Committee of Shenzhen Hospital of Southern Medical University (approval Nos. NYSZYYEC20200036 and NYSZYYEC20200042) and the Ethics Committee of Shenzhen University General Hospital (approval No. 2020-003-002). Written informed consent was obtained from all participants before endoscopy.
Consent for publication
Not applicable.
Competing interests
The authors declare no competing interests.
Footnotes
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Data Availability Statement
The datasets generated and/or analyzed during the current study are not publicly available because they contain clinical data from individual participants and are subject to institutional and ethical restrictions. The data are available from the corresponding author on reasonable request.
Not applicable.