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CC BY 4.0 · Endosc Int Open 2025; 13: a26764144
DOI: 10.1055/a-2676-4144
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Artificial Intelligence-Assisted Colonoscopy With or Without Mucosal Exposure Device for Detection of Colorectal Adenomas: A Meta-Analysis

Authors

  • Azizullah Beran 

    1   Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA (Ringgold ID: RIN1772)

  • Tarek Nayfeh

    2   Evidence-based Practice Center, Mayo Clinic, Rochester, MN, USA (Ringgold ID: RIN10668)
    3   Department of Medicine, MedStar Union Memorial Hospital, Georgetown University, Baltimore, MD, USA (Ringgold ID: RIN6915)

  • Daryl Ramai

    4   Division of Gastroenterology, Hepatology and Endoscopy, Brigham and Women's Hospital, Boston, Massachusetts, USA (Ringgold ID: RIN24508)

  • Almaza Albakri

    5   Department of Medicine, Cleveland Clinic Foundation, Cleveland, OH, USA (Ringgold ID: RIN2569)

  • Nasir Saleem

    1   Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA (Ringgold ID: RIN1772)

  • Marco Spadaccini 

    6   Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy (Ringgold ID: RIN12250)
    7   Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy (Ringgold ID: RIN9268)

  • Cesare Hassan 

    6   Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy (Ringgold ID: RIN12250)
    7   Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy (Ringgold ID: RIN9268)

  • Alessandro Repici

    6   Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy (Ringgold ID: RIN12250)
    7   Endoscopy Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy (Ringgold ID: RIN9268)

  • John J. Guardiola 

    1   Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA (Ringgold ID: RIN1772)

  • Douglas K. Rex

    1   Division of Gastroenterology and Hepatology, Indiana University School of Medicine, Indianapolis, IN, USA (Ringgold ID: RIN1772)
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Abstract

Background and study aims

Artificial intelligence (AI) and mucosal exposure devices like Endocuff have independently improved the adenoma detection rate (ADR) during colonoscopy. This meta-analysis evaluated the combined effect of Endocuff and AI versus AI alone on colorectal neoplasia detection rates.

Methods

We searched PubMed, Embase, and Web of Science for randomized controlled trials (RCTs) comparing the impact of Endocuff+AI versus AI alone on colorectal neoplasia detection. Primary outcome was ADR; secondary outcomes included advanced adenoma detection rate (AADR), sessile serrated lesion detection rate (SSLDR), cecal intubation time, and withdrawal time. Pooled risk ratios (RRs) and mean differences (MDs) with 95% confidence intervals (CIs) were calculated using a random-effects model.

Results

Three RCTs with 2404 subjects were included (n = 1198 Endocuff+AI vs. n = 1206 AI alone). ADR was significantly higher in the Endocuff+AI group than in the AI alone group (54% vs. 48%, respectively) (RR 1.12, 95% CI 1.03–1.21, P = 0.01, I2 = 0%). There was a trend toward higher AADR (12.3% vs. 10%, RR 1.23, 95% CI 0.96–1.59, P = 0.10, I2 = 17%) and SSLDR (17.6% vs. 15.5%, RR 1.16, 95% CI 0.96–1.40, P = 0.13, I2 = 0%) in the Endocuff+AI group compared with the AI alone group, but it did not reach statistical significance. Both cecal intubation time (MD -0.61 minutes; 95% CI -1.54–0.33; P = 0.20; I2 = 87%) and withdrawal time (MD -0.42 minutes; 95% CI -1.01–0.17; P = 0.17, I2 = 60%) were similar between the two groups.

Conclusions

Endocuff combined with AI was superior to AI alone in improving the adenoma detection rate without increasing intubation or withdrawal times.

Keywords

Endoscopy Lower GI Tract - Polyps / adenomas / ... - Quality and logistical aspects - Quality management - CRC screening

Supplementary Material



Publication History

Received: 27 March 2025

Accepted after revision: 14 June 2025

Accepted Manuscript online:
04 August 2025

Article published online:
29 August 2025

© 2025. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

Georg Thieme Verlag KG
Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany

Bibliographical Record
Azizullah Beran, Tarek Nayfeh, Daryl Ramai, Almaza Albakri, Nasir Saleem, Marco Spadaccini, Cesare Hassan, Alessandro Repici, John J. Guardiola, Douglas K. Rex. Artificial Intelligence-Assisted Colonoscopy With or Without Mucosal Exposure Device for Detection of Colorectal Adenomas: A Meta-Analysis. Endosc Int Open 2025; 13: a26764144.
DOI: 10.1055/a-2676-4144
 

  • References

  • 1 Shaukat A, Kahi CJ, Burke CA. et al. ACG Clinical Guidelines: Colorectal Cancer Screening 2021. Am J Gastroenterol 2021; 116: 458-479
    Search in Google Scholar
  • 2 Brenner H, Chang-Claude J, Seiler CM. et al. Protection from colorectal cancer after colonoscopy: a population-based, case-control study. Ann Intern Med 2011; 154: 22-30
    Search in Google Scholar
  • 3 Zauber AG, Winawer SJ, O'Brien MJ. et al. Colonoscopic polypectomy and long-term prevention of colorectal-cancer deaths. N Engl J Med 2012; 366: 687-696
    Search in Google Scholar
  • 4 Rex DK, Anderson JC, Butterly LF. et al. Quality indicators for colonoscopy. Am J Gastroenterol 2024; 119: 1754-1780
    Search in Google Scholar
  • 5 Aniwan S, Vanduangden K, Kerr SJ. et al. Usefulness of mean number of adenomas per positive screenee for identifying meticulous endoscopists among those who achieve acceptable adenoma detection rates. Endoscopy 2021; 53: 394-401
    Search in Google Scholar
  • 6 Corley DA, Jensen CD, Marks AR. et al. Adenoma detection rate and risk of colorectal cancer and death. N Engl J Med 2014; 370: 1298-1306
    Search in Google Scholar
  • 7 Kaminski MF, Wieszczy P, Rupinski M. et al. Increased rate of adenoma detection associates with reduced risk of colorectal cancer and death. Gastroenterology 2017; 153: 98-105
    Search in Google Scholar
  • 8 Pedersen L, Valori R, Bernstein I. et al. Risk of post-colonoscopy colorectal cancer in Denmark: time trends and comparison with Sweden and the English National Health Service. Endoscopy 2019; 51: 733-741
    Search in Google Scholar
  • 9 Wang P, Berzin TM, Glissen Brown JR. et al. Real-time automatic detection system increases colonoscopic polyp and adenoma detection rates: a prospective randomised controlled study. Gut 2019; 68: 1813-1819
    Search in Google Scholar
  • 10 Wang P, Liu X, Berzin TM. et al. Effect of a deep-learning computer-aided detection system on adenoma detection during colonoscopy (CADe-DB trial): a double-blind randomised study. Lancet Gastroenterol Hepatol 2020; 5: 343-351
    Search in Google Scholar
  • 11 Repici A, Badalamenti M, Maselli R. et al. Efficacy of real-time computer-aided detection of colorectal neoplasia in a randomized trial. Gastroenterology 2020; 159: 512-520 e517
    Search in Google Scholar
  • 12 Wang P, Liu P, Glissen Brown JR. et al. Lower adenoma miss rate of computer-aided detection-assisted colonoscopy vs routine white-light colonoscopy in a prospective tandem study. Gastroenterology 2020; 159: 1252-1261 e1255
    Search in Google Scholar
  • 13 Lui TKL, Hui CKY, Tsui VWM. et al. New insights on missed colonic lesions during colonoscopy through artificial intelligence-assisted real-time detection (with video). Gastrointest Endosc 2021; 93: 193-200 e191
    Search in Google Scholar
  • 14 Rex DK, Sagi SV, Kessler WR. et al. A comparison of 2 distal attachment mucosal exposure devices: a noninferiority randomized controlled trial. Gastrointest Endosc 2019; 90: 835-840 e831
    Search in Google Scholar
  • 15 Rex DK, Slaven JE, Garcia J. et al. Endocuff Vision reduces inspection time without decreasing lesion detection: A clinical randomized trial. Clin Gastroenterol Hepatol 2020; 18: 158-162 e151
    Search in Google Scholar
  • 16 Rameshshanker R, Tsiamoulos Z, Wilson A. et al. Endoscopic cuff-assisted colonoscopy versus cap-assisted colonoscopy in adenoma detection: randomized tandem study-DEtection in Tandem Endocuff Cap Trial (DETECT). Gastrointest Endosc 2020; 91: 894-904 e891
    Search in Google Scholar
  • 17 Triantafyllou K, Polymeros D, Apostolopoulos P. et al. Endocuff-assisted colonoscopy is associated with a lower adenoma miss rate: a multicenter randomized tandem study. Endoscopy 2017; 49: 1051-1060
    Search in Google Scholar
  • 18 Page MJ, McKenzie JE, Bossuyt PM. et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021; 372: n71
    Search in Google Scholar
  • 19 Van Houwelingen HC, Zwinderman KH, Stijnen T. A bivariate approach to meta-analysis. Stat Med 1993; 12: 2273-2284
    Search in Google Scholar
  • 20 Higgins JP, Thompson SG, Deeks JJ. et al. Measuring inconsistency in meta-analyses. Bmj 2003; 327: 557-560
    Search in Google Scholar
  • 21 Lui TK, Lam CP, To EW. et al. Endocuff With or Without Artificial Intelligence-Assisted Colonoscopy in Detection of Colorectal Adenoma: A Randomized Colonoscopy Trial. Am J Gastroenterol 2024; 119: 1318-1325
    Search in Google Scholar
  • 22 Guyatt GH, Oxman AD, Vist G. et al. GRADE guidelines: 4. Rating the quality of evidence--study limitations (risk of bias). J Clin Epidemiol 2011; 64: 407-415
    Search in Google Scholar
  • 23 Guyatt GH, Oxman AD, Kunz R. et al. GRADE guidelines 6. Rating the quality of evidence--imprecision. J Clin Epidemiol 2011; 64: 1283-1293
    Search in Google Scholar
  • 24 Guyatt GH, Oxman AD, Kunz R. et al. GRADE guidelines: 8. Rating the quality of evidence--indirectness. J Clin Epidemiol 2011; 64: 1303-1310
    Search in Google Scholar
  • 25 Guyatt GH, Oxman AD, Kunz R. et al. GRADE guidelines: 7. Rating the quality of evidence--inconsistency. J Clin Epidemiol 2011; 64: 1294-1302
    Search in Google Scholar
  • 26 Guyatt GH, Oxman AD, Montori V. et al. GRADE guidelines: 5. Rating the quality of evidence--publication bias. J Clin Epidemiol 2011; 64: 1277-1282
    Search in Google Scholar
  • 27 Zeng L, Brignardello-Petersen R, Hultcrantz M. et al. GRADE guidelines 32: GRADE offers guidance on choosing targets of GRADE certainty of evidence ratings. J Clin Epidemiol 2021; 137: 163-175
    Search in Google Scholar
  • 28 Zeng L, Brignardello-Petersen R, Hultcrantz M. et al. GRADE Guidance 34: update on rating imprecision using a minimally contextualized approach. J Clin Epidemiol 2022; 150: 216-224
    Search in Google Scholar
  • 29 Aniwan S, Mekritthikrai K, Kerr SJ. et al. Computer-aided detection, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized controlled trial. Gastrointest Endosc 2023; 97: 507-516
    Search in Google Scholar
  • 30 Spadaccini M, Hassan C, Rondonotti E. et al. Combination of mucosa-exposure device and computer-aided detection for adenoma detection during colonoscopy: A randomized trial. Gastroenterology 2023; 165: 244-251 e243
    Search in Google Scholar
  • 31 Rex DK, Mori Y, Sharma P. et al. Strengths and weaknesses of an artificial intelligence polyp detection program as assessed by a high-detecting endoscopist. Gastroenterology 2022; 163: 354-358 e351
    Search in Google Scholar
  • 32 Hassan C, Badalamenti M, Maselli R. et al. Computer-aided detection-assisted colonoscopy: classification and relevance of false positives. Gastrointest Endosc 2020; 92: 900-904 e904
    Search in Google Scholar
  • 33 Triantafyllou K, Gkolfakis P, Tziatzios G. et al. Effect of Endocuff use on colonoscopy outcomes: A systematic review and meta-analysis. World J Gastroenterol 2019; 25: 1158-1170
    Search in Google Scholar
  • 34 Patel HK, Chandrasekar VT, Srinivasan S. et al. Second-generation distal attachment cuff improves adenoma detection rate: meta-analysis of randomized controlled trials. Gastrointest Endosc 2021; 93: 544-553 e547
    Search in Google Scholar