Linked color imaging, mucosal exposure device, their combination, and standard colonoscopy for adenoma detection: a randomized trial

Background and Aims: By different mechanisms, image-enhancement techniques (linked color imaging [LCI]) and mucosal exposure devices (Endocuff-assisted colonoscopy [EAC]) can improve the adenoma detection rate (ADR) during screening colonoscopy. The impact of the combination of the 2 techniques has never been studied. This study aimed to compare the ADR between the combination of LCI and EAC (LCIthornEAC), LCI alone, EAC alone, and standard high-definition (HD) colonoscopy. Methods: This prospective randomized controlled trial included participants who underwent screening colonoscopy. Participants were randomized to LCIthornEAC, LCI, EAC, and standard HD colonoscopy. All colonoscopies were performed by endoscopists with a recorded ADR >= 35%. The primary outcome was the ADR. Secondary outcomes were proximal ADR (pADR) and the mean number of adenomas per colonoscopy (APC). Results: One thousand participants were included in the study. The LCIthornEAC group provided the highest ADR and pADR. The ADRs in the LCIthornEAC, LCI, EAC, and standard HD colonoscopy groups were 57.2%, 52.8%, 51.6%, and 47.6%, respectively, with pADRs of 38.4%, 34.8%, 33.6%, and 28.0%, respectively. The mean numbers of APC were 1.28, 1.20, 1.16, and.89, respectively. After a multiple comparison adjustment, a significant difference in pADR was only observed between the LCIthornEAC and standard HD colonoscopy groups (difference, 10.3 percentage points; 95% confidence interval, .02%-17.4%; P = .05). The incidence rate ratios of the adenoma numbers were significantly higher in the LCI+EAC (1.43), LCI (1.34), and EAC (1.30) groups relative to the standard HD colonoscopy group (.89) (P <.009 for all comparisons). Conclusions: The combination of LCI and EAC can significantly improve the detection of pADR and APC but not ADR by high-ADR performers.