Enhanced adenoma detection with Endocuff Vision: a GRADE assessed systematic review and meta-analysis

Ahmed Ali Khan; Fariha Hasan; Mohammed Dheyaa Marsool Marsool; Muhammad Uzair; Kanz Ul Eman Maryam; Muhammad Usman Babar; Mutahhar Talha; Haider Imran; Rayyan Mohammad Makki Bakhsh; Kalsoom Zulfiqar; Fatima Wahid; Amal Shahzad Khan; Daniel Ashraf Guirguis; Christina Tofani; Anthony Infantolino

doi:10.5946/ce.2025.163

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Systematic Review and Meta-analysis Enhanced adenoma detection with Endocuff Vision: a GRADE assessed systematic review and meta-analysis: Ahmed Ali Khan¹, Fariha Hasan², Mohammed Dheyaa Marsool Marsool³, Muhammad Uzair⁴, Kanz Ul Eman Maryam¹, Muhammad Usman Babar¹, Mutahhar Talha¹, Haider Imran¹, Rayyan Mohammad Makki Bakhsh¹, Kalsoom Zulfiqar⁵, Fatima Wahid⁶, Amal Shahzad Khan¹, Daniel Ashraf Guirguis⁷, Christina Tofani⁸, Anthony Infantolino⁸; Clinical Endoscopy 2026;59(3):371-385.
DOI: https://doi.org/10.5946/ce.2025.163
Published online: February 2, 2026

¹Department of Internal Medicine, Foundation University Medical College, Islamabad, Pakistan

²Department of Internal Medicine, Cooper University Hospital, Camden, NJ, USA

³Mayo Clinic, Phoenix, AZ, USA

⁴Department of Internal Medicine, Ziauddin Medical College, Karachi, Pakistan

⁵Department of Internal Medicine, Aga Khan University Hospital, Karachi, Pakistan

⁶Department of Internal Medicine, Gujranwala Medical College Teaching Hospital, Gujranwala, Pakistan

⁷Department of Internal Medicine, St. Luke’s University Hospital-Bethlehem Campus, Bethlehem, PA, USA

⁸Department of Gastroenterology, Cooper University Hospital, Cooper Medical School of Rowan University, Camden, NJ, USA

Correspondence: Fariha Hasan Department of Internal Medicine, Cooper University Hospital, 1 Cooper Plaza, Camden, NJ 08103, USA E-mail: farihahassan100@gmail.com

Correspondence: Daniel Ashraf Guirguis Department of Internal Medicine, St. Luke’s University Hospital-Bethlehem Campus, 801 Ostrum St, Bethlehem, PA 18015, USA E-mail: Daniel.Guirguis@sluhn.org

• Received: May 22, 2025 • Revised: July 2, 2025 • Accepted: July 12, 2025

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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Abstract
Graphical abstract
INTRODUCTION
METHODS
RESULTS
DISCUSSION
Supplementary Material
NOTES
REFERENCES

Abstract

Background/Aims
Colorectal cancer (CRC) is the second leading cause of cancer-related deaths and the third most common cancer worldwide. Detecting adenomas during colonoscopy reduces the CRC risk, with higher adenoma detection rates (ADRs) correlating with lower CRC incidence and mortality. Endocuff Vision (EV) enhances mucosal visualization and may improve ADRs.
Methods
Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, PubMed, Embase, and Cochrane databases were searched through April 2025 for studies comparing EV-assisted and standard colonoscopy. The primary outcomes of interest were the ADRs, polyp detection rates (PDRs), and adverse events (AEs). Outcomes were pooled using a random-effects meta-analysis model and are presented as risk ratios (RRs) and mean differences. Heterogeneity in the pooled outcomes was assessed using the Higgins I².
Results
Thirty-four studies (43,702 participants) were included. EV significantly improved ADRs (RR, 1.15; 95% confidence interval [CI],1.07–1.25) and PDRs (RR, 1.16; 95% CI, 1.10–1.23). EV also improved lesion detection in the left colon (RR, 1.23; 95% CI, 1.11–1.35) and right colon (RR, 1.19; 95% CI, 1.09–1.29). No significant improvement was observed in advanced ADRs or cecal intubation. EV use was associated with more AEs.
Conclusions
EV-assisted colonoscopy improved ADRs and PDRs in both colonic regions and enhanced CRC screening despite increased AEs.
Keywords: Adenoma; Cecum; Colonoscopy; Colorectal neoplasms; Polyps

Graphical abstract

INTRODUCTION

Colorectal cancer (CRC) is the second leading cause of cancer-related death and is the third most frequently diagnosed type of cancer.¹ Screening for CRC improves the prognosis by identifying early-stage cancer and precancerous polyps and mitigating the risk of CRC-related complications, morbidity, and mortality, thereby reducing the need for aggressive treatment.²

Adenomatous polyps can take years to develop into cancer. Colonoscopy aids in detecting these tumors at an earlier stage before they become malignant neoplasms. Studies have shown that regular screening can lead to a 90% five-year survival rate, provided that CRC is detected early.³ The adenoma detection rate (ADR) directly correlates with procedural efficacy, with a higher ADR associated with a lower risk of post-colonoscopy CRC and related mortality. Evidence suggests that for every one percent increase in ADR, there is a corresponding decrease in the risk of post-colonoscopy CRC by 3% and a reduction in CRC-related mortality by up to 5%.⁴^,⁵

The detection of adenomas during colonoscopy can be challenging due to inadequate visualization and a high degree of operator dependency.⁶ Various distal attachments have been developed to enhance ADRs during colonoscopy. One such device is the Endocuff Vision (EV), a disposable mechanical device with soft, flexible arms attached to the distal end of the colonoscope. These arms maximize the field of vision of the visible mucosa by everting, flattening, and manipulating the colonic folds. Improved maneuverability, navigation, and visualization significantly decrease polyp and adenoma miss rates.⁷ The device considerably increases ADRs by up to 11%, with every 1% increase representing a 3% decrease in the risk of interval CRC and a 5% decrease in the risk of fatal interval CRC.⁸

Wang et al.⁹ concluded in their meta-analysis that EV-assisted colonoscopy significantly enhanced the ADR and polyp detection rate (PDR) compared to standard colonoscopy. However, no significant improvement was noted in the detection of lesions in the right colon, advanced adenomas, or the mean number of polyps per patient (MPPP), warranting further exploration. By incorporating recently published randomized controlled trials (RCTs), our meta-analysis provides a more comprehensive and up-to-date evaluation of the advancements in EV-assisted colonoscopy and its efficacy.

METHODS

Methodology

The review was registered with NIHCR PROSPERO (CRD42024583070) and conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines (Fig. 1).¹⁰

Search strategy

A predefined search strategy (Supplementary Table 1) was used to electronically search PubMed, Embase, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials for records from inception to April 2025. The patients were thoroughly screened without language limitations. The bibliographic sections of the retrieved articles, earlier meta-analyses, and review articles were manually screened to identify relevant studies.

Selection criteria

The eligibility criteria for study selection included published RCTs and observational studies that compared outcomes in adult patients (aged >18 years), including both male and female patients who underwent colonoscopies as part of routine screening for CRC. The intervention group consisted of patients who underwent colonoscopies with EV assistance, while patients who underwent standard colonoscopies were included in the control group. The ADR, PDR, and incidence of adverse events (AEs) were considered the primary outcomes of interest. The advanced ADR (AADR), sessile serrated lesion detection rate (SSLDR), left-sided lesion detection rate (LSLDR), right-sided lesion detection rate (RSLDR), ileal intubation rate (IIR), cecal intubation rate, MPPP, mean number of adenomas per patient (MAPP), cecal intubation time, and withdrawal time were analyzed in a meta-analysis as secondary outcomes of interest.

A meta-analysis was conducted when data from more than three similar studies were available. Gray literature and case reports were excluded from analysis.

Data extraction

After searching the listed databases, the retrieved records were imported into EndNote¹¹ for bibliographic management. The reference lists of previous meta-analyses and review articles were also reviewed to ensure that all relevant studies were included. After removing duplicate citations, two reviewers (A.A.K. and R.M.M.B.) independently screened the remaining articles based on titles and abstracts on Rayyan.ai, an online platform designed to manage the screening process for systematic reviews.¹² The ‘blinding’ feature of this tool allows each reviewer to assess articles independently without being influenced by others’ decisions. The initial screening involved shortlisting the articles based on titles and abstracts, followed by a full-text review for relevance. Discrepancies were resolved by consultation with a third investigator (F.H.). Data from only the first phase of crossover trials¹³^-¹⁵ were included in the final analysis to minimize design-related heterogeneity.¹⁶

Quality assessment

Bias assessment in RCTs was performed using the Cochrane Risk of Bias tool, whereas the Newcastle-Ottawa scale was used to assess bias in observational studies.¹⁷^,¹⁸ The certainty of evidence was evaluated using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach.¹⁹

Statistical analyses

RevMan ver. 5.4 (The Cochrane Collaboration, 2020) was used to perform all statistical analyses. The Mantel-Haenszel random-effects model was used to compute pooled effect sizes with 95% confidence intervals (CIs). Dichotomous outcomes are presented as risk ratios (RRs), whereas mean differences (MDs) are used for continuous outcomes. Heterogeneity was evaluated using Higgins I² statistics, with I² values of 0%, 25%, 50%, and 75% indicating absent, low, moderate, and high heterogeneity, respectively. If the I² value for a given outcome exceeded 50%, sensitivity analysis was conducted. We performed a leave-one-out sensitivity analysis to assess the robustness of the pooled estimates by iteratively excluding each study and reevaluating the overall effect size to identify the sources of inconsistency in the pooled results. Funnel plot inspection and Begg’s test were used to assess publication bias (Supplementary Fig. 1). Statistical significance was set at p<0.05.

RESULTS

Characteristics of included studies

In total, 34 studies (32 RCTs and two observational studies) met the inclusion criteria.⁵^,¹³^-¹⁵^,²⁰^-⁴⁹ The final analysis included 43,702 patients, of whom 19,762 underwent EV-assisted colonoscopies. The study-specific characteristics are tabulated in Table 1,⁵^,¹³^-¹⁵^,²⁰^-⁴⁹ and all the outcomes of the included studies are summarized in Table 2.

Primary outcomes

1) Adenoma detection rate

Pooled analysis revealed that the ADR was significantly higher among patients who underwent EV-assisted colonoscopies than among those who underwent standard colonoscopies (RR, 1.15; 95% CI, 1.07–1.25; p=0.0002; I²=88%) (Fig. 2A). Sensitivity analysis did not significantly affect heterogeneity (Supplementary Fig. 2).

2) Polyp detection rate

Pooled analysis revealed that the PDR was significantly higher among patients who underwent EV-assisted colonoscopies than among those who underwent standard colonoscopies (RR, 1.16; 95% CI, 1.10–1.23; p<0.00001; I²=65%) (Fig. 2B). Upon conducting a sensitivity analysis, removing studies by González-Fernández et al.,²⁸ Floer et al.²⁶ and Quach et al.⁴⁸ reduced the heterogeneity to I²=49% (RR, 1.12; 95% CI, 1.07–1.18; p<0.00001; I²=49%) (Supplementary Fig. 3).

3) Incidence of adverse events

Pooled analysis demonstrated a significantly higher risk of AEs in patients who underwent EV-assisted colonoscopies than in those who underwent standard colonoscopies (RR, 2.60; 95% CI, 1.29–5.26; p=0.008; I²=51%) (Fig. 2C). The most commonly reported post-colonoscopy complication in the EV group was minor mucosal laceration (4%). Moreover, post-polypectomy bleeding (0.3%), bleeding due to other causes (0.06%), loss of EV-attachment (0.4%), and bowel perforations (0.04%) have also been reported. Upon conducting a sensitivity analysis by excluding the study by Ngu et al.,⁵ the heterogeneity decreased to I²=40% (RR, 3.04; 95% CI, 1.48–6.22; p=0.002; I²=40%) (Supplementary Fig. 4).

Secondary outcomes

1) Advanced adenoma detection rate

The pooled analysis revealed no statistically significant difference in the AADR between patients who underwent EV-assisted colonoscopies and those who underwent standard colonoscopies (RR, 1.04; 95% CI, 0.93–1.15; p=0.50; I²=38%) (Supplementary Fig. 5).

2) Sessile serrated lesion detection rate

Pooled analysis revealed that the SSLDR was significantly higher in patients who underwent EV-assisted colonoscopies than in those who underwent standard colonoscopies (RR, 1.15; 95% CI, 1.03–1.30; p=0.02; I²=0%) (Supplementary Fig. 6).

3) Left and right-sided lesion detection rate

The pooled analysis revealed that the LSLDR was significantly higher in patients who underwent EV-assisted colonoscopies than in those who underwent standard colonoscopies (RR, 1.23; 95% CI, 1.11–1.35; p<0.0001; I²=30%) (Supplementary Fig. 7). Additionally, a significant improvement in the RSLDR was noted in patients undergoing EV-assisted colonoscopies compared with those undergoing standard colonoscopies (RR, 1.19; 95% CI, 1.09–1.29; p<0.0001; I²=42%) (Supplementary Fig. 8).

4) Cecal and ileal intubation rate

Pooled analysis revealed no statistically significant difference in the cecal intubation rate (CIR) between patients who underwent EV-assisted colonoscopies and those who underwent standard colonoscopies (RR, 1.00; 95% CI, 1.00–1.00; p=0.62; I²=0%) (Fig. 3A).

The pooled analysis revealed a significantly lower Ileal intubation rate (IIR) in patients undergoing EV-assisted Colonoscopies than in those undergoing standard colonoscopies (RR, 0.89; 95% CI, 0.80–0.99; p=0.04; I²=78%) (Fig. 3B). Upon conducting a sensitivity analysis, removing the studies by Biecker et al.²² and Karsenti et al.¹⁴ decreased the heterogeneity to 48% (RR, 0.90; 95% CI, 0.83–0.98; p=0.02; I²=48%) (Supplementary Fig. 9).

5) Cecal intubation time and withdrawal time

Pooled analysis revealed no statistically significant difference in cecal intubation time (MD, –0.34; 95% CI, –0.75–0.07; p=0.11; I²=94%) (Fig. 4) and withdrawal time (MD, –0.27; 95% CI, –0.71–0.17; p=0.22; I²=99%) (Fig. 5) between patients who underwent EV-assisted colonoscopies and those who underwent standard colonoscopies.

6) Mean number of polyps and adenomas per patient

The pooled analysis revealed that the MPPP detected was significantly higher in patients who underwent EV-assisted colonoscopies than in those who underwent standard colonoscopies (MD, 0.29; 95% CI, 0.17–0.40; p<0.00001; I²=98%) (Supplementary Fig. 10). Upon conducting a sensitivity analysis and removing the studies by Biecker et al.,²² Bhattacharyya et al.,²¹ Wada et al.,³⁸ Quach et al.,⁴⁸ and Rees et al.,³² the heterogeneity was reduced to I²=32% (MD, 0.23; 95% CI, 0.15–0.31; p<0.00001; I²=32%) (Supplementary Fig. 11).

The pooled analysis revealed that the MAPP detected was significantly higher in patients who underwent EV-assisted colonoscopies than in those who underwent standard colonoscopies (MD, 0.19 [0.10–0.28]; p<0.0001; I²=96%) (Supplementary Fig. 12). Upon conducting a sensitivity analysis, and excluding studies by Hass et al.,²⁹ Quach et al.,⁴⁸ and Rees et al.,³² the heterogeneity decreased to 12% (MD, 0.21 [0.16–0.26]; p<0.00001; I²=12%) (Supplementary Fig. 13).

7) Risk of bias and quality assessment

The risk of bias assessment for RCTs was conducted using the Cochrane RoB 2 tool (Supplementary Fig. 14), whereas the quality of observational studies was evaluated using the Newcastle-Ottawa scale (Supplementary Table 2).⁴²^,⁴³ The assessment revealed a moderate risk of bias in the included studies (higher in domains 2 and 4), which could be attributed to the operator-dependent nature of colonoscopies. The lack of double blinding in most included studies further added to the risk of observer bias. Visual inspection of the funnel plot revealed a symmetrical distribution of studies around the vertical line representing the pooled effect estimate, suggesting a low risk of publication bias. This observation was supported by Begg’s test, which yielded a p-value of 0.42, indicating that the publication bias was not significant. The certainty of the evidence was assessed using the GRADE approach (Supplementary Table 3).

DISCUSSION

This meta-analysis presents an updated and thorough assessment of the efficacy of EV-assisted colonoscopy compared to standard colonoscopy, including the latest RCTs and data from observational studies. We expanded on previous studies by including a substantially larger patient population. Our findings show that EV-assisted colonoscopy markedly improves the ADR and several other critical detection parameters compared with standard colonoscopies, while also identifying areas where the advantages are less evident. Our updated meta-analysis also demonstrated a statistically significant improvement in the RSLDR and MPPP with EV-assisted colonoscopy, a finding not observed in previously published reviews.

Patients who underwent EV-assisted procedures showed a 14% significant improvement in ADRs. This emphasizes how the EV device (Fig. 6) may enhance mucosal visualization by mechanically manipulating the intestinal folds.⁴⁴^,⁵⁰ Consequently, adenomatous lesions that generally go unnoticed during standard colonoscopy can be identified. A meta-analysis conducted by Aziz et al.⁵¹ evaluated a newer EV device in comparison with the original Endocuff and high-definition colonoscopy for improving ADR and PDR. They analyzed data from 12 RCTs with 8,638 patients, and the results showed that EV did not significantly enhance the ADR compared to standard colonoscopy. This may be attributed to several factors affecting the device's capacity to identify adenomas, such as variability in user experience and patient-specific characteristics, such as colonic anatomy.⁵²

The PDR and SSLDR, which were significantly higher in the EV group, corresponded to the improved visibility offered by the EV device, which aids in identifying both adenomatous and non-adenomatous polyps.⁵³ For example, sessile serrated lesions are particularly challenging to detect owing to their flat morphology and subtle appearance. The enhanced mucosal exposure provided by the EV may facilitate the identification of these lesions, which are essential precursors of the serrated pathway of colorectal carcinogenesis.⁵⁴^,⁵⁵

Similar to the results of a recent study by Wang et al.,⁹ our study demonstrated a notable enhancement in the identification of LSLDR using EV-assisted colonoscopy. However, our findings differ significantly from those of Wang et al. in terms of the RSLDR, which showed significant improvement in patients who underwent EV-assisted colonoscopies compared to those who underwent standard colonoscopies. The colon, which is characterized by its complex structure and numerous angulations, poses difficulties in lesion identification.⁵⁶ The EV device's capacity to evert the intestinal folds and improve vision is very beneficial.⁵⁷

Our analysis showed that the AADR did not differ significantly between the EV-assisted and standard colonoscopy groups. Advanced adenomas are larger lesions with higher malignant potential, and their detection is crucial for effective CRC prevention.⁵⁷ The lack of significant improvement in the AADR may be due to several factors; for example, advanced adenomas are generally larger and more protrusive, making them easier to detect without the need for enhanced visualization.⁵²^,⁵⁷

The improved visualization features of EV devices provide a more comprehensive assessment and identification of various lesions, potentially affecting patient care and monitoring regimens.⁵²^,⁵⁶ For example, if more lesions are detected, physicians can recommend more aggressive treatments, additional follow-up procedures, or closer monitoring of the patient's health. The increased MAPP and MPPP suggest that EV-assisted colonoscopy not only detects more patients with lesions but also identifies multiple lesions within the same patient. This was evident in our analysis of the MPPP and the MAPP rates, as our results revealed significantly higher numbers in the EV group.

Our analysis showed that the IIR was significantly lower in the EV group. This may be because the distal attachment of the EV device interferes with its passage through the ileocecal valve, which requires precise maneuvering.⁵⁸ Although ileal intubation is not a routine requirement in screening colonoscopies, it is crucial in certain clinical contexts, such as suspected inflammatory bowel disease.⁵⁸ Therefore, endoscopists should be aware of these limitations when using the EV device.

Additionally, our analysis revealed an increase in the occurrence of AEs associated with EV-assisted colonoscopy, including mucosal abrasions, mild hemorrhage, and patient discomfort, reported most frequently. These mild risks may be attributed to the mechanical interaction of the EV device's arms with the colonic mucosa, particularly in regions with diverticulosis or delicate mucosa.⁵²^,⁵⁷

Finally, the use of the EV device did not significantly alter the withdrawal time compared to standard colonoscopy techniques. Although withdrawal time is a key quality indicator in colonoscopies, the primary aim of the EV device is to improve the ADR rather than influence procedural timing.⁷^,⁵⁵ Our findings support the notion that incorporating the EV device into routine practice does not compromise procedural efficiency, making it a feasible tool for enhancing CRC screening.

The strengths of this meta-analysis include its large sample size, drawn from multiple RCTs, which significantly enhanced the robustness of the results compared to a previously published review. Moreover, the inclusion of the latest trials in our meta-analysis pool also suggested that EV-assisted colonoscopy was superior to standard colonoscopy in terms of RSLDRs and MPPP detection rates, which was not a feature of the previous meta-analysis. However, several limitations should be acknowledged when interpreting these results. First, bowel preparation quality was inadequately documented using various rating methods in the included trials. Second, high heterogeneity was observed in some outcomes, such as ADRs and procedural times, indicating variability among the included studies. Factors contributing to this heterogeneity include differences in study design, patient population, and endoscopist expertise. However, we conducted a sensitivity analysis to confirm our findings. Third, the endoscopists in both cohorts were not blinded (a practice typical of most endoscopic investigations aimed at evaluating external attachments), which increased the risk of performance and detection bias. Endoscopists assigned to the external attachment group might have subconsciously tried harder to detect lesions, which would translate into exaggerated observed effect sizes. Additionally, concerns regarding the completeness of the outcomes introduce reporting bias. These biases should be carefully considered when interpreting the magnitude and generalizability of the pooled effect estimates. Nonetheless, our findings show that EV-assisted colonoscopy is superior to standard colonoscopy because it improves mucosal visualization and lesion detection, particularly in the proximal colon, where standard colonoscopy often fails. Given the strong correlation between ADR and long-term CRC outcomes, integrating EV into routine screening practices will enable the earlier detection and removal of precancerous lesions, thereby lowering CRC-related morbidity and mortality.

In conclusion, our review indicates that EV-assisted colonoscopy improves ADRs and PDRs compared to standard colonoscopy, especially in challenging regions, such as the left and right colon. The occurrence of minor AEs and the absence of substantial enhancement in the identification of advanced adenomas highlight areas that require further investigation. Nevertheless, EV-assisted colonoscopy may be a valuable tool to increase CRC screening rates.

Supplementary Material

Supplementary Table 1. Search strategy.

ce-2025-163-Supplementary-Table-1.pdf

Supplementary Table 2. Risk of bias in observation studies using the Newcastle-Ottawa scale.

ce-2025-163-Supplementary-Table-2.pdf

Supplementary Table 3. Summary of findings and evaluation of certainty in evidence using the GRADE approach.

ce-2025-163-Supplementary-Table-3.pdf

Supplementary Fig. 1. Funnel plot showing the risk of publication bias. SE, standard error; RR, risk ratio; RCT, randomized controlled trial.

ce-2025-163-Supplementary-Fig-1.pdf

Supplementary Fig. 2. Forest plot showing sensitivity analysis of adenoma detection rate. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-2.pdf

Supplementary Fig. 3. Forest plot showing sensitivity analysis of polyp detection rate. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-3.pdf

Supplementary Fig. 4. Forest plot showing sensitivity analysis of incidence of adverse events. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-4.pdf

Supplementary Fig. 5. Forest plot showing advanced adenoma detection rate. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-5.pdf

Supplementary Fig. 6. Forest plot showing sessile serrated lesion detection rate. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-6.pdf

Supplementary Fig. 7. Forest plot showing left-sided lesion detection rate. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-7.pdf

Supplementary Fig. 8. Forest plot showing right-sided lesion detection rate. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-8.pdf

Supplementary Fig. 9. Forest plot showing sensitivity analysis of ileal intubation rate. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-9.pdf

Supplementary Fig. 10. Forest plot showing mean number of polyps per patient. EV, Endocuff Vision; SD, standard deviation; IV, intravenous; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-10.pdf

Supplementary Fig. 11. Forest plot showing sensitivity analysis for mean number of polyps per patient. EV, Endocuff Vision; SD, standard deviation; IV, intravenous; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-11.pdf

Supplementary Fig. 12. Forest plot showing mean number of adenomas per patient. EV, Endocuff Vision; SD, standard deviation; IV, intravenous; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-12.pdf

Supplementary Fig. 13. Forest plot showing sensitivity analysis of the mean number of adenomas per patient. EV, Endocuff Vision; SD, standard deviation; IV, intravenous; CI, confidence interval; df, degree of freedom.

ce-2025-163-Supplementary-Fig-13.pdf

Supplementary Fig. 14. (A) Cochrane Risk of bias graph and (B) summary.

ce-2025-163-Supplementary-Fig-14.pdf

Supplementary materials related to this article can be found online at https://doi.org/10.5946/ce.2025.163.

Ethical Statements

Not applicable.

Conflicts of Interest

The authors have no potential conflicts of interest.

Funding

None.

Author Contributions

Conceptualization: AAK, FH; Data curation: MDMM, MU, KUEM, MUB, MT, HI, RMMB, KZ, FW, ASK, DAG; Formal analysis: AAK, MU, KUEM, MUB; Investigation: AAK, FH, MDMM, HI, RMMB; Methodology: AAK, FH; Project administration: AAK, FH, MDMM; Resources: FH, MDMM, HI, DAG; Software: AAK, MU, MT; Supervision: AAK, FH, CT, AI; Validation: AAK, FH, MU, RMMB, KZ; Visualization: AAK, MU; Writing – original draft: AAK, FH, MDMM, KUEM, MUB; Writing – review & editing: AAK, FH, MDMM, KUEM, CT.

Fig. 1.

Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram.

Fig. 2.

(A) Forest plot showing adenoma detection rate. (B) Forest plot showing polyp detection rate. (C) Forest plot showing incidence of adverse events. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

Fig. 3.

(A) Forest plot showing cecal intubation rate. (B) Forest plot showing ileal intubation. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

Fig. 4.

Forest plot showing cecal intubation time. EV, Endocuff Vision; SD, standard deviation; IV, intravenous; CI, confidence interval; df, degree of freedom.

Fig. 5.

Forest plot showing withdrawal time. EV, Endocuff Vision; SD, standard deviation; IV, intravenous; CI, confidence interval; df, degree of freedom.

Fig. 6.

(A) Photograph taken in person and featured in the open-access article by Ngu et al.⁵ showing the EV device. This picture was annotated to highlight key components of the device. Adapted from Ngu, et al. Gut 2019;68:280–288, according to the Creative Commons license.⁵ More information on the EV device can be obtained from the official supplier’s online brochure.⁵⁰ (B) Schematic diagram showing literature search and allocation of patients to each colonoscopic modality.

Table 1.

Characteristics of included studies

Study	Study design	Country	Year	Study period	Device	Center	No. of patients		Mean age (y)		Gender (man %)
Study	Study design	Country	Year	Study period	Device	Center	EVC	SC	EVC	SC	EVC	SC
Ngu et al.⁵	RCT	UK	2019	2014–2016	Endocuff Vision	7	888	884	61.7	62.1	57.1	56.8
Sherif Naguib et al.¹³	RCT, crossover	Egypt	2024	2018–2020	Endocuff Vision	1	214	214	NA	NA	NA	NA
Karsenti et al.¹⁴	RCT	France	2020	2017–2018	Endocuff Vision	1	1026	1032	59.25	57.4	47.4	49
van Keulen et al.¹⁵	RCT, crossover	USA, Italy, The Netherlands, Germany, Hong Kong, Greece	2024	2017–2020	Endocuff Vision	10	660	656	61.5	61.3	48.2	47.1
Aniwan et al.²⁰	RCT	Thailand	2021	2019–2020	Endocuff Vision	1	250	250	61.1	61.1	34.4	33.2
Bhattacharyya et al.²¹	RCT	UK	2017	2015–2016	Endocuff Vision	1	266	265	68	67	60.9	67.9
Biecker et al.²²	RCT	Germany	2015	2013.2–2013.8	Endocuff	2	245	253	65	68	48.2	51.8
Catalano et al.²³	RCT	USA	2017	NA	Endocuff	Multi-center	809	764	NA	NA	NA	NA
Cattau et al.²⁴	RCT	USA	2015	2015.1–2015.5	Endocuff	3	329	329	58	NA	48.2	NA
Ferreira et al.²⁵	RCT	Portugal	2022	2018–2019	Endocuff Vision	1	81	89	62.4	NA	57.4	NA
Floer et al.²⁶	RCT	Germany	2014	2014.2–2014.7	Endocuff	4	249	243	64	63	49	44.9
Floer et al.²⁷	RCT	Germany and Poland	2021	2015.1–2017.12	Endocuff	2	189	195	62	63	49.7	45.6
González-Fernández et al.²⁸	RCT	Mexico	2017	2014–2015	Endocuff	1	174	163	60	62	29	24
Hass et al.²⁹	RCT	USA	2016	NA	Endocuff	1	281	281	NA	NA	NA	NA
Jacob et al.³⁰	RCT	Australia	2019	2016–2017	Endocuff Vision	1	182	138	NA	NA	56.7	59.3
Marsano et al.³¹	RCT	USA	2019	2016.3–2017.1	Endocuff	1	42	42	60	59.3	54.8	54.8
Rees et al.³²	RCT	UK	2020	2017–2018	Endocuff Vision	16	1610	1612	55	55	53	53
Rex et al.³³	RCT	USA and Italy	2018	NA	Endocuff	3	299	295	63.2	62.6	53	53
Rex et al.³⁴	RCT	USA	2020	2017–2018	Endocuff Vision	2	101	99	62.7	61.7	56.4	42.4
Rivero-Sánchez et al. ³⁵	RCT	Spain	2019	2015–2017	Endocuff Vision	4	62	60	61.2	60.2	68	52
van Doorn et al.³⁶	RCT	The Netherlands	2017	2013–2014	Endocuff	5	530	533	65	65	50	54
Vanduangden et al.³⁷	RCT	Thailand	2020	NA	Endocuff Vision	1	200	204	NA	NA	NA	NA
Wada et al.³⁸	RCT	Japan	2018	2015.4–2015.9	Endocuff	2	239	238	61.2	62.2	51	48.3
Zorzi et al.³⁹	RCT	Italy	2022	2021	Endocuff Vision	13	908	905	60.2	60.1	53.7	53.8
Desai et al.⁴⁰	RCT	USA	2022	2018.3–2022.6	Endocuff Vision	3	379	379	62.1	62	80.5	81.3
Aniwan et al.⁴¹	RCT	Thailand	2023	2020–2022	Endocuff	1	315	310	62.1	62	33.33	42.9
Forbes et al.⁴²	Observational study	Canada	2021	2018–2019	Endocuff Vision	1	6,141	9,673	57.5	57.5	53.7	52.5
Calita et al.⁴³	Observational study	Romania	2021	2018	Endocuff	1	128	837	60.2	55.4	50, 3	49, 61
Jaensch et al.⁴⁴	RCT	Denmark	2022	2017–2018	Endocuff Vision	1	588	590	63	63.3	61.2	57.6
Abdelbary et al.⁴⁵	RCT	Egypt	2021	2017–2018	Endocuff	1	700	716	61.1	61.1	49.3	47.1
Zimmermann-Fraedrich et al.⁴⁶	RCT	Germany	2023	2017–2020	Endocuff Vision	2	700	716	61.1	61.1	49.3	47.1
Spadaccini et al.⁴⁷	RCT	Italy and Switzerland	2023	2021.7–2022.5	Endocuff Vision	6	618	618	61.5	61.3	48.2	47.1
Quach et al.⁴⁸	RCT	Vietnam	2025	2022–2023	Endocuff Vision	1	241	235	51.2	52.0	45.6	38.7
von Figura et al.⁴⁹	RCT	Germany	2020	NA	Endocuff Vision	1	118	122	63.6	65.3	51.7	62.3

EVC, Endocuff Vision colonoscopy; SC, standard colonoscopy; RCT, randomized controlled trial; UK, United Kingdom; NA, not applicable; USA, United States of America.

Table 2.

Summary of outcomes in the included studies

Serial no.	Outcome	No. of studies	EV %	SC %	Effect size (95% CI)	p-value	I² (%)
1	ADR	30 RCTs	41.5	36	1.16 (1.09–1.22)	<0.0001	65
2		2 Observational studies	46.6	54.2	1.05 (0.65–1.71)	0.84	82
3	AADR	12 RCTs	10.3	10.7	1.03 (0.92–1.15)	0.59	38
4	PDR	19 RCTs+1 observational study	50.6	44.5	1.16 (1.10–1.23)	<0.0001	65
5	SSLDR	15 RCTs	7.03	6.1	1.15 (1.03–1.30)	0.02	0
6	LSLDR	8 RCTs	26.4	21.4	1.23 (1.11–1.35)	<0.0001	30
7	RSLDR	11 RCTs	31.0	26.4	1.19 (1.09–1.29)	<0.0001	42
8	Cecal intubation rate	12 RCTs	98.3	98.2	1 (1.00–1.00)	0.62	0
9	Ileal intubation rate	7 RCTs	48.6	56.4	0.89 (0.80–0.99)	0.04	78
10	Cecal intubation time	15 RCTs+1 observational study	-	-	–0.28 (–0.83 to 0.27)	0.31	95
		2 Crossover RCTs	-	-	–0.56 (–0.92 to –0.19)	0.003	0
11	Withdrawal time	18 RCTs	-	-	–0.34 (–0.85 to 0.17)	0.19	98
		2 Crossover RCTs	-	-	–0.28 (–0.46 to –0.10)	0.002	0
		2 Observational studies	-	-	0.26 (–1.70 to 2.22)	0.79	96
12	MAPP	14 RCTs	-	-	0.19 (0.10–0.28)	<0.0001	96
13	MPPP	11 RCTs+1 observational study	-	-	0.29 (0.17–0.40)	<0.0001	98
14	Adverse events	16 RCTs	1.59	0.49	2.60 (1.29–5.26)	0.008	51

EV, Endocuff Vision; SC, standard colonoscopy; CI, confidence interval; ADR, adenoma detection rate; RCT, randomized controlled trial; AADR, advanced adenoma detection rate; PDR, polyp detection rate; SSLDR, sessile serrated lesion detection rate; LSLDR, left-sided lesion detection rate; RSLDR, right-sided lesion detection rate; MAPP, mean number of adenomas per patient; MPPP, mean number of polyps per patient; -, event rates (%) do not apply to continuous outcomes.

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Enhanced adenoma detection with Endocuff Vision: a GRADE assessed systematic review and meta-analysis

Clin Endosc. 2026;59(3):371-385. Published online February 2, 2026

DOI: https://doi.org/10.5946/ce.2025.163

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Enhanced adenoma detection with Endocuff Vision: a GRADE assessed systematic review and meta-analysis

Fig. 1. Preferred Reporting Items for Systematic Reviews and Meta-Analysis flow diagram.

Fig. 2. (A) Forest plot showing adenoma detection rate. (B) Forest plot showing polyp detection rate. (C) Forest plot showing incidence of adverse events. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

Fig. 3. (A) Forest plot showing cecal intubation rate. (B) Forest plot showing ileal intubation. EV, Endocuff Vision; M-H, Mantel-Haenszel; CI, confidence interval; df, degree of freedom.

Fig. 4. Forest plot showing cecal intubation time. EV, Endocuff Vision; SD, standard deviation; IV, intravenous; CI, confidence interval; df, degree of freedom.

Fig. 5. Forest plot showing withdrawal time. EV, Endocuff Vision; SD, standard deviation; IV, intravenous; CI, confidence interval; df, degree of freedom.

Fig. 6. (A) Photograph taken in person and featured in the open-access article by Ngu et al.5 showing the EV device. This picture was annotated to highlight key components of the device. Adapted from Ngu, et al. Gut 2019;68:280–288, according to the Creative Commons license.5 More information on the EV device can be obtained from the official supplier’s online brochure.50 (B) Schematic diagram showing literature search and allocation of patients to each colonoscopic modality.

Graphical abstract

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Fig. 2.

Fig. 3.

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Graphical abstract

Enhanced adenoma detection with Endocuff Vision: a GRADE assessed systematic review and meta-analysis

Study	Study design	Country	Year	Study period	Device	Center	No. of patients		Mean age (y)		Gender (man %)
Study	Study design	Country	Year	Study period	Device	Center	EVC	SC	EVC	SC	EVC	SC
Ngu et al.5	RCT	UK	2019	2014–2016	Endocuff Vision	7	888	884	61.7	62.1	57.1	56.8
Sherif Naguib et al.13	RCT, crossover	Egypt	2024	2018–2020	Endocuff Vision	1	214	214	NA	NA	NA	NA
Karsenti et al.14	RCT	France	2020	2017–2018	Endocuff Vision	1	1026	1032	59.25	57.4	47.4	49
van Keulen et al.15	RCT, crossover	USA, Italy, The Netherlands, Germany, Hong Kong, Greece	2024	2017–2020	Endocuff Vision	10	660	656	61.5	61.3	48.2	47.1
Aniwan et al.20	RCT	Thailand	2021	2019–2020	Endocuff Vision	1	250	250	61.1	61.1	34.4	33.2
Bhattacharyya et al.21	RCT	UK	2017	2015–2016	Endocuff Vision	1	266	265	68	67	60.9	67.9
Biecker et al.22	RCT	Germany	2015	2013.2–2013.8	Endocuff	2	245	253	65	68	48.2	51.8
Catalano et al.23	RCT	USA	2017	NA	Endocuff	Multi-center	809	764	NA	NA	NA	NA
Cattau et al.24	RCT	USA	2015	2015.1–2015.5	Endocuff	3	329	329	58	NA	48.2	NA
Ferreira et al.25	RCT	Portugal	2022	2018–2019	Endocuff Vision	1	81	89	62.4	NA	57.4	NA
Floer et al.26	RCT	Germany	2014	2014.2–2014.7	Endocuff	4	249	243	64	63	49	44.9
Floer et al.27	RCT	Germany and Poland	2021	2015.1–2017.12	Endocuff	2	189	195	62	63	49.7	45.6
González-Fernández et al.28	RCT	Mexico	2017	2014–2015	Endocuff	1	174	163	60	62	29	24
Hass et al.29	RCT	USA	2016	NA	Endocuff	1	281	281	NA	NA	NA	NA
Jacob et al.30	RCT	Australia	2019	2016–2017	Endocuff Vision	1	182	138	NA	NA	56.7	59.3
Marsano et al.31	RCT	USA	2019	2016.3–2017.1	Endocuff	1	42	42	60	59.3	54.8	54.8
Rees et al.32	RCT	UK	2020	2017–2018	Endocuff Vision	16	1610	1612	55	55	53	53
Rex et al.33	RCT	USA and Italy	2018	NA	Endocuff	3	299	295	63.2	62.6	53	53
Rex et al.34	RCT	USA	2020	2017–2018	Endocuff Vision	2	101	99	62.7	61.7	56.4	42.4
Rivero-Sánchez et al. 35	RCT	Spain	2019	2015–2017	Endocuff Vision	4	62	60	61.2	60.2	68	52
van Doorn et al.36	RCT	The Netherlands	2017	2013–2014	Endocuff	5	530	533	65	65	50	54
Vanduangden et al.37	RCT	Thailand	2020	NA	Endocuff Vision	1	200	204	NA	NA	NA	NA
Wada et al.38	RCT	Japan	2018	2015.4–2015.9	Endocuff	2	239	238	61.2	62.2	51	48.3
Zorzi et al.39	RCT	Italy	2022	2021	Endocuff Vision	13	908	905	60.2	60.1	53.7	53.8
Desai et al.40	RCT	USA	2022	2018.3–2022.6	Endocuff Vision	3	379	379	62.1	62	80.5	81.3
Aniwan et al.41	RCT	Thailand	2023	2020–2022	Endocuff	1	315	310	62.1	62	33.33	42.9
Forbes et al.42	Observational study	Canada	2021	2018–2019	Endocuff Vision	1	6,141	9,673	57.5	57.5	53.7	52.5
Calita et al.43	Observational study	Romania	2021	2018	Endocuff	1	128	837	60.2	55.4	50, 3	49, 61
Jaensch et al.44	RCT	Denmark	2022	2017–2018	Endocuff Vision	1	588	590	63	63.3	61.2	57.6
Abdelbary et al.45	RCT	Egypt	2021	2017–2018	Endocuff	1	700	716	61.1	61.1	49.3	47.1
Zimmermann-Fraedrich et al.46	RCT	Germany	2023	2017–2020	Endocuff Vision	2	700	716	61.1	61.1	49.3	47.1
Spadaccini et al.47	RCT	Italy and Switzerland	2023	2021.7–2022.5	Endocuff Vision	6	618	618	61.5	61.3	48.2	47.1
Quach et al.48	RCT	Vietnam	2025	2022–2023	Endocuff Vision	1	241	235	51.2	52.0	45.6	38.7
von Figura et al.49	RCT	Germany	2020	NA	Endocuff Vision	1	118	122	63.6	65.3	51.7	62.3

Serial no.	Outcome	No. of studies	EV %	SC %	Effect size (95% CI)	p-value	I² (%)
1	ADR	30 RCTs	41.5	36	1.16 (1.09–1.22)	<0.0001	65
2		2 Observational studies	46.6	54.2	1.05 (0.65–1.71)	0.84	82
3	AADR	12 RCTs	10.3	10.7	1.03 (0.92–1.15)	0.59	38
4	PDR	19 RCTs+1 observational study	50.6	44.5	1.16 (1.10–1.23)	<0.0001	65
5	SSLDR	15 RCTs	7.03	6.1	1.15 (1.03–1.30)	0.02	0
6	LSLDR	8 RCTs	26.4	21.4	1.23 (1.11–1.35)	<0.0001	30
7	RSLDR	11 RCTs	31.0	26.4	1.19 (1.09–1.29)	<0.0001	42
8	Cecal intubation rate	12 RCTs	98.3	98.2	1 (1.00–1.00)	0.62	0
9	Ileal intubation rate	7 RCTs	48.6	56.4	0.89 (0.80–0.99)	0.04	78
10	Cecal intubation time	15 RCTs+1 observational study	-	-	–0.28 (–0.83 to 0.27)	0.31	95
		2 Crossover RCTs	-	-	–0.56 (–0.92 to –0.19)	0.003	0
11	Withdrawal time	18 RCTs	-	-	–0.34 (–0.85 to 0.17)	0.19	98
		2 Crossover RCTs	-	-	–0.28 (–0.46 to –0.10)	0.002	0
		2 Observational studies	-	-	0.26 (–1.70 to 2.22)	0.79	96
12	MAPP	14 RCTs	-	-	0.19 (0.10–0.28)	<0.0001	96
13	MPPP	11 RCTs+1 observational study	-	-	0.29 (0.17–0.40)	<0.0001	98
14	Adverse events	16 RCTs	1.59	0.49	2.60 (1.29–5.26)	0.008	51

Table 1. Characteristics of included studies

EVC, Endocuff Vision colonoscopy; SC, standard colonoscopy; RCT, randomized controlled trial; UK, United Kingdom; NA, not applicable; USA, United States of America.

Table 2. Summary of outcomes in the included studies