Efficacy of image-enhanced endoscopy for colorectal polyp detection

Reo Kobayashi; Naohisa Yoshida; Ken Inoue

doi:10.5946/ce.2025.221

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Review Efficacy of image-enhanced endoscopy for colorectal polyp detection: Reo Kobayashi, Naohisa Yoshida, Ken Inoue; Clinical Endoscopy 2026;59(4):485-496.
DOI: https://doi.org/10.5946/ce.2025.221
Published online: March 3, 2026

Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, Kyoto, Japan

Correspondence: Naohisa Yoshida Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, Graduate School of Medical Science, 465 Kajii-cho, Kawaramachi-Hirokoji, Kamigyo-ku, Kyoto 602-8566, Japan E-mail: naohisa@koto.kpu-m.ac.jp

• Received: July 9, 2025 • Revised: August 9, 2025 • Accepted: August 10, 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
INTRODUCTION
PRINCIPLES OF NBI AND TXI AND IMPROVEMENT OF THE ENDOSCOPY SYSTEM
TUMOR DETECTION WITH NBI AND TXI
DIAGNOSIS OF ABILITIES OF TUMORS WITH IEE
PRINCIPLES OF BLI/LCI AND THEIR USEFULNESS IN DETECTING AND DIAGNOSING TUMORS
CONCLUSIONS
NOTES
REFERENCES

Abstract

Colonoscopy plays a key role in reducing the incidence and mortality of colorectal cancer by detecting precancerous lesions, such as adenomas. Image-enhanced endoscopy (IEE) has been reported to effectively improve lesion detection and characterization in many cases. With the development of new endoscopic instruments, the IEE technology is rapidly advancing, and new endoscopes using light-emitting diode light sources, in addition to xenon and laser light sources, have been introduced, and various types of IEEs are used. Several observational methods have been validated for detecting and preventing missed lesions, such as narrow-band imaging (NBI), blue laser/light imaging (BLI), linked color imaging, and texture and color enhancement imaging, which have been suggested to be more effective than white light observation. The Japan NBI Expert Team classification, a unified classification of NBI magnification developed in Japan, can be used alongside NBI and BLI magnification to evaluate surface and vessel patterns and diagnose lesions. In this review, we describe the usefulness of each IEE with reference to the latest data.
Keywords: Blue laser imaging; Blue light imaging; Image-enhanced endoscopy; Linked color imaging; Narrow-band imaging

INTRODUCTION

Colorectal cancer (CRC) ranked third in cancer morbidity and second in cancer mortality worldwide in 2020.¹ In South Korea, CRC ranked second in cancer morbidity in 2021, with 32,751 cases, and third in cancer mortality, with 8,902 deaths.² Colonoscopy plays a key role in reducing CRC mortality; an increase in the adenoma detection rate (ADR) by approximately 1% leads to a 3% reduction in CRC incidence.³ Furthermore, polypectomy has been reported to reduce CRC-related mortality by 53%.⁴ As the population ages, CRC-related deaths are expected to increase, making the early detection and treatment of lesions by colonoscopy increasingly important.

Colonoscopy is usually performed using white-light imaging (WLI). However, a meta-analysis of 43 studies showed that the adenoma miss rate in patients who underwent WLI observation during colonoscopy was 26% (95% confidence interval [CI], 23%–30%).⁵ Various methods have been reported to prevent missed lesions, including repeated observation, retroflex observation, and the use of a hood. In addition to these approaches, many studies have been conducted worldwide on the use of image-enhanced endoscopy (IEE) to improve lesion detection.⁶^,⁷ Narrow-band imaging (NBI) was launched in 2006, followed by blue laser imaging using light amplification by stimulated emission of radiation (BLI/LASER) endoscopy in 2012. Their effectiveness in tumor detection has been verified and reported.⁸^-¹⁵ Blue light imaging using light-emitting diode (BLI/LED) endoscopy was developed in 2016, followed by linked color imaging (LCI) in 2017 and texture and color enhancement imaging (TXI) in 2020. All IEEs have been reported to improve tumor detection.¹⁶^-³⁵

Additionally, IEE plays an important role in tumor diagnosis. Tumor diagnosis using WLI has limitations, whereas diagnosis using NBI and BLI/LASER and LED has already become popular worldwide.³⁶^-⁵¹ This review discusses the current status and future challenges of IEE.

PRINCIPLES OF NBI AND TXI AND IMPROVEMENT OF THE ENDOSCOPY SYSTEM

NBI is a narrow-band light observation mode developed and reported for colonoscopic use in 2005 by Sano and Muto,¹⁰ along with Olympus Co., to enhance lesion detection and diagnosis. The principle is that the spectral characteristics of a xenon light source endoscope can be altered to emit two narrow-band wavelengths (415 nm and 540 nm)—the absorption wavelengths of oxygenated hemoglobin—by using a specialized filter. This enables visualization of the mucosal surface structures and blood vessels. Consequently, NBI is now widely used worldwide to detect colorectal tumors and improve diagnostic quality. Initially, the LUCERA SPECTRUM (LUCERA EVIS 260 series; Olympus Co.) with a sequential imaging scope and EXERA II (EXERA 180 series; Olympus Co.) with a simultaneous imaging scope were introduced as the first generation of NBI.⁵²^,⁵³ In 2012, new systems, such as the second-generation EVIS LUCERA ELITE SYSTEM (Olympus Co.) and EVIS EXERA III, were developed, offering greater brightness and higher resolution than before. A 170° wide field-of-view function became standard, along with a dual focus function.⁵⁴ In July 2020, a new endoscope system, EVIS X1 (CV-1500; Olympus Co.), was introduced, featuring a 170° wide field-of-view angle function as standard equipment and a dual focus function. This system uses a LED light source instead of the previous xenon light source. It employs five LED light sources (violet, blue, green, amber, and red) and enables simultaneous imaging (CF-EZ1500D; Olympus Co.) with minimal color shift. It also supports plane sequential imaging (CF-XZ-1200, scope for colonoscopy; Olympus Co.) as previously described. In terms of IEE, NBI offers greater brightness and higher resolution, and a new mode, TXI, has been introduced.²⁸^,²⁹

TXI is designed to enhance three image factors—texture, brightness, and color—using image-processing techniques based on retinex theory.⁵⁵^,⁵⁶ There are two types of TXI: TXI mode 1, which emphasizes unevenness, brightness, and color, and mode 2, which emphasizes unevenness and brightness. TXI mode 2 does not include color enhancement; therefore, its image is more similar to the color tone of WLI observations than those of mode 1.

TUMOR DETECTION WITH NBI AND TXI

Although the first generation of NBI improved lesion visibility, the screen appeared dark, the resolution was insufficient, and there were various reports on its usefulness in detecting lesions (Table 1, Fig. 1).⁵⁷^-⁶⁷ The next-generation EVIS LUCERA ELITE SYSTEM and EVIS EXERA III provided a brighter, wider view, higher image quality, and improved visibility of polyps in NBI compared with WLI (Fig. 2).⁶⁸ Regarding detection rates, a randomized controlled trial (RCT) by Leung et al.⁶⁹ showed an improved ADR for NBI compared with WLI (NBI vs. WLI, 48.3% vs. 34.4%; 95% CI, 3.7–23.7; p=0.01). Another RCT comparing NBI with LCI reported that NBI had higher polyp detection rates (PDR) and serrated lesion detection (SLDR) rates (NBI vs. LCI, PDR: 71.3% vs. 55.9%; SLDR: 34.6% vs. 22.1%; p=0.008 and 0.05, respectively), despite a longer withdrawal time.⁷⁰ Furthermore, the detection rates of NBI and LCI were similar in the patients with poor bowel preparation (Boston bowel preparation scale ≤6), however a meta-analysis also reported that NBI was more effective than WLI in terms of ADR, with 1.30 (95% CI, 1.04–1.62, p=0.04) in the group whose bowel preparations were good (Table 2).⁶⁷^,⁷¹^-⁷⁷ NBI has also been reported to be effective in detecting flat and depressed lesions, as well as in preventing missed non-adenomatous lesions.⁷⁵^,⁷⁶

However, NBI has the disadvantage that residual fluid appears reddish, and the endoscopic screen becomes dark if bowel preparation is inadequate. Therefore, we previously developed a method of performing an additional 30-second NBI observation after WLI observation in the cecum and ascending colon to assess for polyps that were not detected during the initial observation.⁷⁴ The second NBI observation, performed after fluid and residue aspiration, significantly increased the number of adenomas detected by 35.7% compared with the first WLI observation, and the ADR increased by 3.9%.

In the third generation of NBI with EVIS X1, introduced in 2020, further increases in brightness and better lesion visibility were reported (Figs. 3, 4).²⁸^,²⁹^,⁷⁸

Several reports on TXI have demonstrated improved visibility in esophageal and gastric cancers.⁷⁹^-⁸¹ Unlike NBI, the residual fluid appears yellow, and bright endoscopic images can be obtained even in cases of insufficient bowel preparation during colonoscopy. We previously analyzed the endoscopist’s polyp visibility scores and color difference (CD) values in each of the three modes for 101 lesions observed using WLI, TXI, and NBI. TXI was significantly better than WLI in both polyp visibility score and CD values compared to WLI (polyp visibility score: TXI vs. WLI, 3.42 vs. 2.85; p<0.001) (CD value, TXI vs. WLI, 13.3±6.3 vs. 9.7±6.0; p<0.001).²⁸ Other reports have also demonstrated improved polyp visibility scores and CD values.⁷⁸^,⁸²^-⁸⁴ This superior visibility has also been reported to contribute to improved lesion detection (Table 3).²⁹^-³⁵ In a meta-analysis of three studies, TXI showed a higher ADR than WLI (TXI vs. WLI, 57.8% vs. 43.6%; relative risk [RR], 1.32; 95% CI, 1.20–1.46; p<0.001; I²=0%).³² We reviewed 515 patients who underwent colonoscopy with additional 30-second observation of the right-sided colon, and found TXI observation increased right-sided ADR and Adenoma and sessile serrated lesion (SSL) detection rate (ASDR) by 7.4% and 9.5% (p<0.01).³⁵ However, an RCT reported from Japan showed no improvement in ADR with TXI compared with WLI (57.2% vs. 56.0%; p=0.705). It only demonstrated a higher PDR for TXI than for WLI, particularly for flat lesions (76.5% vs. 70.3%, p=0.036).³³

We also compared the lesion detection abilities of NBI and TXI in a multicenter RCT using an additional 30-second observation of the right-sided colon.²⁹ We reported non-inferiority in the number of adenomas and SSLs detected per patient in the second observation (TXI vs. NBI, 0.29 vs. 0.30; p<0.01).²⁹ The study also showed an additional effect on ADR of 10.2% and 10.5% for TXI and NBI, respectively.

Based on these results, to prevent polyps from being missed, tools such as TXI, in addition to WLI, should be selected according to each endoscopist’s preferences and the facility’s conditions, while taking bowel preparation and other factors into consideration.

DIAGNOSIS OF ABILITIES OF TUMORS WITH IEE

To achieve an accurate diagnosis of colorectal lesions, not only WLI but also NBI/BLI/LASER and LED, pit pattern, and endoscopic ultrasonography are recommended.⁸⁵^,⁸⁶ Magnifying endoscopic diagnosis of colorectal tumors with IEE is widely used. In 2016, the Japan NBI Expert Team (JNET) classification—a unified Japanese NBI magnification classification that considers both surface and vessel pattern findings—was developed and is now widely used.³⁶^-⁴² The JNET classification can be used with NBI and BLI/LASER and LED. The JNET classification corresponds to the histopathological findings and is useful for determining treatment strategies. JNET type 1 is characterized by surface structures with regular dark/white dots or similar to surrounding normal mucosa and blood vessels with no recognition and is histopathologically equivalent to hyperplastic polyps (HP) and SSL. JNET type 2A is defined as regular vascular and surface structures equivalent to low-grade adenomas. JNET type 2B is defined as having vascular structures of variable caliber and irregular distribution and irregular or obscure surface structures and corresponds to high-grade dysplasia and T1a cancer. JNET type 3 is defined as having either loose vessel areas, interrupted or thick vessels, or amorphous areas, and corresponds to T1b cancer. Previously, JNET type 1 had a sensitivity of 75.0%–85.7%, specificity of 89.6%–99.5% and an accuracy of 93%–98.5%; type 2A had a sensitivity of 81.5%–96.0%, specificity of 66.1%–81.9% and accuracy of 69.4%–92.0%, and type 2B had a sensitivity of 42%–75.6%, specificity of 87.0%–95.0%, and an accuracy of 87.0%–93.0%; type 3 had a sensitivity of 29.4%–50.0%, specificity of 99.3%–100.0% and an accuracy of 94.0%–99.7%.⁴³^-⁴⁶ In particular, Type 2B is recommended to be used in combination with chromoendoscopy and pit pattern classification, because it includes a variety of pathological diagnoses. However, the use of crystal violet for chromoendoscopy is not recommended by the World Health Organization and should be used in limited cases.⁸⁶

In the diagnosis of SSL, findings such as dilated vessels and expanded crypt openings (ECO) are useful in differentiating HP from SSL, as the latter is diagnosed as JNET type 1.⁴⁷^-⁵⁰ In a study evaluating the diagnostic ability of these findings in 126 polyps diagnosed as NBI International Colorectal Endoscopic (NICE) classification type 1, ECOs were defined as brownish, oval crypt openings, and thick-branched vessels (TBVs) were defined as large branching vessels on the surface of the lesions. The sensitivity, specificity, and accuracy of TBV alone were 45.1%, 68.9%, and 59.2%, respectively. The sensitivity, specificity, and accuracy of ECO alone were 84.3%, 81.1%, and 82.4%, respectively. And those of either TBV or ECO were 98.0%, 59.5%, and 75.0%, respectively.⁴⁷ We similarly examined the diagnostic ability of SSL and reported that TBV alone had a sensitivity of 84.5%, specificity of 42.6% and an accuracy of 71.4%, ECO alone had a sensitivity of 96.6%, specificity of 35.1% and an accuracy of 77.5% and either TBV or ECO had a sensitivity of 98.8%, specificity of 23.0% and an accuracy of 75.2%.⁵⁰ However, as SSL also exhibits characteristic findings on WLI and chromoendoscopy, these modalities should be considered alongside IEE findings when making a diagnosis.⁴⁹

PRINCIPLES OF BLI/LCI AND THEIR USEFULNESS IN DETECTING AND DIAGNOSING TUMORS

BLI/LASER, launched in 2012, is a narrow-band light observation mode that uses a LASER light source endoscope (LASEREO; Fujifilm Co.) to enable simultaneous imaging. The principle is that a 410 nm laser beam is used to enhance the blood vessels and mucosal structures, while a 450 nm laser beam is used to excite phosphors to ensure brightness.¹¹ BLI/LASER has two modes: the BLI mode, suitable for magnification, and the BLI-bright mode, which offers slightly higher brightness than the BLI mode and is suitable for lesion detection. Since 2016, an LED light source endoscopy system (ELUXEO; Fujifilm Co.) has been used and is currently widely used worldwide. Blue light imaging, which is narrow-band light observation using LED light, can be used in the same way as BLI/LASER for LASER endoscopy (Figs. 5, 6).¹⁴ The principle of BLI/LED is based on multi-light technology using four types of LED lights (blue-violet, blue, green, and red) to enhance visualization of blood vessels and mucosal structures, and its usefulness has been suggested for the detection of colorectal polyps and the diagnosis of the colorectal lesions. This LED endoscopy system became available in the Japanese market in 2020. Additionally, a compact tricolor LED endoscope system with an integrated processor light source (ELUXEO Lite: 6000 series, EP-6000; Fujifilm Co.) is also available, which can also perform both BLI/LED and LCI observations.¹⁵ Multiple studies have been published on lesion detection, and we previously reported a significant increase in the number of polyps detected per patient with BLI-bright compared to WLI in a multicenter RCT (BLI-bright vs. WLI, 1.84±2.09 vs. 1.43±1.64; p=0.001) (Table 4).¹²^,¹³

LCI was developed as a mode of the LASER endoscopy system to provide higher contrast and brightness than BLI/LASER by strengthening the red color of the lesions and the white color of normal mucosa in the processor, in addition to the light balance used in the BLI-bright mode. This enhancement improves the diagnosis of Helicobacter pylori-associated gastritis and increases the visibility of early gastric cancer.¹⁴^,²⁶ LCI can also be used with LED endoscopes; however, the color and brightness differ slightly between LASER and LED light sources. To improve lesion visibility in the colon, we recommend B8 for structure enhancement for both LASER and LED endoscopy, and C2 for color enhancement for LASER endoscopy and C3 for LED endoscopy. LCI also provides a brighter view during colonoscopy, and multiple studies have reported its usefulness in improving lesion visibility and detection (Table 4).¹⁶^,²⁰^,²¹^,²³^-²⁵^,²⁷^,⁶⁹^,⁷⁷^,⁸⁷^-⁹²

Recent reviews and meta-analyses have shown that both PDR and ADR are significantly higher in LCI compared with WLI.¹⁸^,²⁴ In our study, the ADR in the right colon increased from 26.2% to 36.9% as a result of the above-mentioned additional 30-second observation of the right-sided colon in LCI.²⁷ When compared with NBI, one study reported that NBI had a higher PDR than LCI, while the polyp miss rate (PMR) was similar. However, we examined the additional 30-second observation of the right-sided colon and found that the effect of the second observation on the ADR was not significantly different between NBI and LCI (increase of ADRs: NBI vs. LCI, 7.2% vs. 7.5%; p=0.84).²³^,⁶⁹ These findings are based on a limited sample size, and further research is warranted.

In magnifying observations, our group has previously reported that the same classification performed with NBI can also be performed with BLI/LASER and LED magnification. We have also reported that the JNET classification is routinely used in BLI/LASER and LED in clinical practice and that it has the same diagnostic performance as NBI (Fig. 7).³⁶^-⁴²^,⁴⁶^,⁵¹ Furthermore, we have reported that BLI exhibits a diagnostic performance equivalent to NBI in serrated lesions.⁵⁰

A new LED system (EP-8000; Fujifilm Co.) for BLI/LED and LCI was launched in 2024. This system has four different LED wavelengths (blue-violet, blue, green, and amber-red) compared with the previous LED system and features advanced noise reduction technology. The updated LED system improves brightness, reduces halation, and enhances lesion visibility (Fig. 8).⁹³

CONCLUSIONS

The review has detailed the usefulness of NBI, TXI, BLI and LCI in the detection and diagnosis of gastrointestinal lesions, supported by various images and evidence. Using various IEEs in addition to WLI enables more accurate lesion detection and diagnosis, thereby facilitating endoscopic care; therefore, it is desirable to disseminate them further.

Conflicts of Interest

Naohisa Yoshida is the editor of Gastroenterology Research and Practice. Naohisa Yoshida received a research grant from the Fujifilm Co. Naohisa Yoshida received payment for lectures from Fujifilm Co. Other authors have no potential conflicts of interest.

Funding

None.

Acknowledgments

We thank all members of the Department of Molecular Gastroenterology and Hepatology, Kyoto Prefectural University of Medicine, for their help with this study.

Author Contributions

Conceptualization: RK, NY; Data curation: RK, NY; Formal analysis: RK, NY; Writing–original draft: all authors; Writing–review & editing: all authors.

Fig. 1.

A non-polypoid tumor 50 mm in size in the ascending colon with high-grade dysplasia was viewed using a xenon light source endoscope (LUCERA EVIS 260, PCF-Q240AZI; Olympus Co.). (A) White-light imaging. Non-polypoid lesion with a nodule in the center, 50 mm in the ascending colon. High-grade dysplasia. (B) Narrow-band imaging (NBI) showed brownish. (C) Magnified NBI shows an irregular surface and vessel patterns similar to Japan NBI Expert Team type 2B.

Fig. 2.

A polypoid tumor 25 mm in size in the sigmoid colon, high-grade dysplasia, as viewed with a xenon light source endoscope (EVIS LUCERA ELITE, PCF-H290ZI; Olympus Co.). (A) White-light imaging. Polypoid lesions measuring 25 mm in the sigmoid colon. High-grade dysplasia. (B) Narrow-band imaging (NBI) is brown. The image was brighter than that of first-generation NBI. (C) Magnified NBI shows an irregular surface and vessel patterns similar to Japan NBI Expert Team type 2B.

Fig. 3.

A non-polypoid tumor 80 mm in size in the rectum, high-grade dysplasia, as viewed with a light-emitting diode light source endoscope (EVIS X1, CF-XZ1200I; Olympus Co.). (A) White-light imaging. A non-polypoid lesion with a nodule in the center and 80 mm in the rectum. High-grade dysplasia. (B) Narrow-band imaging (NBI) is brown. The image was brighter than that of second-generation NBI. (C) Texture and color enhancement imaging emphasized the redness of the nodule. (D) Magnified NBI showed an irregular surface and vessel patterns similar to Japan NBI Expert Team type 2B.

Fig. 4.

A non-polypoid tumor 20 mm in size in the cecum, a sessile serrated lesions (SSL), as viewed with a light-emitting diode light source endoscope (EVIS X1, CF-XZ1200I; Olympus Co.). (A) White-light imaging. Faded non-polypoid lesion measuring 20 mm in the cecum. (B) Narrow-band imaging (NBI) showed whitish. (C) Texture and color enhancement imaging emphasized the redness. (D) Magnified NBI showing dilated vessels in the vessel pattern and expanded crypt opening in the surface pattern.

Fig. 5.

A non-polypoid tumor 40 mm in size in the rectum, high-grade dysplasia, as viewed with a light amplification by stimulated emission of radiation (LASER) light source endoscope (LASEREO, EC-L600ZP7; Fujifilm Co.). (A) White-light imaging (WLI). A non-polypoid lesion with a nodule in the center and 40 mm in the rectum. High-grade dysplasia. (B) Blue laser imaging (BLI/LASER) showed brownish. (C) Linked color imaging emphasizes the nodular redness. It was also brighter than that of WLI. (D) Magnified BLI/LASER showing irregular surface and vessel patterns as Japan NBI Expert Team type 2B. NBI, narrow-band imaging.

Fig. 6.

A non-polypoid tumor 40 mm in size in the rectum, high-grade dysplasia, as viewed with a light-emitting diode (LED) light source endoscope (ELUXEO, EC-760ZP-V/M; Fujifilm Co.) (same case as Fig. 5). (A) White-light imaging (WLI). A non-polypoid lesion with a nodule in the center and 40 mm in the rectum. High-grade dysplasia. (B) Blue light imaging (BLI/LED) showed brownish. (C) Linked color imaging emphasizes the nodular redness. It was also brighter than that of WLI. (D) Magnified BLI/LED showing irregular surface and vessel patterns as Japan NBI Expert Team (JNET) type 2B. NBI, narrow-band imaging.

Fig. 7.

Japan NBI Expert Team (JNET) classification. NBI, narrow-band imaging; BLI, blue laser/light imaging.

Fig. 8.

A case presentation of a colonic lesion with a new light-emitting diode system and endoscope (EP-8000 and EC-860ZP; Fujifilm Co.). (A) White-light imaging of an IIc lesion 2 mm in size in the transverse colon with low-grade dysplasia. (B) Linked color imaging. (C) Magnified blue light imaging showing regular surface and vessel patterns similar to the Japan NBI Expert Team type 2A. NBI, narrow-band imaging.

Table 1.

Reports on the usefulness of IEE for polyp detection (first-generation NBI)

Study	Setting	No. of cases	Methods	Efficacy
Nagorni et al.⁵⁷	Meta-analysis 8 RCTs	3,673	ADR	NBI vs. WLI: RR, 0.94; 95% CI, 0.87–1.02
Dinesen et al.⁵⁸	Meta-analysis 6 RCTs	2,936	ADR	NBI vs. WLI, 36% vs. 34%; RR, 1.06; 95% CI, 0.97–1.16; p=0.41
Pasha et al.⁵⁹	Meta-analysis 6 RCTs	2,284	ADR	NBI vs. WLI: RR, 1.01; 95% CI, 0.74–1.37
Gross et al.⁶⁰	RCT	96	PMR	NBI vs. WLI, 31% vs. 57%; p=0.005
Paggi et al.⁶¹	RCT	222	ADR	NBI vs. WLI, 57.3% vs. 58.3%; p=0.88
Uraoka et al.⁶²	Prospective	153	No. of neoplastic lesions	NBI vs. WLI, 134 vs. 116; p=0.02
Kaltenbach et al.⁶³	RCT	276	PMR	NBI vs. WLI, 12.6% vs 12.1%; 95% CI, -7.2–8.3
Inoue et al.⁶⁴	RCT	122	No. of adenomas	NBI vs. WLI, 65 vs. 102; p<0.05
Rex et al.⁶⁵	RCT	434	ADR	NBI vs. WLI, 65% vs. 67%; p=0.61
Jin et al.⁶⁶	Meta-analysis 8 RCTs	3,049	ADR	NBI vs. WLI: pooled RR, 1.09; 95% CI, 1.00–1.19; p=0.05
Qi et al.⁶⁷	RCT	4,211	ADR	NBI vs. WLI, 21.2% vs. 21.8%; p=0.67

IEE, image-enhanced endoscopy; NBI, narrow-band imaging; RCT, randomized controlled trial; ADR, adenoma detection rate; WLI, white-light imaging; RR, relative risk; CI, confidence interval; PMR, polyp miss rate.

Table 2.

Reports on the usefulness of IEE for polyp detection (second-generation NBI)

Study	Setting	No. of cases	Methods	Efficacy
Horimatsu et al.⁷¹	RCT	431	Mean number of polyps per patient	NBI vs. WLI, 2.00 vs. 1.54; p=0.031
Rex et al.⁷²	RCT	431	Mean number of serrated lesions	NBI vs. WLI, 0.25 vs. 0.15; p=0.027
Atkinson et al.⁷³	Meta-analysis 11 RCTs	4,491	ADR	NBI vs. WLI, 45.2% vs. 42.3%; p=0.04
Yoshida et al.⁷⁴	Parallel	130	No. of additional polyps in the second observation (right-sided colon)	NBI vs. WLI, 23 vs. 10; p=0.02
Minamide et al.⁷⁵	Observational	1,831	Mean number of flat and depressed lesions per patient	NBI vs. WLI, 0.62±1.34 vs. 0.44±1.01; p=0.035
Kim et al.⁷⁶	RCT	117	PMR for non-adenomatous polyps	NBI vs. WLI, 11.5% vs. 52.2%; p=0.002
Leung et al.⁷⁷	RCT	901	Proximal PDR (pPDRs) and ADR (pADRs)	NBI vs. WLI in pPDRs, 41.6% vs. 36.6%, p=0.045; pADRs, 33.8% vs. 28.3%, p=0.025
Qi et al.⁶⁷	RCT	4,211	ADR	NBI vs. WLI, 27.0% vs. 21.8%, p=0.01

IEE, image-enhanced endoscopy; NBI, narrow-band imaging; RCT, randomized controlled trial; WLI, white-light imaging; ADR, adenoma detection rate; right-sided colon, cecum and ascending colon; PMR, polyp miss rate; PDR, polyp detection rate.

Table 3.

Reports on the usefulness of IEE for polyp detection (NBI/TXI)

Study	Setting and system	No. of cases	Methods	Efficacy
Yoshida et al.²⁹	RCT, TXI and NBI	381	Mean number of polyps in the second observation (right-sided colon)	TXI vs. NBI, 0.29 vs. 0.30; p<0.01
Sakamoto et al.³⁰	Retrospective cohort study, TXI	470	ADR	TXI vs. WLI, 58.2% vs. 46.8%
Antonelli et al.³¹	RCT, TXI	747	ADR	TXI vs. WLI, 58.9% vs. 42.7%; adjusted RR, 1.38; 95% CI, 1.20–1.59
Mitev et al.³²	Meta-analysis 3 RCTs, TXI	1,541	ADR	TXI vs. WLI, 57.8% vs. 43.6%; RR, 1.32; 95% CI, 1.20–1.46; p<0.001; I²=0%
Toyoshima et al.³³	RCT, TXI	956	PDR	TXI vs. WLI, 82.5% vs 74.4%; p=0.003
Young et al.³⁴	RCT, TXI	324	ADR	TXI vs. WLI, 54.6% vs 41.0%; p=0.01
Inagaki et al.³⁵	Retrospective observational study, TXI	515	ADR, ASDR	TXI vs. WLI, ADR, 37.7% vs. 30.3%, p<0.01; ASDR, 47.8% vs. 38.3%, p< 0.01

IEE, image-enhanced endoscopy; NBI, narrow-band imaging; TXI, texture and color enhancement imaging; RCT, randomized controlled trial; right-sided colon, cecum and ascending colon; ADR, adenoma detection rate; WLI, white-light imaging; RR, relative risk; CI, confidence interval; PDR, polyp detection rate; SSL, sessile serrated lesions; ASDR: adenoma and SSL detection rate.

Table 4.

Reports on the usefulness of IEE for polyp detection (BLI/LCI)

Study	Setting and system	No. of cases	Methods	Efficacy
Ikematsu et al.¹²	RCT, BLI with LASER	963	No. of polyps per patient	BLI vs. WLI, 1.84±2.09 vs. 1.43±1.64; p=0.001
Shimoda et al.¹³	RCT, BLI with LASER	127	AMR	BLI vs. WLI, 1.6% vs. 10.0%; p=0.001
Suzuki et al.²¹	RCT, LCI with LASER/LED	3,050	ADR	LCI vs. WLI, 58.7% vs. 46.7%; p<0.01
Hashimoto et al.²³	Parallel, LCI with LASER/LED	748	Increase in ADR in the second observation (right-sided colon)	NBI vs. LCI, 7.2% vs. 7.5%, p=0.84
Zwetkoff et al.²⁴	Meta-analysis 16 RCTs, LCI with LASER/LED	10,558	ADR	LCI vs. WCI: RR, 1.20; 95% CI, 1.13–1.28
Karsenti et al.²⁵	RCT, LCI with LED	686	Proximal AMR	LCI vs. WLI, 31.8% vs. 36.7%; p=0.34
Yoshida et al.²⁷	Parallel, LCI with LASER	130	ASDR in the second observation (right-sided colon)	LCI vs. WLI, 18.5% vs. 6.1%; p=0.03
Leung et al.⁷⁰	RCT, LCI with LED	272	PDR	NBI vs. LCI, 71.3% vs. 55.9%; p=0.008
Leung et al.⁷⁷	RCT, BLI with LED	901	Proximal PDR	BLI vs. WLI, 45.8% vs. 36.6%, p=0.027
Oliveira Dos Santos et al.⁸⁷	RCT, BLI/LCI with LASER	379	ADR	LCI vs. WLI, 56.9% vs. 43.2%; p=0.02
Paggi et al.⁸⁸	RCT, LCI with LED	600	AMR for the right-sided colon	LCI vs. WLI, 11.8% vs. 30.6%; p<0.001
Miyaguchi et al.⁸⁹	RCT, LCI with LASER	995	ADR	LCI vs. WLI, 47.1% vs. 46.9%; p=0.93
Aniwan et al.⁹⁰	RCT, LCI with LED	1,000	ADR	LCI vs. WLI: RR, 1.49; 95% CI, 1.09–2.03; p=0.007
Min et al.⁹¹	RCT, LCI with LASER	141	ADR	LCI vs. WLI, 37% vs. 28%; 95% CI, 2.39%–19.41%
Fujimoto et al.⁹²	RCT, LCI with LASER	44	SSL detection rate	LCI vs. WLI, 21.6% vs. 3.2%; p=0.02

IEE, image-enhanced endoscopy; BLI, blue laser/light imaging; LASER, light amplification by stimulated emission of radiation; LCI, linked color imaging; RCT, randomized controlled trial; WLI, white-light imaging; NBI, narrow-band imaging; AMR, adenoma miss rate; ADR, adenoma detection rate; right-sided colon, cecum, and ascending colon; LED, light-emitting diode; SSL, sessile serrated lesions; ASDR, adenoma and SSL detection rate; PDR, polyp detection rate; RR, relative risk; CI, confidence interval.

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Efficacy of image-enhanced endoscopy for colorectal polyp detection

Clin Endosc. 2026;59(4):485-496. Published online March 3, 2026

DOI: https://doi.org/10.5946/ce.2025.221

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Efficacy of image-enhanced endoscopy for colorectal polyp detection

Fig. 1. A non-polypoid tumor 50 mm in size in the ascending colon with high-grade dysplasia was viewed using a xenon light source endoscope (LUCERA EVIS 260, PCF-Q240AZI; Olympus Co.). (A) White-light imaging. Non-polypoid lesion with a nodule in the center, 50 mm in the ascending colon. High-grade dysplasia. (B) Narrow-band imaging (NBI) showed brownish. (C) Magnified NBI shows an irregular surface and vessel patterns similar to Japan NBI Expert Team type 2B.

Fig. 2. A polypoid tumor 25 mm in size in the sigmoid colon, high-grade dysplasia, as viewed with a xenon light source endoscope (EVIS LUCERA ELITE, PCF-H290ZI; Olympus Co.). (A) White-light imaging. Polypoid lesions measuring 25 mm in the sigmoid colon. High-grade dysplasia. (B) Narrow-band imaging (NBI) is brown. The image was brighter than that of first-generation NBI. (C) Magnified NBI shows an irregular surface and vessel patterns similar to Japan NBI Expert Team type 2B.

Fig. 3. A non-polypoid tumor 80 mm in size in the rectum, high-grade dysplasia, as viewed with a light-emitting diode light source endoscope (EVIS X1, CF-XZ1200I; Olympus Co.). (A) White-light imaging. A non-polypoid lesion with a nodule in the center and 80 mm in the rectum. High-grade dysplasia. (B) Narrow-band imaging (NBI) is brown. The image was brighter than that of second-generation NBI. (C) Texture and color enhancement imaging emphasized the redness of the nodule. (D) Magnified NBI showed an irregular surface and vessel patterns similar to Japan NBI Expert Team type 2B.

Fig. 4. A non-polypoid tumor 20 mm in size in the cecum, a sessile serrated lesions (SSL), as viewed with a light-emitting diode light source endoscope (EVIS X1, CF-XZ1200I; Olympus Co.). (A) White-light imaging. Faded non-polypoid lesion measuring 20 mm in the cecum. (B) Narrow-band imaging (NBI) showed whitish. (C) Texture and color enhancement imaging emphasized the redness. (D) Magnified NBI showing dilated vessels in the vessel pattern and expanded crypt opening in the surface pattern.

Fig. 5. A non-polypoid tumor 40 mm in size in the rectum, high-grade dysplasia, as viewed with a light amplification by stimulated emission of radiation (LASER) light source endoscope (LASEREO, EC-L600ZP7; Fujifilm Co.). (A) White-light imaging (WLI). A non-polypoid lesion with a nodule in the center and 40 mm in the rectum. High-grade dysplasia. (B) Blue laser imaging (BLI/LASER) showed brownish. (C) Linked color imaging emphasizes the nodular redness. It was also brighter than that of WLI. (D) Magnified BLI/LASER showing irregular surface and vessel patterns as Japan NBI Expert Team type 2B. NBI, narrow-band imaging.

Fig. 6. A non-polypoid tumor 40 mm in size in the rectum, high-grade dysplasia, as viewed with a light-emitting diode (LED) light source endoscope (ELUXEO, EC-760ZP-V/M; Fujifilm Co.) (same case as Fig. 5). (A) White-light imaging (WLI). A non-polypoid lesion with a nodule in the center and 40 mm in the rectum. High-grade dysplasia. (B) Blue light imaging (BLI/LED) showed brownish. (C) Linked color imaging emphasizes the nodular redness. It was also brighter than that of WLI. (D) Magnified BLI/LED showing irregular surface and vessel patterns as Japan NBI Expert Team (JNET) type 2B. NBI, narrow-band imaging.

Fig. 7. Japan NBI Expert Team (JNET) classification. NBI, narrow-band imaging; BLI, blue laser/light imaging.

Fig. 8. A case presentation of a colonic lesion with a new light-emitting diode system and endoscope (EP-8000 and EC-860ZP; Fujifilm Co.). (A) White-light imaging of an IIc lesion 2 mm in size in the transverse colon with low-grade dysplasia. (B) Linked color imaging. (C) Magnified blue light imaging showing regular surface and vessel patterns similar to the Japan NBI Expert Team type 2A. NBI, narrow-band imaging.

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Efficacy of image-enhanced endoscopy for colorectal polyp detection

Study	Setting	No. of cases	Methods	Efficacy
Nagorni et al.57	Meta-analysis 8 RCTs	3,673	ADR	NBI vs. WLI: RR, 0.94; 95% CI, 0.87–1.02
Dinesen et al.58	Meta-analysis 6 RCTs	2,936	ADR	NBI vs. WLI, 36% vs. 34%; RR, 1.06; 95% CI, 0.97–1.16; p=0.41
Pasha et al.59	Meta-analysis 6 RCTs	2,284	ADR	NBI vs. WLI: RR, 1.01; 95% CI, 0.74–1.37
Gross et al.60	RCT	96	PMR	NBI vs. WLI, 31% vs. 57%; p=0.005
Paggi et al.61	RCT	222	ADR	NBI vs. WLI, 57.3% vs. 58.3%; p=0.88
Uraoka et al.62	Prospective	153	No. of neoplastic lesions	NBI vs. WLI, 134 vs. 116; p=0.02
Kaltenbach et al.63	RCT	276	PMR	NBI vs. WLI, 12.6% vs 12.1%; 95% CI, -7.2–8.3
Inoue et al.64	RCT	122	No. of adenomas	NBI vs. WLI, 65 vs. 102; p<0.05
Rex et al.65	RCT	434	ADR	NBI vs. WLI, 65% vs. 67%; p=0.61
Jin et al.66	Meta-analysis 8 RCTs	3,049	ADR	NBI vs. WLI: pooled RR, 1.09; 95% CI, 1.00–1.19; p=0.05
Qi et al.67	RCT	4,211	ADR	NBI vs. WLI, 21.2% vs. 21.8%; p=0.67

Study	Setting	No. of cases	Methods	Efficacy
Horimatsu et al.71	RCT	431	Mean number of polyps per patient	NBI vs. WLI, 2.00 vs. 1.54; p=0.031
Rex et al.72	RCT	431	Mean number of serrated lesions	NBI vs. WLI, 0.25 vs. 0.15; p=0.027
Atkinson et al.73	Meta-analysis 11 RCTs	4,491	ADR	NBI vs. WLI, 45.2% vs. 42.3%; p=0.04
Yoshida et al.74	Parallel	130	No. of additional polyps in the second observation (right-sided colon)	NBI vs. WLI, 23 vs. 10; p=0.02
Minamide et al.75	Observational	1,831	Mean number of flat and depressed lesions per patient	NBI vs. WLI, 0.62±1.34 vs. 0.44±1.01; p=0.035
Kim et al.76	RCT	117	PMR for non-adenomatous polyps	NBI vs. WLI, 11.5% vs. 52.2%; p=0.002
Leung et al.77	RCT	901	Proximal PDR (pPDRs) and ADR (pADRs)	NBI vs. WLI in pPDRs, 41.6% vs. 36.6%, p=0.045; pADRs, 33.8% vs. 28.3%, p=0.025
Qi et al.67	RCT	4,211	ADR	NBI vs. WLI, 27.0% vs. 21.8%, p=0.01

Study	Setting and system	No. of cases	Methods	Efficacy
Yoshida et al.29	RCT, TXI and NBI	381	Mean number of polyps in the second observation (right-sided colon)	TXI vs. NBI, 0.29 vs. 0.30; p<0.01
Sakamoto et al.30	Retrospective cohort study, TXI	470	ADR	TXI vs. WLI, 58.2% vs. 46.8%
Antonelli et al.31	RCT, TXI	747	ADR	TXI vs. WLI, 58.9% vs. 42.7%; adjusted RR, 1.38; 95% CI, 1.20–1.59
Mitev et al.32	Meta-analysis 3 RCTs, TXI	1,541	ADR	TXI vs. WLI, 57.8% vs. 43.6%; RR, 1.32; 95% CI, 1.20–1.46; p<0.001; I²=0%
Toyoshima et al.33	RCT, TXI	956	PDR	TXI vs. WLI, 82.5% vs 74.4%; p=0.003
Young et al.34	RCT, TXI	324	ADR	TXI vs. WLI, 54.6% vs 41.0%; p=0.01
Inagaki et al.35	Retrospective observational study, TXI	515	ADR, ASDR	TXI vs. WLI, ADR, 37.7% vs. 30.3%, p<0.01; ASDR, 47.8% vs. 38.3%, p< 0.01

Study	Setting and system	No. of cases	Methods	Efficacy
Ikematsu et al.12	RCT, BLI with LASER	963	No. of polyps per patient	BLI vs. WLI, 1.84±2.09 vs. 1.43±1.64; p=0.001
Shimoda et al.13	RCT, BLI with LASER	127	AMR	BLI vs. WLI, 1.6% vs. 10.0%; p=0.001
Suzuki et al.21	RCT, LCI with LASER/LED	3,050	ADR	LCI vs. WLI, 58.7% vs. 46.7%; p<0.01
Hashimoto et al.23	Parallel, LCI with LASER/LED	748	Increase in ADR in the second observation (right-sided colon)	NBI vs. LCI, 7.2% vs. 7.5%, p=0.84
Zwetkoff et al.24	Meta-analysis 16 RCTs, LCI with LASER/LED	10,558	ADR	LCI vs. WCI: RR, 1.20; 95% CI, 1.13–1.28
Karsenti et al.25	RCT, LCI with LED	686	Proximal AMR	LCI vs. WLI, 31.8% vs. 36.7%; p=0.34
Yoshida et al.27	Parallel, LCI with LASER	130	ASDR in the second observation (right-sided colon)	LCI vs. WLI, 18.5% vs. 6.1%; p=0.03
Leung et al.70	RCT, LCI with LED	272	PDR	NBI vs. LCI, 71.3% vs. 55.9%; p=0.008
Leung et al.77	RCT, BLI with LED	901	Proximal PDR	BLI vs. WLI, 45.8% vs. 36.6%, p=0.027
Oliveira Dos Santos et al.87	RCT, BLI/LCI with LASER	379	ADR	LCI vs. WLI, 56.9% vs. 43.2%; p=0.02
Paggi et al.88	RCT, LCI with LED	600	AMR for the right-sided colon	LCI vs. WLI, 11.8% vs. 30.6%; p<0.001
Miyaguchi et al.89	RCT, LCI with LASER	995	ADR	LCI vs. WLI, 47.1% vs. 46.9%; p=0.93
Aniwan et al.90	RCT, LCI with LED	1,000	ADR	LCI vs. WLI: RR, 1.49; 95% CI, 1.09–2.03; p=0.007
Min et al.91	RCT, LCI with LASER	141	ADR	LCI vs. WLI, 37% vs. 28%; 95% CI, 2.39%–19.41%
Fujimoto et al.92	RCT, LCI with LASER	44	SSL detection rate	LCI vs. WLI, 21.6% vs. 3.2%; p=0.02

Table 1. Reports on the usefulness of IEE for polyp detection (first-generation NBI)

Table 2. Reports on the usefulness of IEE for polyp detection (second-generation NBI)