Dupuis O, Mavromatis S, Mavromatis A, Compas CN, Sabbagh C, Oliveira L, Hassard P. Endocuff Vision-enhanced colonoscopy: Does it improve polyp detection? World J Gastroenterol 2026; 32(12): 113927 [DOI: 10.3748/wjg.v32.i12.113927]
Corresponding Author of This Article
Philip Hassard, MD, Assistant Professor, Department of Medicine, University of Ottawa, 713 Montreal Road, Ottawa K1K 0T3, Ontario, Canada. philiphassard@montfort.on.ca
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Gastroenterology & Hepatology
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Prospective Study
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This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Mar 28, 2026 (publication date) through Mar 19, 2026
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World Journal of Gastroenterology
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1007-9327
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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
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Dupuis O, Mavromatis S, Mavromatis A, Compas CN, Sabbagh C, Oliveira L, Hassard P. Endocuff Vision-enhanced colonoscopy: Does it improve polyp detection? World J Gastroenterol 2026; 32(12): 113927 [DOI: 10.3748/wjg.v32.i12.113927]
Author contributions: Hassard P contributed to conceptualization and supervision; Dupuis O, Mavromatis S, Mavromatis A, and Hassard P contributed to methodology; Dupuis O, Mavromatis S, and Compas CN contributed to data collection; Dupuis O, Mavromatis S, Mavromatis A, Compas CN, and Hassard P contributed to formal analysis; Dupuis O, Mavromatis S, and Mavromatis A contributed to original draft preparation; all authors contributed to review and editing, and have read and agreed to the published version of the manuscript.
Institutional review board statement: This study was approved by the Montfort Hospital Research Ethics Board, No. 22-23-04-002.
Clinical trial registration statement: This study was registered at ClinicalTrials.gov, No. NCT05615857.
Informed consent statement: Written informed consent was obtained from all participants prior to participation in the study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
CONSORT 2010 statement: This study did not conduct a randomized study, therefore, the consort 2010 checklist for randomized studies does not apply to this.
Data sharing statement: The data will be kept at Institute du Savoir Montfort and will be available on request. To have access to the identified data, a request to the privacy office will be mandatory.
Corresponding author: Philip Hassard, MD, Assistant Professor, Department of Medicine, University of Ottawa, 713 Montreal Road, Ottawa K1K 0T3, Ontario, Canada. philiphassard@montfort.on.ca
Received: September 8, 2025 Revised: November 9, 2025 Accepted: February 5, 2026 Published online: March 28, 2026 Processing time: 193 Days and 12.5 Hours
Abstract
BACKGROUND
Screening by colonoscopy plays a pivotal role in the decreasing incidence and mortality rates associated with colorectal cancer. However, studies continue to highlight significant miss rates in standard colonoscopy. To address this challenge, an endoscopic-assisting device, Endocuff-Vision, aims to enhance mucosal inspection and improve polyp detection. Although many studies have discovered promising results with the Endocuff, other large studies report inconsistent findings.
AIM
To evaluate the real-world effectiveness and safety profile of the Endocuff.
METHODS
We conducted a non-randomized prospective trial by recruiting consenting and eligible participants aged 18+ years (n = 375) undergoing a colonoscopy at the Montfort Hospital (Ontario, Canada). The Endocuff Vision was used in all colonoscopies. Primary outcomes assessed the Endocuff’s polyp detection rate compared to retrospective controls of standard colonoscopy dating up to 5 years. The control cohort (n = 375) was established by sample-matching. Secondary outcomes included safety and patient tolerance.
RESULTS
Colonoscopy with Endocuff in our study yielded a significantly lower overall polyp detection rate compared to controls (72.2% vs 88.7%, P < 0.01). The Endocuff device was well tolerated (94.7%), with no adverse events reported.
CONCLUSION
In this real-world study, Endocuff-enhanced colonoscopy was not superior to standard colonoscopy. Further larger scale studies with our population are required to validate findings.
Core Tip: The Endocuff device has been previously shown to improve polyp detection in screening colonoscopy. We demonstrate in this study that in an experienced group of gastroenterologists the device did not improve polyp detection, possibly diminishing polyp detection for experienced endoscopists. While several limitations, the Endocuff did not offer a clinically meaningful improvement in polyp detection.
Citation: Dupuis O, Mavromatis S, Mavromatis A, Compas CN, Sabbagh C, Oliveira L, Hassard P. Endocuff Vision-enhanced colonoscopy: Does it improve polyp detection? World J Gastroenterol 2026; 32(12): 113927
In North America, colorectal cancer (CRC) diagnosis and treatment continues to pose a significant burden on healthcare systems and medical practitioners. In 2024, it was projected that 25200 Canadians will be newly diagnosed with some form of CRC[1]. Death linked to CRC is expected to reach 9400 Canadians, equating to approximately 26 CRC related deaths each day[1]. In response to this alarming trend, researchers worldwide have contributed to a steady decline in CRC incidence and mortality through improving screening methods, particularly by colonoscopy.
Colonoscopy has been globally adopted and proven to be efficient in diagnosis and prevention of CRC related deaths[2-4]. It enables the identification and removal of precancerous polyps via polypectomy, thereby reducing the risk of progression to cancer[3-5]. The quality of the colonoscopy has recently been recognized as a critical factor in its diagnostic accuracy and preventive capacity[6]. Inconsistencies in the quality of colonoscopy leading to incomplete evaluations of the rectum and colon have been linked to higher occurrence of post-colonoscopy CRC[6,7]. Commonly cited quality markers include cecal intubation rate, withdrawal time and adenoma detection rate (ADR), among others[8,9].
To improve these quality markers, various adjunctive techniques and tools have been developed. These methods led to the creation of endoscopic assistive devices, among them, distal attachment devices. The Endocuff is a second-generation endoscopic distal attachment device designed with soft star-like projections to flatten the mucosal folds of the colon bringing the difficult-to-assess mucosa to view[10]. It is claimed to improve mucosal inspection, and thus, polyp detection[11]. Although numerous meta-analyses and randomized control trials (RCTs) have demonstrated an improvement in ADR and overall quality of colonoscopy with the use of Endocuff; there remains opposing large RCTs demonstrating inconsistent or negligible clinical benefits of the Endocuff[12-17]. Given these conflicting findings, our study aims to evaluate the real-world effectiveness of the Endocuff in improving polyp detection and its utility in experienced endoscopist. We compare its performance to that of standard colonoscopy using retrospective controls.
MATERIALS AND METHODS
This single-center real-world prospective matched-cohort study was based on a non-randomized, non-blinded approach with retrospective comparison (n = 750). We recruited eligible and consenting participants aged 18+ years (n = 375) undergoing a screening, surveillance or urgent colonoscopy at the Montfort Hospital in Ottawa, Ontario (Canada). The inclusion period extended from August 2022 to February 2023. The Endocuff Vision was used as an adjunct to all colonoscopies for the prospective cohort. A total of 4 certified Fellow of the Royal College of Physicians of Canada experienced gastroenterologists offered the participants colonoscopies and subsequently wrote operative reports according to their findings; no residents or trainee fellows were involved in this study. The colon was assessed once by Endocuff-enhanced colonoscopy (EEC). Polyps were removed and documented. The retrospective control cohort (n = 375) was established by identifying retrospective charts of individuals having undergone standard non-Endocuff colonoscopy from January 2017 to August 2022. The controls were sample matched based on age, sex and gastroenterologist performing the colonoscopy. All operative reports of both retrospective and prospective cohorts were reviewed on three occasions independently by 2 examiners according to the inclusion and exclusion criteria (Table 1).
(1) Ability to provide informed consent; (2) ≥ 18 years of age; (3) Undergoing a colonoscopy for screening or surveillance matters by a gastroenterologist
(1) Inability to provide consent; (2) Use of anticoagulation and anti-platelet agents that precludes the removal of polyps; (3) Prior history or current active inflammatory bowel disease; (4) History of polyposis syndromes or hereditary non-polyposis colorectal cancer; (5) Acute diverticulitis; (6) Previous colon surgery (excluding appendectomy); (7) Diagnosis of toxic megacolon; (8) Radiation therapy to abdomen or pelvis; (9) Pregnancy/lactation; (10) History of stroke or ischemia in previous 3 months; (11) Being deemed high risk by the performing endoscopist; (12) Fecal immunochemical test positive; and (13) Poor bowel prep (defined as abandoning the procedure prior to or inability to intubate the cecum)
The study’s primary outcome focuses on assessing the EEC’s real-world utility to detect polyps [polyp detection rate (PDR)] as compared to retrospective controls of standard colonoscopy. Secondary outcomes were procedure safety and patient tolerance of procedure which were described qualitatively by absence of recorded adverse events in the operative report and patient report, respectively.
The data was gathered by reviewing the treatment and the control cohort’s operative reports. PDR is calculated based on the total number of individuals with the presence of ≥ 1 polyp(s) in the colon or rectum per their respective cohort (prospective vs retrospective). PDR data was collected and calculated using ratios through Excel (Version 16.16.26). Statistical analysis was completed via data analyst from the Institute du Savoir Montfort for P value calculation by 2 proportion z-test including Bonferoni correction. Secondary outcomes were scaled on a tolerance qualitative scale defined as “excellent”, “good, though required support” and “poor” tolerance.
RESULTS
Participant demographics
The treatment (T) and control (C) cohort consisted of 375 individuals, for a total of 750 participants. Age distribution was stratified equally across cohorts as follows: 18-30 years (1.1%), 31-50 years (23.5%), 51-65 years (45.6%) and 66+ years (29.9%). Sex proportions are represented by 62.4% (T) and 58.1% (C) for males and 37.6% (T) and 41.9% (C) for females. The participant’s time since last colonoscopy was quantified (nT = 375, nC = 214) and divided by 0-5 years (T: 74%, C: 74%), 6-10 years (T: 21%, C: 18%), 10+ years (T: 4%, C: 7%). Additionally, a subset of participants underwent their first colonoscopy as part of the study (T: 38%, C: 18%). The distribution of procedures by endoscopist was comparable between cohorts: Endoscopist A (T: 7%, C: 13%), endoscopist B (T: 54%, C: 35%), endoscopist C (T: 24%, C: 32%), and endoscopist D (T: 28%, C: 32%). A history of CRC was found in 3 participants (1%) in the treatment group and 6 participants (2%) in the control group (Table 2).
Table 2 Baseline demographic and clinical characteristics of study participants by cohort, n (%).
The PDR in the T cohort was 72.3%, compared to 88.3% in the C cohort, indicating a significantly lower performance in the Endocuff group (P < 0.001). When analyzed per endoscopist, independent PDRs showed a significant decrease for endoscopist B through D in the treatment group (P < 0.01, Bonferroni-adjusted). Although endoscopist A also exhibited a decrease in PDR, this reduction was not statistically significant. The percentage change for each independent endoscopist (A-D) is 8.7%, 12.8%, 26.7%, 16.5%, respectively (Table 3).
Table 3 Polyp detection rate by cohort and endoscopist, %.
The qualitative assessment of procedural safety revealed no documented adverse events attributable to the Endocuff, including perforation, failure to intubate the cecum as a result of the Endocuff, and significant post polypectomy bleeding in the treatment cohort. Additionally, a review of the prospective cohort’s operative demonstrated high overall tolerance and comfort during EEC’s (Table 4).
Table 4 Tolerance of Endocuff-enhanced colonoscopy in the treatment cohort, n (%).
Colonoscopy remains a gold standard for CRC detection and prevention, contributing substantially to reductions in its incidence and mortality[3,5,18,19]. By enabling the identification and removal of precancerous polyps, it effectively lowers the risk of progression to malignancy[3,4]. Despite its proven safety and accuracy, colonoscopy has limitations. In a back-to-back colonoscopy study, Rex et al[20] reported an overall adenoma miss rate of 24%, with smaller lesions (< 1 cm) disproportionately affected in 1997. Proximal lesions, particularly those hidden behind haustral folds, are especially prone to being overlooked[21,22]. Recognition of these limitations has driven the development of quality indicators prompted the development of adjunct endoscopic technologies, notably the Endocuff[8,9,23,24].
In 2011, the Endocuff was introduced to the market as a second-generation endoscopic distal attachment designed to improve mucosal visualization. This single-use, radiopaque device features hinged projections that flatten colonic folds, enhancing exposure of hard-to-evaluate areas such as the proximal aspects of haustra[25]. By improving visualization and stabilizing the endoscope, Endocuff aims to facilitate detection of small polyps (< 1 cm) and reduce scope slippage during flexure navigation and polypectomy[25,26]. Nonetheless, certain limitations have been reported. Increased bulk may complicate cecal intubation, raising concerns about incomplete examinations, though findings remain inconsistent[12]. Minor mucosal petechiae and occasional device dislodgement have also been documented[12,25].
Over the last decade, the Endocuff has been extensively studied through meta-analyses and RCTs to determine its true clinical benefit beyond theoretical advantages. Chin et al[12], pooled data from nine comparative studies across varied clinical settings and populations showing a higher ADR with the Endocuff compared to standard colonoscopy (50.4% vs 43.3%). Their findings corresponded to a number needed to treat of 14 to detect one additional adenoma. More recently, Wang et al[15], conducted a meta-analysis of 23 RCTs (17999 patients), and found a modest increase in overall ADR with the Endocuff use; however, no significant benefit was observed for advanced adenoma detection or mean polyp count per patient. Similarly, van Doorn et al[27] also reported a higher total adenoma detection with the Endocuff, though it did not affect the proportion of patients in whom at least one adenoma was found and there was no meaningful difference in advanced adenoma detection. Interestingly, the ADENOMA trial also reported improved ADR with Endocuff use; however, its population consisted of higher-risk patients (fecal occult blood test-positive) enrolled in the Bowel Cancer Screening Program, in contrast to the average-risk population included in our study[26]. While Endocuff use is associated with higher overall ADR in controlled studies, its generalizability of these findings in real-world settings and its true clinical impact on reducing rates of CRC in patients remains uncertain.
Our real-world evaluation of the Endocuff cap, conducted in a setting with experienced endoscopists, did not demonstrate a clinically meaningful improvement in PDR. When analyzing independent PDR by endoscopist, our study found a clinically significant decrease in PDR for endoscopist B-D. This suggests that even under favorable conditions, the benefits of the device may be limited. This outcome may also reflect confounding factors including level of Endocuff training and familiarity, endoscopist experience, or heterogeneity in patient population and baseline risk profiles. Overall, our study adds to growing evidence suggesting that Endocuff-assisted colonoscopy may not meaningfully enhance polyp detection in routine real-world practice. Specifically, higher number needed to treat and no significant effect in mean number of adenomas per colonoscopy[12,13].
These findings also highlight the need to consider the cost-effectiveness of Endocuff use in routine practice. Although a formal cost analysis was beyond the scope of this study, our results demonstrated a negligible incremental benefit of the Endocuff cap in our patient population. When coupled with the uncertain real-world utility and value to the patient, this raises questions about the justification of its additional cost in resource-limited healthcare settings. This emphasizes the need for careful consideration of when to use the device. Further economic analyses are warranted to better understand the true cost of the Endocuff, as well as to identify the clinical context or patient populations in which it provides the greatest value.
As described above, ADR is widely accepted as the benchmark for colonoscopy quality. However, research suggests that PDR can serve as a practical surrogate measure for ADR. For instance, Ng et al[28] analyzed over 1600 colonoscopies performed by 24 trainees and found a strong positive correlation between overall ADR and PDR (r = 0.87, P < 0.0001). Some concerns have been raised about heterogeneity in this correlation of ADR and PDR across different segments of the colon, with a stronger correlation in the right colon compared to the left[28-30]. Despite these nuances, PDR remains a useful proxy especially in the setting where calculating ADR is impractical[31]. It is important to note, however, that PDR may overestimate true adenoma detection by including non-adenomatous polyps, such as hyperplastic polyps.
When creating a successful screening procedure, it is important to consider the patient comfort and complication rates, hence our secondary outcomes. The risks of these items must be acceptable to the screened population. Our data demonstrated no reported adverse events within our treatment cohort and no association with increased intra-procedure complications. There was no Endocuff dislodgement recorded. Comfort was qualified by the performing endoscopist and resulted with no increase in pain scores with Endocuff device use.
Limitations
There are several limitations to this study. First, it was non-blinded, as the Endocuff device remained visible throughout the endoscopic procedure, increasing the risk of performance and detection bias. Additionally, this was a single-center, observational, non-randomized study involving a relatively small sample size and a limited number of endoscopists (n = 4), which restricts generalizability of the findings, limits causal inference, and may introduce selection bias. The control data was collected retrospectively, potentially leading to inconsistencies in data quality and comparability with the prospective cohort. Furthermore, the difference in time periods between the retrospective (2017-2022) and prospective data (2022-2023) data collection may have introduced confounding factors related to advancements in endoscopic techniques or equipment. Although controls were matched by age, sex and gastroenterologist, other potential confounders, such as comorbidities outside the defined exclusion criteria and colonoscopy indications, were not accounted for. Missing data was encountered in both retrospective and prospective operative reports, necessitating exclusions during analyses. In addition, time for withdrawal and procedural time was not indicated on the operative reports limiting analysis of data. The primary outcome, PDR, was measured based solely on the presence of at least one polyp per participants rather than the total number of polyps detected, which may have impacted the internal validity of the findings. Moreover, although PDR is considered a reliable surrogate marker for ADR in colonoscopies, it has inherent limitations as addressed in the discussion[28,31]. Specifically, PDR does not provide histologic confirmation of the identified polyps as it was not available on the operative report, limiting the assessment of their malignant potential. Another limitation is that the secondary outcomes were based on a qualitative assessment of procedural safety and patient tolerance, rather than active follow-up, which may have resulted in underreporting of complications and patient discomfort.
CONCLUSION
This single center matched cohort study challenges the notion of the real-world utility of the Endocuff cap emphasizing the need for careful, cost-conscious consideration of its routine use in clinical practice. While several study limitations are acknowledged, the Endocuff did not offer a clinically meaningful improvement in polyp detection. Further studies are warranted.
ACKNOWLEDGEMENTS
We gratefully acknowledge the support of Institute du Savoir Montfort for providing access to research facilities and support staff for the completion of this study.
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