Combining techniques and technologies increases adenoma detection rates in colonoscopy: More is more.

Screening colonoscopy with adenoma removal is the gold standard strategy to reduce colorectal cancer (CRC) incidence. Nevertheless, it remains an imperfect tool as nearly Twenty-five percent of adenomas can be missed during inspection by experienced endoscopists. Missed lesions are one of the primary reasons for post colonoscopy CRC and are associated with a significant variability in adenoma detection rate (ADR), which is the most important quality indicator for colonoscopy. Increasing ADR unquestionably decreases carcinoma miss rate. Simple measures to improve ADR include among others slower withdrawal time and position change. The introduction of optical imaging innovations has improved mucosal visualization. Moreover, auxiliary devices attached to the colonoscope tip have been introduced, aiming to improve lumen visualization by flattening the folds and revealing lesions hidden in blind spots, thereby increasing ADR. Digital image analysis using artificial intelligence is the latest approach to polyp detection. All of the above approaches have been separately evaluated concerning their effect in ADR; however, it has not been thoroughly investigated whether any benefit exists from their combined use. We aim to review the available data on the efficacy of each technique/technology and whether their combination offers any additional benefit while remaining cost-effective.