Texture and color enhancement imaging improves visibility of superficial non- ampullary duodenal epithelial tumors

Purpose Although image-enhanced endoscopy (IEE) is useful, its benefit over white light imaging (WLI) for the detection of superficial non-ampullary duodenal epithelial tumors (SNADETs) remains unclear. We evaluated whether narrow-band imaging (NBI) and texture and color enhancement imaging (TXI) could improve SNADET visibility compared to WLI under CO ₂ insufflation and underwater conditions. Methods We conducted a post-hoc analysis using a prospectively collected image database from patients with SNADET enrolled in a multicenter observational study. We used the EVIS X1 system with a GIF-H290Z or GIF-EZ1500 endoscope to compare the visibility scores for the recognition of SNADETs. We also measured the color difference (ΔE*), saturation difference (ΔC*), and lightness difference(ΔL*) between the tumor and background mucosa. Results We analyzed 50 lesions, comprising 46 intramucosal adenocarcinomas and 4 adenomas. Under CO ₂ insufflation, TXI provided a significantly higher visibility score than the WLI (2.7 ± 0.8 vs 2.5 ± 0.9, P  = 0.002); however, no significant differences were observed between TXI and NBI (2.7 ± 0.8 vs 2.6 ± 0.7, P  = 0.072). Underwater conditions yielded significantly higher visibility scores than CO ₂ insufflation across the three modes (WLI, 3.1 ± 0.6 vs. 2.5 ± 0.9, P  < 0.001; NBI, 2.9 ± 0.7 vs. 2.6 ± 0.7, P  < 0.001; TXI, 3.2 ± 0.5 vs. 2.7 ± 0.8, P  < 0.001). The ΔC* in TXI was significantly higher than that in WLI under CO ₂ insufflation (8.5 ± 6.0 vs 5.9 ± 3.9, P  < 0.001) and underwater condition (9.2 ± 5.6 vs 6.6 ± 3.5, P  < 0.001). Conclusion TXI significantly improved SNADET visibility compared to WLI under CO ₂ insufflation and underwater conditions, likely due to the increased saturation difference.