Second-generation distal attachment cuff improves adenoma detection rate: meta-analysis of randomized controlled trials

Published:October 04, 2020DOI:

      Background and Aims

      Multiple randomized controlled trials (RCTs) using the second-generation distal attachment cuff device (Endocuff Vision; Olympus America, Center Valley, Pa, USA) have reported conflicting results in improving adenoma detection rate (ADR) compared with standard high-definition colonoscopy without the distal attachment. We conducted a systematic review and meta-analysis of RCTs to compare outcomes between second-generation cuff colonoscopy (CC) versus colonoscopy without the distal attachment (standard colonoscopy [SC]).


      An electronic literature search was performed using PubMed, Google Scholar, Embase, and Cochrane Library through May 2020. The primary outcome was reporting of ADR, and secondary outcomes were polyp detection rate (PDR), mean withdrawal time, mean adenomas per colonoscopy (APC), sessile serrated lesion detection rate, and adverse events. Pooled rates and risk ratios (RRs) with 95% confidence intervals were reported.


      Eight RCTs with 5695 patients were included in the final analysis, with 2862 patients (mean age, 62.8 years; 52.9% men) in the CC group and 2833 patients (mean age, 62.6 years; 54.2% men) in the SC group. Compared with SC, use of CC was associated with a significant improvement in ADR (49.8% vs 45.6%, respectively; RR, 1.12; P = .02), PDR (58.1% vs 53%, respectively; RR, 1.12; P = .009), and APC (P < .01). Furthermore, use of CC had a .93-minute lower mean withdrawal time (P < .01) when compared with SC. The difference in ADR was larger in the screening/surveillance population (6.5%, P = .02) and when used by endoscopists with ADRs <30% (9.4%, P = .03).


      The results of this meta-analysis of randomized trials show a significant improvement in ADR and APC with shorter withdrawal times using the second-generation cuff device compared with SC.


      ADR (adenoma detection rate), APC (mean adenomas per colonoscopy), A-ADR (advanced adenoma detection rate), CC (cuff colonoscopy), FOBT+ (fecal occult blood test–positive), D-ADR (distal adenoma detection rate), NNT (number needed to treat), PDR (polyp detection rate), P-ADR (proximal adenoma detection rate), RCT (randomized controlled trial), RR (risk ratio), SC (standard colonoscopy), SDR (sessile serrated lesion detection rate)
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        • Howlader N.
        • Noone A.M.
        • Krapcho M.
        • et al.
        SEER cancer statistics review, 1975-2017. National Cancer Institute. Bethesda, MD.
        (Available at:)
        Date accessed: February 1, 2020
        • Winawer S.J.
        • Zauber A.G.
        • Ho M.N.
        • et al.
        Prevention of colorectal cancer by colonoscopic polypectomy. The National Polyp Study Workgroup.
        N Engl J Med. 1993; 329: 1977-1981
        • Kaminski M.F.
        • Regula J.
        • Kraszewska E.
        • et al.
        Quality indicators for colonoscopy and the risk of interval cancer.
        N Engl J Med. 2010; 362: 1795-1803
        • Corley D.A.
        • Jensen C.D.
        • Marks A.R.
        • et al.
        Adenoma detection rate and risk of colorectal cancer and death.
        N Engl J Med. 2014; 370: 1298-1306
        • Centers for Medicare & Medicaid Services MIPS clinical quality measures quality ID #343
        Screening colonoscopy adenoma detection rate. 2019.
        (Available at:)
        • Rex D.K.
        • Bond J.H.
        • Winawer S.
        • et al.
        Quality in the technical performance of colonoscopy and the continuous quality improvement process for colonoscopy: recommendations of the U.S. Multi-Society Task Force on Colorectal Cancer.
        Am J Gastroenterol. 2002; 97: 1296-1308
        • Pioche M.
        • Matsumoto M.
        • Takamaru H.
        • et al.
        Endocuff-assisted colonoscopy increases polyp detection rate: a simulated randomized study involving an anatomic colorectal model and 32 international endoscopists.
        Surg Endosc. 2016; 30: 288-295
        • Floer M.
        • Biecker E.
        • Fitzlaff R.
        • et al.
        Higher adenoma detection rates with endocuff-assisted colonoscopy—a randomized controlled multicenter trial.
        PLoS One. 2014; 9: e114267
        • Cavallaro L.G.
        • Hassan C.
        • Lecis P.
        • et al.
        The impact of Endocuff-assisted colonoscopy on adenoma detection in an organized screening program.
        Endosc Int Open. 2018; 6: E437-E442
        • Biecker E.
        • Floer M.
        • Heinecke A.
        • et al.
        Novel endocuff-assisted colonoscopy significantly increases the polyp detection rate: a randomized controlled trial.
        J Clin Gastroenterol. 2015; 49: 413-418
        • González-Fernández C.
        • García-Rangel D.
        • Aguilar-Olivos N.E.
        • et al.
        Higher adenoma detection rate with the endocuff: a randomized trial.
        Endoscopy. 2017; 49: 1061-1068
        • Bhattacharyya R.
        • Chedgy F.
        • Kandiah K.
        • et al.
        Endocuff-assisted vs standard colonoscopy in the fecal occult blood test-based UK Bowel Cancer Screening Programme (E-cap study): a randomized trial.
        Endoscopy. 2017; 49: 1043-1050
        • Ngu W.S.
        • Bevan R.
        • Tsiamoulos Z.P.
        • et al.
        Improved adenoma detection with Endocuff Vision: the ADENOMA randomised controlled trial.
        Gut. 2019; 68: 280-288
        • Liberati A.
        • Altman D.G.
        • Tetzlaff J.
        • et al.
        The PRISMA statement for reporting systematic reviews and meta-analyses of studies that evaluate health care interventions: explanation and elaboration.
        PLoS Med. 2009; 6: e1000100
        • Higgins J.P.T.
        • Altman D.G.
        • Gøtzsche P.C.
        • et al.
        The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials.
        BMJ. 2011; 343: d5928
      1. Schünemann H. Brożek J. Guyatt G. GRADE handbook for grading quality of evidence and strength of recommendations updated October 2013: the GRADE Working Group, 2013. 2013
        • Rex D.K.
        • Slaven J.E.
        • Garcia J.
        • et al.
        Endocuff Vision reduces inspection time without decreasing lesion detection: a clinical randomized trial.
        Clin Gastroenterol Hepatol. 2020; 18: 158-162
        • Jacob A.
        • Schafer A.
        • Yong J.
        • et al.
        Endocuff Vision-assisted colonoscopy: a randomized controlled trial.
        Austr N Z J Surg. 2019; 89: E174-E178
        • von Figura G.
        • Hasenöhrl M.
        • Haller B.
        • et al.
        Endocuff Vision-assisted vs. standard polyp resection in the colorectum (the EVASTA study): a prospective randomized study.
        Endoscopy. 2020; 52: 45-51
        • Costa Santos M.
        • Palmela C.
        • Gouveia C.
        • et al.
        Sessile serrated lesions detection with endocuff-assisted colonoscopy—a randomized controlled trial.
        United Eur Gastroenterol J. 2019; 7: 264-265
        • Karsenti D.
        • Tharsis G.
        • Perrot B.
        • et al.
        Adenoma detection by Endocuff-assisted versus standard colonoscopy in routine practice: a cluster-randomised crossover trial.
        Gut. 2020; 69: 2159-2164
        • Vanduangden K.
        • Aniwan S.
        • Wisedopas N.
        • et al.
        A comparison on the combination of linked color imaging and endocuff-assisted technologies and procedural innovation.
        Gastrointest Endosc. 2020; 6: AB45
        • Robertson D.J.
        • Lee J.K.
        • Boland C.R.
        • et al.
        Recommendations on fecal immunochemical testing to screen for colorectal neoplasia: a consensus statement by the US Multi-Society Task Force on colorectal cancer.
        Gastrointest Endosc. 2017; 85: 2-21
        • Rex D.K.
        • Repici A.
        • Gross S.A.
        • et al.
        High-definition colonoscopy versus Endocuff versus EndoRings versus full-spectrum endoscopy for adenoma detection at colonoscopy: a multicenter randomized trial.
        Gastrointest Endosc. 2018; 88: 335-344
        • Williet N.
        • Tournier Q.
        • Vernet C.
        • et al.
        Effect of Endocuff-assisted colonoscopy on adenoma detection rate: meta-analysis of randomized controlled trials.
        Endoscopy. 2018; 50: 846-860
        • Chin M.
        • Karnes W.
        • Jamal M.M.
        • et al.
        Use of the Endocuff during routine colonoscopy examination improves adenoma detection: a meta-analysis.
        World J Gastroenterol. 2016; 22: 9642-9649