Image-enhanced endoscopy versus white-light imaging for the detection of early gastric cancers: A systematic review and meta-analysis

Background & aims Imaged-enhanced endoscopy (IEE) improves mucosal and vascular visualization. However, its advantage over white-light imaging (WLI) in detecting early gastric cancer (EGC) remains unclear. We assessed the efficacy of IEE versus WLI for detecting EGC. Methods We searched MEDLINE, Embase, Cochrane CENTRAL from inception to August 2025 for eligible randomized controlled trials. Primary outcome was detection of early gastric cancer; secondary outcomes were detection of neoplastic lesions (cancer and high-/low-grade intraepithelial neoplasia) and H. pylori infection. Certainty of evidence was rated with GRADE. Results were expressed as relative risk (RR) of detecting lesion using a random-effect model. We simulated population-based scenarios using age-specific incidence and estimated the number needed to screen (NNS) by region. Results We included 12 trials with 15,660 patients. IEE may modestly increase detection of EGC (RR 1.28, 95% confidence interval [CI] 1.03–1.59; NNS 192, 95% CI 91–1,785; low-certainty evidence). IEE may increase the detection of neoplastic lesions (RR 1.39, 95% CI 1.08–1.78; NNS 75, 95% CI 38–364; low-certainty evidence). Evidence for effect of IEE on H. pylori detection is uncertain (RR 1.19, 95% CI 1.00–1.41; NNS 7, 95% CI 4–∞; very low-certainty evidence). In population-based simulations, IEE has greater impact in high-risk regions such as East-Asia and Eastern Europe, and in high-risk immigrant and minority populations in the United States. Conclusions IEE may increase detection of early gastric cancer compared with WLI. Use of IEE can be considered in detecting early gastric cancer in high-risk populations.