Review for 10.1186/s12876-025-03679-4 (2025)

Title: One in Three Adenomas Could Be Missed by White-Light Colonoscopy – Findings from
a Systematic Review and Meta-analysis
Version: 3 Date: 29 Nov 2024
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
This systematic review and meta-analysis delivers a comprehensive examination of the
diagnostic accuracy of white-light colonoscopy for detecting adenomas, illuminating the crucial
limitations of this widely used screening tool.
-The introduction effectively highlights several categories of new colonoscopy technologies
(NCT), including behind-fold visualization technologies, image enhancement, and AI-assisted
detection. However, these descriptions should be expanded with clear examples to contextualize
their pivotal role in reducing adenoma miss rates (AMR).
-The discussion on the limitations of previous reviews requires greater precision. Instead of
simply listing "second-look white-light colonoscopy" and "adjusted white-light colonoscopy,"
it is essential to articulate why these methodological issues significantly impact the validity of
results and their generalizability.
-Moreover, it is imperative to provide a clear and explicit explanation of the different types
of tandem studies. For instance, elucidating the necessity of "type II" studies—where a
second endoscopist is blinded to the prior examination results—underscores the importance of
minimizing bias in research.
-While the mention of "study arms" is valuable, it is crucial to clarify that this term refers to
either WLC versus NCT arms within each study or distinct study groups involving different
colonoscopy techniques.
-Additionally, a focused discussion on how the high risk of bias in certain domains affects the
overall findings, particularly the reliability of the pooled AMR, will enrich the analysis.
-Changing heterogeneity (I²) following meta-regression deserves attention as well;
understanding its implications for the consistency of study outcomes is vital for accurate
interpretation.
-The sensitivity analysis results are clearly presented, yet it is critical to elaborate on the rationale
behind each analysis. For instance, clarifying why restricting the analysis to studies examining
the entire colon or focusing on tandem type I studies is essential for drawing meaningful
conclusions.
-Some statistical results lack clear explanations, such as the "test for trend: p < 0.001." It is
important to briefly define the "test for trend" and highlight its significance in interpreting AMR
results based on adenoma size.
-Secondary outcomes—including adenoma detection rate (ADR), polyp miss rate (PtMR),
cancer incidence rate (CIR), and significant cancer incidence rate (SICR)—are vital for
understanding the effectiveness of screening. Detailed interpretations of these metrics will
provide crucial insights into their implications for clinical practice.
-The analysis of ADR is on point, yet it can be further developed by explicitly connecting
ADR to AMR. For instance, a pooled ADR of 0.37 reflects the overall quality of colonoscopy
performance and warrants attention.
-Furthermore, expanding the discussion to offer practical recommendations for clinical practice
is essential. Considerations should be made regarding whether all patients should undergo
adjunctive imaging techniques or if specific risk factors should dictate the use of enhanced
detection methods.
-The reported miss rates for "non-advanced adenomas" at 42% compared to 21% for "advanced
adenomas" also require clarification. A precise definition distinguishing "advanced" from "non-
advanced" adenomas based on size, histological features, or malignancy risk is critical for
comprehending the clinical significance of this difference.
If advanced adenomas are characterized by dysplasia or larger size, this definition should be
explicitly stated.
-In conclusion, there is a need for actionable recommendations in clinical practice, including
potential changes to colonoscopy protocols and the integration of NCT technologies to enhance
adenoma detection effectively.