Acetic acid chromoendoscopy and linked color imaging demonstrate significant clinical utility in enhancing the visibility of Barrett's neoplasia during endoscopy. However, there are limited data examining the incremental benefit of utilizing these imaging modalities in combination. The aim of this study is to assess the effect of acetic acid-enhanced linked color imaging (AA-LCI) on enhancing Barrett's neoplasia visibility, compared with acetic acid chromoendoscopy alone. 

We retrospectively examined paired endoscopic images of 17 lesions from 17 consecutive patients with Barrett’s neoplasia who underwent endoscopic submucosal dissection between April 2023 and March 2025 at a single Canadian tertiary referral centre. Images of each lesion were captured under acetic acid chromoendoscopy and AA-LCI during index endoscopy. Within these images, neoplastic and non-neoplastic Barrett's mucosa were identified and demarcated by an expert endoscopist, and ten 50-by-50-pixel regions of interest were randomly selected from each of the demarcated mucosal zones using image analysis software (ImageJ, NIH, Bethesda, MD, USA). We then quantified the mean color contrast (ΔE*) between the neoplastic and non-neoplastic regions of interest for each lesion, using the Commission Internationale de l’Eclairage (CIE) lab color system. We also performed exploratory analyses of the geometric and textural contrast between the lesion and adjacent non-neoplastic mucosa using the Sobel operator and grey-level co-occurrence matrix, respectively. Paired differences in color, geometric, and textural contrast between acetic acid chromoendoscopy and AA-LCI were analysed using a Wilcoxon signed-rank test.

Overall, 680 regions of interest were analysed across 17 neoplastic lesions with paired acetic acid chromoendoscopy and AA-LCI images (340 neoplastic and 340 adjacent non-neoplastic). Quantitative image analysis demonstrated that AA-LCI produced a moderate increase in the lesion-to-background color contrast when compared to acetic acid chromoendoscopy alone (median paired difference 2.8 ΔE*; Z = 2.34, p = 0.017, r = 0.57). Differences in geometric contrast did not favor either modality (median paired difference −0.68 units; Z = 0.78, p = 0.459, r = 0.19), and textural contrast similarly showed no significant advantage for AA-LCI (median paired difference −1.33 units; Z = 0.59, p = 0.579, r = 0.14).

In this single-centre review of Barrett’s neoplasia treated with ESD, AA-LCI was associated with a moderate increase in color contrast between neoplastic lesions and adjacent non-neoplastic Barrett’s mucosa when compared to acetic acid chromoendoscopy alone. We did not observe significant differences in geometric or textural metrics between modalities, suggesting that the potential benefit of AA-LCI in this context may be driven principally by color contrast rather than by changes in edge or texture features. These findings support AA-LCI as a useful adjunct for enhancing color-based delineation of Barrett’s neoplasia. However, this study was limited by its small sample size and the absence of endoscopist visibility scores, diagnostic performance measures, or clinical outcome data. Larger studies are needed to further evaluate whether AA-LCI meaningfully improves the optical detection of Barrett’s neoplasia.