Conventional white light imaging (WLI) frequently fails to detect subtle colorectal lesions, which contributes significantly to the incidence of interval colorectal cancer. Texture and Color Enhancement Imaging (TXI^TM) is a novel endoscopic technology utilizing a proprietary algorithm to enhance image clarity, thus facilitating the detection, particularly of subtle lesions. Preliminary studies have reported conflicting evidence: one trial indicated that TXI improved the adenoma detection rate (ADR), while another demonstrated improvement only in the detection of flat lesions [1, 2]. This systematic review and meta-analysis was therefore conducted to comprehensively assess the efficacy of TXI compared to WLI for colorectal lesion detection.

We performed a systematic literature search in accordance with the PRISMA guidelines up to 3th november 2025 after protocol registration on OSF. Articles were retrieved from PubMed and EMBASE, limited to English, full-text, original research papers on adults comparing the efficacy of TXI vs WLI. Two independent, blinded reviewers will perform the selection process. Primary endpoint was evaluate the performance in ADR of TXI vs. WLI. Secondary endpoints include serrated polyp detection rate (SPDR), right ADR (rADR), and flat polyp detection rate (FDR). 

Overall, seven studies were included in the analysis [1-7]. For the primary endpoint, five studies involving 6377 participants were included. The pooled random-effects model showed a statistically significant improvement in ADR with TXI (RR 1.19; 95% CI 1.07–1.32; p=0.0015) compared to WLI. The right ADR was evaluated across three studies including 2451 patients. The pooled analysis demonstrated a statistically significant improvement with TXI (RR 1.26; 95% CI 1.13–1.42; p < 0.0001) compared to WLI. The serrated polyp detection rate was evaluate in four studies comprising 5907 patients. The pooled analysis evidenced a significant, but bordeline, benefit for TXI compared to WLI (RR 1.13; 95% CI 1.00–1.27; p=0.048). Lastly, for the flat polyp detection rate, two studies involving 4687 patients, showed a pooled RR of 1.19 (95% CI 0.98–1.46; p=0.0845), indicating a non-significant trend toward improved detection with TXI. General heterogeneity across outcomes was low to moderate (ADR: I² = 70%; SPDR, rADR; I² = 0%; FDR: I² = 26%)

This systematic review and meta-analysis including recent RCTs, evidences that TXI provides a significant improvement compared to WLI in overall ADR, SPDR and especially rADR, suggesting enhanced recognition of clinically relevant lesions, including serrated and right-sided precursors associated with interval colorectal cancer risk. While the benefit for flat lesions was not statistically significant, the direction of effect aligns with the broader pattern favoring TXI. Further studies are needed to evaluate its impact on mortality.