Texture and color enhancement imaging improves visibility of superficial non- ampullary duodenal epithelial tumors

Texture and color enhancement imaging improves visibility of superficial non- ampullary duodenal epithelial tumors | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Texture and color enhancement imaging improves visibility of superficial non- ampullary duodenal epithelial tumors Katsuma Yamauchi, Osamu Dohi, Naoto Iwai, Azumi Yahara, Tomoko Ochiai, and 9 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8802398/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract Purpose Although image-enhanced endoscopy (IEE) is useful, its benefit over white light imaging (WLI) for the detection of superficial non-ampullary duodenal epithelial tumors (SNADETs) remains unclear. We evaluated whether narrow-band imaging (NBI) and texture and color enhancement imaging (TXI) could improve SNADET visibility compared to WLI under CO 2 insufflation and underwater conditions. Methods We conducted a post-hoc analysis using a prospectively collected image database from patients with SNADET enrolled in a multicenter observational study. We used the EVIS X1 system with a GIF-H290Z or GIF-EZ1500 endoscope to compare the visibility scores for the recognition of SNADETs. We also measured the color difference (ΔE*), saturation difference (ΔC*), and lightness difference(ΔL*) between the tumor and background mucosa. Results We analyzed 50 lesions, comprising 46 intramucosal adenocarcinomas and 4 adenomas. Under CO 2 insufflation, TXI provided a significantly higher visibility score than the WLI (2.7 ± 0.8 vs 2.5 ± 0.9, P = 0.002); however, no significant differences were observed between TXI and NBI (2.7 ± 0.8 vs 2.6 ± 0.7, P = 0.072). Underwater conditions yielded significantly higher visibility scores than CO 2 insufflation across the three modes (WLI, 3.1 ± 0.6 vs. 2.5 ± 0.9, P < 0.001; NBI, 2.9 ± 0.7 vs. 2.6 ± 0.7, P < 0.001; TXI, 3.2 ± 0.5 vs. 2.7 ± 0.8, P < 0.001). The ΔC* in TXI was significantly higher than that in WLI under CO 2 insufflation (8.5 ± 6.0 vs 5.9 ± 3.9, P < 0.001) and underwater condition (9.2 ± 5.6 vs 6.6 ± 3.5, P < 0.001). Conclusion TXI significantly improved SNADET visibility compared to WLI under CO 2 insufflation and underwater conditions, likely due to the increased saturation difference. Narrow-band imaging superficial non-ampullary duodenal epithelial tumor texture and color enhancement imaging visibility white light imaging Figures Figure 1 Figure 2 Figure 3 Introduction Superficial non-ampullary duodenal epithelial tumors (SNADETs) are rare, with endoscopic detection rates of 0.15%–0.3% for adenomas and 0.0023%–0.7% for carcinomas [1-4]. However, duodenal cancers are often identified at advanced stages, leading to poor prognosis with five-year survival rates estimated at 2.1-58.2% [5]. Early detection and treatment are essential to improve the prognosis of SNADETs. Recent advancements in endoscopic technology and improved observational capabilities have increased SNADET detection rates [6, 7]. However, there is little evidence to establish effective methods for early detection of SNADETs. Several image-enhanced endoscopic modalities have been reported to facilitate the detection of gastrointestinal tumors [8-10]. Texture and color enhancement imaging (TXI), developed in 2020, highlights subtle color and structural changes [11]. Previous reports have demonstrated that TXI improves the visibility of gastric tumors compared to white light imaging (WLI) [12-14]. Although TXI may improve the visibility of SNADET compared to WLI, its effectiveness has not been fully established. Endoscopic resection is often performed for SNADETs measuring ≤20 mm. Recent studies have highlighted the utility of techniques such as underwater endoscopic mucosal resection (UEMR) [15-18], leading to a growing demand for underwater observation and treatment. However, achieving optimal visibility using WLI under underwater conditions is challenging. Furthermore, to date, no studies have examined whether image-enhanced endoscopy (IEE) can improve the visibility of SNADETs under underwater conditions. Therefore, this study aimed to investigate whether TXI improves SNADET visibility under both insufflation and underwater conditions. Enhanced visibility may facilitate early detection and treatment and reduce complications associated with larger lesions. Understanding the effectiveness of TXI under these conditions could expand its application in endoscopic practice and potentially improve patient prognosis. Methods Study design and eligible patients This study was conducted as a post-hoc analysis of prospectively collected endoscopic images. Patients with SNADETs were prospectively enrolled at the Kyoto Prefectural University of Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Fukuchiyama City Hospital, and Omihachiman Community Medical Center. This study spanned from July 2022 to March 2023 and targeted SNADETs prior to endoscopic and surgical treatments. Patients with recurrent lesions or markers around the tumor were excluded. Endoscopic system, device, and setting Esophagogastroduodenoscopy was performed using an EVIS X1 video system with a GIF-H290Z or GIF-EZ1500 scope (Olympus Medical Systems Co., Tokyo, Japan). Only TXI mode 1 was employed in this study, because TXI mode 2 lacked color enhancement.[11, 19] For the enhanced structural level, A3 was selected for WLI and TXI, whereas B8 was selected for narrow-band imaging (NBI). All the lesions were captured under both CO2 insufflation and underwater conditions using WLI, NBI, and TXI. To ensure consistency in evaluating SNADET visibility, images were captured from the same distance and angle for each mode under both conditions. The endoscopic treatment was performed by an endoscopist at each institution. Visibility score Images were presented to four endoscopists, including two experts and two non-experts. These four endoscopists were independently selected without prior knowledge of SNADET or the study concept. Experts (T.O. and K.I.) were defined as endoscopists certified by the Japan Gastroenterological Endoscopy Society, whereas non-experts (A.Y. and H.M.) were defined as endoscopists with ≤5 years of experience and without certification. Each image was randomly presented on a single slide. The visibility score was defined using a four-level visibility scale for detection: 4, excellent visibility (easily detectable); 3, good visibility (detectable with careful observation); 2, fair visibility (hardly detectable without careful examination); and 1, poor visibility (undetectable without repeated careful examination).[20] Pathological diagnosis All the neoplastic specimens obtained via biopsy or endoscopic resection were fixed in 10% formalin for pathological evaluation. Diagnoses were categorized by experienced clinical pathologists at each participating institution. If there were any discrepancies between the biopsy and endoscopically resected specimens, the final diagnosis was determined based on the endoscopically resected specimens. Sample size calculation The mean visibility scores for duodenal tumors were reported as 2.66, 2.92, and 2.40 for WLI and 3.53, 3.85, and 3.21 for LCI by all, expert, and trainee endoscopists, respectively [21]. Based on this report, assuming that the visibility scores of TXI and WLI were equivalent to the minimum of LCI and maximum of WLI, with an assumed visibility score of 3.3 for TXI and 2.9 for WLI, setting the detection power to 80% with an alpha error rate of 5%, the sample size was calculated to be 50 cases. A total of 50 images were required for each mode under CO 2 insufflation and underwater conditions. Color measurement and analysis To objectively assess the color differences in SNADETs, images were evaluated based on the CIE1976(L*a*b*) color space system (CIELAB) using Adobe Photoshop (Adobe Inc., San Jose, CA, USA). As mentioned in previous reports,[22] the tumor area was first defined, and the regions of interest (ROIs) were selected within a 20 × 20-pixel range for each mode. Two points were designated inside and outside the lesion, along a straight line in the short-axis direction (Fig. 1). The color values (L*/a*/b*) of the inside and outside ROIs were measured and the mean color difference (ΔE*) between the two regions was calculated using the following formula: ΔE* = [(ΔL*)2+(Δa*)2+(Δb*)2]1/2 Where: ΔL* = L*i − L*o (inside minus outside the lesion) Δa* = a*i − a*o (inside minus outside the lesion) Δb* = b*i − b*o (inside minus outside the lesion) Additionally, the saturation difference (ΔC*) was calculated as follows: C＝[(a*)2+(b*)2]1/2 ΔC*＝C*i − C*o Where C*i and C*o represent the saturation measurements inside and outside the lesion, respectively. Endpoint The primary endpoint was the visibility score for each mode. The secondary endpoints included color value differences, such as color difference (ΔE*), saturation difference (ΔC*), and lightness difference (ΔL*), between the tumor and background mucosa, as assessed using WLI, NBI, and TXI. Statistical analysis For lesion characteristics and continuous variables, such as visibility score and color difference, t-tests were applied. Chi-squared tests were used for categorical variables and other analyses. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R ( R Foundation for Statistical Computing, Vienna, Austria). EZR is a modified version of the R Commander software, designed to include statistical functions frequently used in biostatistics.[23] Results Characteristics of the patients and lesions A total of 56 lesions were examined, of which six were excluded due to evaluation difficulties or pathological diagnoses indicating that they were not SNADETs, Consequently, 50 lesions were analyzed, comprising 46 intramucosal adenocarcinomas and 4 adenomas. Patients and lesion characteristics are summarized in Table 1. The mean patient age was 65.1 years, and there were 29 male participants. The mean lesion size was 15.0 mm. Underwater endoscopic mucosal resection (UEMR) was performed for 31 lesions, and endoscopic submucosal dissection (ESD) was performed for 19 lesions. Visibility score The mean visibility scores for WLI, NBI, and TXI in detecting SNADETs are presented in Table 2 and Figure 2. Under CO 2 insufflation, visibility score for TXI was significantly higher than that for WLI (2.7±0.8 vs 2.5±0.9, respectively, P = 0.002); however, no differences were observed between TXI and NBI (2.7±0.8 vs 2.6±0.7, respectively, P = 0.072). The visibility score in underwater condition were significantly higher than those in CO 2 insufflation condition in the three modes (WLI, 3.1±0.6 vs. 2.5±0.9, P ＜0.001; NBI, 2.9±0.7 vs. 2.6±0.7, P < 0.001; TXI, 3.2±0.5 vs. 2.7±0.8, P < 0.001). Color difference Color differences between SNADETs and background mucosa for WLI, NBI, and TXI are presented in Table 3 and Figure 3. No significant differences were observed in ΔE* and ΔL* between TXI and WLI under either CO 2 insufflation or underwater conditions. However, ΔC* in TXI was significantly higher than that in WLI under CO 2 insufflation (8.5±6.0 vs 5.9±3.9, P < 0.001) and underwater condition (9.2±5.6 vs 6.6±3.5, P < 0.001). Moreover, ΔE* and ΔL* in NBI were significantly higher than that in WLI under CO 2 insufflation (ΔE*, 15.7±7.6 vs 13.1±7.3, P = 0.004; ΔL*, 12.6±8.1 vs 10.0±6.9, P = 0.007) and underwater condition (ΔE*, 16.2±9.4 vs 13.4±6.7, P = 0.002; ΔL*, 13.5±9.7 vs 10.0±6.1, P < 0.001). In contrast, no significant differences were observed in ΔC* between NBI and WLI under either CO 2 insufflation or underwater conditions. Discussion To the best of our knowledge, this is the first study to evaluate the visibility and color differences of TXI in SNADETs. The visibility score for TXI under CO 2 insufflation was significantly higher than that for WLI but comparable to that for NBI. Furthermore, the saturation difference (ΔC*) for TXI was significantly higher than that for WLI. These findings suggest that TXI enhances the visibility of SNADETs compared to WLI, both subjectively and objectively. TXI is designed to emphasize the three-axis elements of texture, brightness, and color tone to clearly depict subtle differences in tissue characteristics [11]. It is hypothesized that TXI enhances subtle changes in reddish or white coloration and mucosal structure, which are difficult to recognize using WLI, and improves the visibility of SNADETs. Enhanced visibility of esophageal squamous cell carcinoma and gastric cancer was observed with TXI mode 1 compared with WLI [13-16]. These results, which align with the findings of this study, suggest that TXI mode 1 augments color contrast with the surrounding mucosa in upper gastrointestinal cancers. TXI mode 1 is expected to contribute to the detection of upper gastrointestinal cancers during screening. In the Lab color space, brightness is represented by the L-axis, and hue is represented by the a- and b-axes, with chroma (C*) defined as the saturation of a and b. In a detailed analysis of color differences, TXI demonstrated a higher ΔC* but a slightly lower ΔL* than WLI. This discrepancy is likely attributable to the underlying principle of TXI, which increases color contrast and brightness in both cancerous and non-cancerous areas, resulting in a higher ΔC* and lower ΔL* for TXI than for WLI. Conversely, NBI demonstrated a slightly lower ΔC* than that of WLI, with no significant difference. In contrast, NBI demonstrated a significantly higher ΔL* than WLI, indicating a different color contrast profile compared with TXI. These differences in the color values reflect the distinct features of each image enhancement technology. The detection of lesions requires a cognitive process that involves the identification of specific targets from visual information corresponding to a 'visual search' in the field of view [24]. Conspicuity is considered to play a major role in visual searches, particularly in detection. Conspicuity is closely associated with saturation difference (ΔC*), with warm colors typically exhibiting high conspicuity [25-28]. The color enhancement function in TXI emphasizes red hues, potentially increasing conspicuity, and significantly contributing to lesion detection. This likely led to improved visibility observed in the present study. This study also evaluated the visibility under underwater conditions, which has not been assessed extensively. Underwater conditions offer several advantages such as preventing light reflection from the mucosal surface, enhancing the visibility of fine mucosal structures, improving resolution, preventing bleeding due to mucosal contact, and facilitating the observation of lesions within the folds [29, 30]. Visibility scores under underwater conditions were significantly higher across all three modes compared with CO 2 insufflation, indicating that underwater conditions provide a superior field of view. Appropriate utilization of IEE can enable more accurate lesion diagnosis and treatment. Although numerous studies have reported the efficacy of magnified observations using NBI under underwater conditions, this study suggests that non-magnified observations can also enhance lesion visibility. Furthermore, various studies have demonstrated the utility of underwater observation and treatment in endoscopic procedures, such as UEMR, and the demand for underwater IEE for observation and treatment is expected to increase. This study had several limitations. First, the sample size was small, with potential biases related to the lesion location, size, shape, and observation environment. Additionally, the pathological evaluation and treatment choices were influenced by institutional standards. Further studies including more lesions across multiple institutions are required to address this limitation. Second, still images were used. In endoscopic observations, videos are typically used to visualize and search for lesions; therefore, the actual observation conditions and evaluation methods may differ. In conclusion, TXI significantly improved the visibility of SNADET compared to WLI. In particular, underwater observations significantly enhanced SNADET visibility compared to CO 2 insufflation. The increased visibility with TXI is likely due to the saturation difference (ΔC*) compared with WLI. These results indicated the effectiveness of TXI under both CO 2 insufflation and underwater conditions. Declarations Funding Olympus Co. loaned GIF-EZ1500 endoscopes and EVIS X1 systems for use during this study. Conflict of interest The authors have no relevant financial or non-financial interests to disclose. E thics approval Approval of the research protocol by an Institutional Reviewer Board: This study was approved by the Institutional Review Board of the Kyoto Prefectural University of Medicine under a central ethical review system (ERB-C-2009). P atient consent All patients provided written informed consent for participation in this trial and for receiving endoscopic or surgical treatment for SNADETs. P ermission to reproduce material from other sources Not applicable. C linical trial registration The study was registered with the University Hospital Medical Information Network Clinical Trials Registry, and the registration number was UMIN000043573. Authors’ contributions : Study design: Osamu Dohi. Acquisition of data: Katsuma Yamauchi, Naoto Iwai, Takahiro Nakano, Hiroaki Sakai, Toshifumi Tsuji, and Hiroaki Kitae. Image evaluation: Azumi Yahara, Hiroki Mukai, Tomoko Ochiai, Ken Inoue. Data analysis and interpretation: Katsuma Yamauchi and Osamu Dohi. Drafting of the manuscript: Katsuma Yamauchi. Final approval of the manuscript: Katsuma Yamauchi, Osamu Dohi, Naoto Iwai, Azumi Yahara, Tomoko Ochiai, Hiroki Mukai, Ken Inoue, Takahiro Nakano, Naoya Tomatsuri, Hiroaki Sakai, Toshifumi Tsuji, Hiroaki Kitae, Naoaki Akamatsu, Yoshito Itoh. Acknowledgements We thank all members of four facilities for reviewing this manuscript. 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Patients and lesions characteristics n = 50 Sex, n Male 29 Female 21 Age average (range), year 65.1 (31-85) Size, mean, mm (range) 15.0 (2-75) Location, n 1st portion 11 2nd portion 37 3rd portion 2 Morphological type 0-I 4 0-IIa 25 0-IIc 21 Treatment UEMR 31 ESD 19 Pathological diagnosis Adenoma 4 Adenocarcinoma 46 UEMR, underwater endoscopic mucosal resection; ESD, endoscopic submucosal dissection. Table 2. Visibility score for the three modes in both CO 2 insufflation and underwater conditions Visibility Score WLI NBI TXI WLI vs NBI, P value WLI vs TXI, P value NBI vs TXI, P value CO 2 2.5±0.9 2.6±0.7 2.7±0.8 0.105 0.002 0.072 Underwater 3.1±0.6 2.9±0.7 3.2±0.5 0.003 0.016 <0.001 CO 2 vs Underwater, P value <0.001 <0.001 <0.001 ― ― ― WLI, white-light imaging; NBI, narrow-band imaging; TXI, texture and color-enhancement imaging. Table 3. Color value difference WLI NBI TXI WLI vs NBI, P value WLI vs TXI, P value NBI vs TXI, P value ΔE* CO 2 13.1±7.3 15.7±7.6 14.2±7.7 0.004 0.125 0.093 Underwater 13.4±6.7 16.2±9.4 14.8±6.6 0.002 0.140 0.222 ΔC* CO 2 5.9±3.9 5.7±2.9 8.5±6.0 0.806 <0.001 0.003 Underwater 6.6±3.5 5.2±2.8 9.2±5.6 0.024 <0.001 <0.001 ΔL* CO 2 10.0±6.9 12.6±8.1 9.2±6.3 0.007 0.311 <0.001 Underwater 10.0±6.1 13.5±9.7 9.2±5.7 <0.001 0.265 <0.001 Δa* CO 2 5.9±3.9 6.5±3.6 8.1±5.7 0.419 <0.001 0.090 Underwater 6.4±3.9 6.3±3.7 9.1±5.5 0.956 <0.001 0.002 Δb* CO 2 3.5±1.9 2.9±1.4 4.2±2.6 0.016 0.016 <0.001 Underwater 3.6±2.7 2.7±1.5 4.0±2.4 0.016 0.464 0.003 WLI, white-light imaging; NBI, narrow-band imaging; TXI, texture and color-enhancement imaging. Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8802398","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":591012740,"identity":"6d05d68c-783d-4d3f-966c-441b79a298a9","order_by":0,"name":"Katsuma Yamauchi","email":"","orcid":"","institution":"Kyoto Prefectural University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Katsuma","middleName":"","lastName":"Yamauchi","suffix":""},{"id":591012741,"identity":"6cbcd8c4-5f0b-4883-b69d-25f89a699e58","order_by":1,"name":"Osamu 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Medicine","correspondingAuthor":false,"prefix":"","firstName":"Naoto","middleName":"","lastName":"Iwai","suffix":""},{"id":591012745,"identity":"9da1d43b-e008-47ef-8aa5-9beb7efcc02d","order_by":3,"name":"Azumi Yahara","email":"","orcid":"","institution":"Otsu city Hospital","correspondingAuthor":false,"prefix":"","firstName":"Azumi","middleName":"","lastName":"Yahara","suffix":""},{"id":591012746,"identity":"80534a82-5fe8-47aa-8294-95a04e90f6d0","order_by":4,"name":"Tomoko Ochiai","email":"","orcid":"","institution":"Kyoto Prefectural University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Tomoko","middleName":"","lastName":"Ochiai","suffix":""},{"id":591012748,"identity":"edf959e0-190a-455a-842a-42631154a6e1","order_by":5,"name":"Hiroki Mukai","email":"","orcid":"","institution":"Kyoto Prefectural University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Hiroki","middleName":"","lastName":"Mukai","suffix":""},{"id":591012749,"identity":"8d5758ca-a78b-42a3-8655-b5b11b0f4388","order_by":6,"name":"Ken Inoue","email":"","orcid":"","institution":"Kyoto Prefectural University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Ken","middleName":"","lastName":"Inoue","suffix":""},{"id":591012753,"identity":"893dca63-f45d-4798-939f-725a245b395d","order_by":7,"name":"Takahiro Nakano","email":"","orcid":"","institution":"Medical Corporation Keishinkai, Kyoto Kizugawa Hospital","correspondingAuthor":false,"prefix":"","firstName":"Takahiro","middleName":"","lastName":"Nakano","suffix":""},{"id":591012754,"identity":"c6b547d2-e548-4ca7-9c0c-60712cea8103","order_by":8,"name":"Naoya Tomatsuri","email":"","orcid":"","institution":"Japanese Red Cross Kyoto Daiichi Hospital","correspondingAuthor":false,"prefix":"","firstName":"Naoya","middleName":"","lastName":"Tomatsuri","suffix":""},{"id":591012755,"identity":"04453299-9d7c-4f68-953d-1eaa40392210","order_by":9,"name":"Hiroaki Sakai","email":"","orcid":"","institution":"Fukuchiyama City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Hiroaki","middleName":"","lastName":"Sakai","suffix":""},{"id":591012756,"identity":"02d23813-9347-485f-928d-ef63715f687d","order_by":10,"name":"Toshifumi Tsuji","email":"","orcid":"","institution":"Fukuchiyama City Hospital","correspondingAuthor":false,"prefix":"","firstName":"Toshifumi","middleName":"","lastName":"Tsuji","suffix":""},{"id":591012758,"identity":"0fbbd54c-6126-40e2-bc27-a09325f2cd9f","order_by":11,"name":"Hiroaki Kitae","email":"","orcid":"","institution":"Omihachiman Community Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Hiroaki","middleName":"","lastName":"Kitae","suffix":""},{"id":591012761,"identity":"150aec9a-3e04-4f27-ba73-a46f3b0377dd","order_by":12,"name":"Naoaki Akamatsu","email":"","orcid":"","institution":"Omihachiman Community Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Naoaki","middleName":"","lastName":"Akamatsu","suffix":""},{"id":591012763,"identity":"2eb67d1b-1b65-4d9a-a276-b8117c7c1a3b","order_by":13,"name":"Yoshito Itoh","email":"","orcid":"","institution":"Kyoto Prefectural University of Medicine","correspondingAuthor":false,"prefix":"","firstName":"Yoshito","middleName":"","lastName":"Itoh","suffix":""}],"badges":[],"createdAt":"2026-02-06 04:08:30","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8802398/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8802398/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102791332,"identity":"a1b430de-cb6d-479f-be53-1af22409ac9c","added_by":"auto","created_at":"2026-02-16 17:18:35","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":609970,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eImage evaluation\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe images were captured using three modes from the same site and angle during CO\u003csub\u003e2\u003c/sub\u003e insufflation and under water conditions. Two points were designated inside and outside the lesion, along a straight line in the short-axis direction. The color values were calculated at four points. (a) white light imaging (WLI), (b) narrow-band imaging (NBI), (c) texture and color-enhancement imaging (TXI).\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8802398/v1/1c558755678ac63872ad6da9.png"},{"id":102962345,"identity":"d10729ab-1d2b-4c6b-843b-c0c353e1122d","added_by":"auto","created_at":"2026-02-19 04:07:19","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":50213,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eMean visibility score under CO\u003c/strong\u003e\u003csub\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sub\u003e\u003cstrong\u003e insufflation and underwater conditions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe orange and blue bars represent CO\u003csub\u003e2\u003c/sub\u003e insufflation and underwater conditions, respectively. TXI had the highest score compared to WLI and NBI, with a significant difference in both conditions. The visibility score in each mode under underwater conditions was higher than that under CO\u003csub\u003e2\u003c/sub\u003e insufflation. WLI, white light imaging; NBI, narrow-band imaging; TXI, texture and color-enhancement imaging.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8802398/v1/a0486232314ba4614c4da7fe.png"},{"id":102791331,"identity":"98b1c202-07a6-4a54-8b13-2d7f468ef32b","added_by":"auto","created_at":"2026-02-16 17:18:34","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":74586,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eColor value evaluation in CO\u003c/strong\u003e\u003csub\u003e\u003cstrong\u003e2\u003c/strong\u003e\u003c/sub\u003e\u003cstrong\u003e insufflation.\u003c/strong\u003e (a) color difference (ΔE*), (b) saturation difference (ΔC*) and (c) lightness difference (ΔL*). ΔE*and ΔL* in NBI were significantly higher than those in WLI and TXI (*\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05). ΔC* in TXI was significantly higher than that in WLI and NBI (*\u003cem\u003eP\u003c/em\u003e \u0026lt; 0.05). NBI, narrow-band imaging; TXI, texture and color-enhancement imaging; WLI, white light imaging.\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-8802398/v1/f384db746f180dc9249cbab6.png"},{"id":102965808,"identity":"0359c19a-0a86-4ccb-a8aa-1d3541c22c6f","added_by":"auto","created_at":"2026-02-19 04:33:02","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1600881,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8802398/v1/d4d60208-d13f-4047-8845-5f4b8808951f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Texture and color enhancement imaging improves visibility of superficial non- ampullary duodenal epithelial tumors","fulltext":[{"header":"Introduction","content":"\u003cp\u003eSuperficial non-ampullary duodenal epithelial tumors (SNADETs) are rare, with endoscopic detection rates of 0.15%–0.3% for adenomas and 0.0023%–0.7% for carcinomas [1-4]. However, duodenal cancers are often identified at advanced stages, leading to poor prognosis with five-year survival rates estimated at 2.1-58.2% [5]. Early detection and treatment are essential to improve the prognosis of SNADETs. Recent advancements in endoscopic technology and improved observational capabilities have increased SNADET detection rates [6, 7]. However, there is little evidence to establish effective methods for early detection of SNADETs.\u003c/p\u003e\n\u003cp\u003eSeveral image-enhanced endoscopic modalities have been reported to facilitate the detection of gastrointestinal tumors\u0026nbsp;[8-10]. Texture and color enhancement imaging (TXI), developed in 2020, highlights subtle color and structural changes [11]. Previous reports have demonstrated that TXI improves the visibility of gastric tumors compared to white light imaging (WLI)\u0026nbsp;[12-14]. Although TXI may improve the visibility of SNADET compared to WLI, its effectiveness has not been fully established.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eEndoscopic resection is often performed for SNADETs measuring ≤20 mm. Recent studies have highlighted the utility of techniques such as underwater endoscopic mucosal resection (UEMR) [15-18], leading to a growing demand for underwater observation and treatment. However, achieving optimal visibility using WLI under underwater conditions is challenging. Furthermore, to date, no studies have examined whether image-enhanced endoscopy (IEE) can improve the visibility of SNADETs under underwater conditions.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTherefore, this study aimed to investigate whether TXI improves SNADET visibility under both insufflation and underwater conditions. Enhanced visibility may facilitate early detection and treatment and reduce complications associated with larger lesions. Understanding the effectiveness of TXI under these conditions could expand its application in endoscopic practice and potentially improve patient prognosis.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003e\u003cem\u003eStudy design and eligible patients\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThis study was conducted as a post-hoc analysis of prospectively collected endoscopic images. Patients with SNADETs were prospectively enrolled at the Kyoto Prefectural University of Medicine, Japanese Red Cross Kyoto Daiichi Hospital, Fukuchiyama City Hospital, and Omihachiman Community Medical Center. This study spanned from July 2022 to March 2023 and targeted SNADETs prior to endoscopic and surgical treatments. Patients with recurrent lesions or markers around the tumor were excluded.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEndoscopic system, device, and setting\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eEsophagogastroduodenoscopy was performed using an EVIS X1 video system with a GIF-H290Z or GIF-EZ1500 scope (Olympus Medical Systems Co., Tokyo, Japan). Only TXI mode 1 was employed in this study, because TXI mode 2 lacked color enhancement.[11, 19] For the enhanced structural level, A3 was selected for WLI and TXI, whereas B8 was selected for narrow-band imaging (NBI).\u003c/p\u003e\n\u003cp\u003eAll the lesions were captured under both CO2 insufflation and underwater conditions using WLI, NBI, and TXI. To ensure consistency in evaluating SNADET visibility, images were captured from the same distance and angle for each mode under both conditions. The endoscopic treatment was performed by an endoscopist at each institution.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVisibility score\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eImages were presented to four endoscopists, including two experts and two non-experts. These four endoscopists were independently selected without prior knowledge of SNADET or the study concept. Experts (T.O. and K.I.) were defined as endoscopists certified by the Japan Gastroenterological Endoscopy Society, whereas non-experts (A.Y. and H.M.) were defined as endoscopists with ≤5 years of experience and without certification. Each image was randomly presented on a single slide. The visibility score was defined using a four-level visibility scale for detection: 4, excellent visibility (easily detectable); 3, good visibility (detectable with careful observation); 2, fair visibility (hardly detectable without careful examination); and 1, poor visibility (undetectable without repeated careful examination).[20]\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePathological diagnosis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eAll the neoplastic specimens obtained via biopsy or endoscopic resection were fixed in 10% formalin for pathological evaluation. Diagnoses were categorized by experienced clinical pathologists at each participating institution. If there were any discrepancies between the biopsy and endoscopically resected specimens, the final diagnosis was determined based on the endoscopically resected specimens.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSample size calculation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe mean visibility scores for duodenal tumors were reported as 2.66, 2.92, and 2.40 for WLI and 3.53, 3.85, and 3.21 for LCI by all, expert, and trainee endoscopists, respectively [21]. Based on this report, assuming that the visibility scores of TXI and WLI were equivalent to the minimum of LCI and maximum of WLI, with an assumed visibility score of 3.3 for TXI and 2.9 for WLI, setting the detection power to 80% with an alpha error rate of 5%, the sample size was calculated to be 50 cases. A total of 50 images were required for each mode under CO\u003csub\u003e2\u003c/sub\u003e insufflation and underwater conditions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eColor measurement and analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eTo objectively assess the color differences in SNADETs, images were evaluated based on the CIE1976(L*a*b*) color space system (CIELAB) using Adobe Photoshop (Adobe Inc., San Jose, CA, USA). As mentioned in previous reports,[22] the tumor area was first defined, and the regions of interest (ROIs) were selected within a 20 × 20-pixel range for each mode. Two points were designated inside and outside the lesion, along a straight line in the short-axis direction (Fig. 1). The color values (L*/a*/b*) of the inside and outside ROIs were measured and the mean color difference (ΔE*) between the two regions was calculated using the following formula:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eΔE* = [(ΔL*)2+(Δa*)2+(Δb*)2]1/2\u003c/p\u003e\n\u003cp\u003eWhere:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eΔL* = L*i − L*o (inside minus outside the lesion)\u003c/p\u003e\n\u003cp\u003eΔa* = a*i − a*o (inside minus outside the lesion)\u003c/p\u003e\n\u003cp\u003eΔb* = b*i − b*o (inside minus outside the lesion)\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;Additionally, the saturation difference (ΔC*) was calculated as follows:\u003c/p\u003e\n\u003cp\u003eC＝[(a*)2+(b*)2]1/2\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp;ΔC*＝C*i − C*o\u003c/p\u003e\n\u003cp\u003eWhere C*i and C*o represent the saturation measurements inside and outside the lesion, respectively.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEndpoint\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe primary endpoint was the visibility score for each mode. The secondary endpoints included color value differences, such as color difference (ΔE*), saturation difference (ΔC*), and lightness difference (ΔL*), between the tumor and background mucosa, as assessed using WLI, NBI, and TXI.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analysis\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFor lesion characteristics and continuous variables, such as visibility score and color difference, t-tests were applied. Chi-squared tests were used for categorical variables and other analyses. All statistical analyses were performed using EZR (Saitama Medical Center, Jichi Medical University, Saitama, Japan), which is a graphical user interface for R ( R Foundation for Statistical Computing, Vienna, Austria). EZR is a modified version of the R Commander software, designed to include statistical functions frequently used in biostatistics.[23]\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eCharacteristics of the patients and lesions\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eA total of 56 lesions were examined, of which six were excluded due to evaluation difficulties or pathological diagnoses indicating that they were not SNADETs, Consequently, 50 lesions were analyzed, comprising 46 intramucosal adenocarcinomas and 4 adenomas. Patients and lesion characteristics are summarized in Table 1. The mean patient age was 65.1 years, and there were 29 male participants. The mean lesion size was 15.0 mm. Underwater endoscopic mucosal resection (UEMR) was performed for 31 lesions, and endoscopic submucosal dissection (ESD) was performed for 19 lesions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eVisibility score\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe mean visibility scores for WLI, NBI, and TXI in detecting SNADETs are presented in Table 2 and Figure 2. Under CO\u003csub\u003e2\u003c/sub\u003e insufflation, visibility score for TXI was significantly higher than that for WLI (2.7±0.8 vs 2.5±0.9, respectively, \u003cem\u003eP\u003c/em\u003e = 0.002); however, no differences were observed between TXI and NBI (2.7±0.8 vs 2.6±0.7, respectively, \u003cem\u003eP\u003c/em\u003e = 0.072). The visibility score in underwater condition were significantly higher than those in CO\u003csub\u003e2\u003c/sub\u003e insufflation condition in the three modes (WLI, 3.1±0.6 vs. 2.5±0.9, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e＜0.001; NBI, 2.9±0.7 vs. 2.6±0.7, \u003cem\u003eP\u0026nbsp;\u003c/em\u003e\u0026lt; 0.001; TXI, 3.2±0.5 vs. 2.7±0.8, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eColor difference\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eColor differences between SNADETs and background mucosa for WLI, NBI, and TXI are presented in Table 3 and Figure 3. No significant differences were observed in ΔE* and ΔL* between TXI and WLI under either CO\u003csub\u003e2\u0026nbsp;\u003c/sub\u003einsufflation or underwater conditions. However, ΔC* in TXI was significantly higher than that in WLI under CO\u003csub\u003e2\u0026nbsp;\u003c/sub\u003einsufflation (8.5±6.0 vs 5.9±3.9, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001) and underwater condition (9.2±5.6 vs 6.6±3.5, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001).\u003c/p\u003e\n\u003cp\u003eMoreover, ΔE* and ΔL* in NBI were significantly higher than that in WLI under CO\u003csub\u003e2\u0026nbsp;\u003c/sub\u003einsufflation (ΔE*, 15.7±7.6 vs 13.1±7.3, \u003cem\u003eP\u003c/em\u003e = 0.004; ΔL*, 12.6±8.1 vs 10.0±6.9, \u003cem\u003eP\u003c/em\u003e = 0.007) and underwater condition (ΔE*, 16.2±9.4 vs 13.4±6.7, \u003cem\u003eP\u003c/em\u003e = 0.002; ΔL*, 13.5±9.7 vs 10.0±6.1, \u003cem\u003eP\u003c/em\u003e \u0026lt; 0.001). In contrast, no significant differences were observed in ΔC* between NBI and WLI under either CO\u003csub\u003e2\u0026nbsp;\u003c/sub\u003einsufflation or underwater conditions.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eTo the best of our knowledge, this is the first study to evaluate the visibility and color differences of TXI in SNADETs. The visibility score for TXI under CO\u003csub\u003e2\u003c/sub\u003e insufflation was significantly higher than that for WLI but comparable to that for NBI. Furthermore, the saturation difference (ΔC*) for TXI was significantly higher than that for WLI. These findings suggest that TXI enhances the visibility of SNADETs compared to WLI, both subjectively and objectively.\u003c/p\u003e\n\u003cp\u003eTXI is designed to emphasize the three-axis elements of texture, brightness, and color tone to clearly depict subtle differences in tissue characteristics [11]. It is hypothesized that TXI enhances subtle changes in reddish or white coloration and mucosal structure, which are difficult to recognize using WLI, and improves the visibility of SNADETs. Enhanced visibility of esophageal squamous cell carcinoma and gastric cancer was observed with TXI mode 1 compared with WLI [13-16]. These results, which align with the findings of this study, suggest that TXI mode 1 augments color contrast with the surrounding mucosa in upper gastrointestinal cancers. TXI mode 1 is expected to contribute to the detection of upper gastrointestinal cancers during screening.\u003c/p\u003e\n\u003cp\u003eIn the Lab color space, brightness is represented by the L-axis, and hue is represented by the a- and b-axes, with chroma (C*) defined as the saturation of a and b. In a detailed analysis of color differences, TXI demonstrated a higher ΔC* but a slightly lower ΔL* than WLI. This discrepancy is likely attributable to the underlying principle of TXI, which increases color contrast and brightness in both cancerous and non-cancerous areas, resulting in a higher ΔC* and lower ΔL* for TXI than for WLI. Conversely, NBI demonstrated a slightly lower ΔC* than that of WLI, with no significant difference. In contrast, NBI demonstrated a significantly higher ΔL* than WLI, indicating a different color contrast profile compared with TXI. These differences in the color values reflect the distinct features of each image enhancement technology.\u003c/p\u003e\n\u003cp\u003eThe detection of lesions requires a cognitive process that involves the identification of specific targets from visual information corresponding to a 'visual search' in the field of view [24]. Conspicuity is considered to play a major role in visual searches, particularly in detection. Conspicuity is closely associated with saturation difference (ΔC*), with warm colors typically exhibiting high conspicuity [25-28]. The color enhancement function in TXI emphasizes red hues, potentially increasing conspicuity, and significantly contributing to lesion detection. This likely led to improved visibility observed in the present study.\u003c/p\u003e\n\u003cp\u003eThis study also evaluated the visibility under underwater conditions, which has not been assessed extensively. Underwater conditions offer several advantages such as preventing light reflection from the mucosal surface, enhancing the visibility of fine mucosal structures, improving resolution, preventing bleeding due to mucosal contact, and facilitating the observation of lesions within the folds [29, 30]. Visibility scores under underwater conditions were significantly higher across all three modes compared with CO\u003csub\u003e2\u003c/sub\u003e insufflation, indicating that underwater conditions provide a superior field of view. Appropriate utilization of IEE can enable more accurate lesion diagnosis and treatment. Although numerous studies have reported the efficacy of magnified observations using NBI under underwater conditions, this study suggests that non-magnified observations can also enhance lesion visibility. Furthermore, various studies have demonstrated the utility of underwater observation and treatment in endoscopic procedures, such as UEMR, and the demand for underwater IEE for observation and treatment is expected to increase.\u003c/p\u003e\n\u003cp\u003eThis study had several limitations. First,\u0026nbsp;the sample size was small, with potential biases related to the lesion location, size, shape, and observation environment. Additionally, the pathological evaluation and treatment choices were influenced by institutional standards. Further studies including more lesions across multiple institutions are required to address this limitation. Second, still images were used. In endoscopic observations, videos are typically used to visualize and search for lesions; therefore, the actual observation conditions and evaluation methods may differ.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eIn conclusion, TXI significantly improved the visibility of SNADET compared to WLI. In particular, underwater observations significantly enhanced SNADET visibility compared to CO\u003csub\u003e2\u003c/sub\u003e insufflation. The increased visibility with TXI is likely due to the saturation difference (ΔC*) compared with WLI. These results indicated the effectiveness of TXI under both CO\u003csub\u003e2\u003c/sub\u003e insufflation and underwater conditions.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eOlympus Co. loaned GIF-EZ1500 endoscopes and EVIS X1 systems for use during this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflict of interest\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors have no relevant financial or non-financial interests to disclose.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eE\u003c/strong\u003e\u003cstrong\u003ethics approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eApproval of the research protocol by an Institutional Reviewer Board: This study was approved by the Institutional Review Board of the Kyoto Prefectural University of Medicine under a central ethical review system (ERB-C-2009).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003cstrong\u003eatient consent\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll patients provided written informed consent for participation in this trial and for receiving endoscopic or surgical treatment for SNADETs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eP\u003c/strong\u003e\u003cstrong\u003eermission to reproduce material from other sources\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eC\u003c/strong\u003e\u003cstrong\u003elinical trial registration\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe study was registered with the University Hospital Medical Information Network Clinical Trials Registry, and the registration number was UMIN000043573.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e: Study design: Osamu Dohi. Acquisition of data: Katsuma Yamauchi, Naoto Iwai, Takahiro Nakano, Hiroaki Sakai, Toshifumi Tsuji, and Hiroaki Kitae. Image evaluation: Azumi Yahara, Hiroki Mukai, Tomoko Ochiai, Ken Inoue. Data analysis and interpretation: Katsuma Yamauchi and Osamu Dohi. Drafting of the manuscript: Katsuma Yamauchi. Final approval of the manuscript: Katsuma Yamauchi, Osamu Dohi, Naoto Iwai, Azumi Yahara, Tomoko Ochiai, Hiroki Mukai, Ken Inoue, Takahiro Nakano, Naoya Tomatsuri, Hiroaki Sakai, Toshifumi Tsuji, Hiroaki Kitae, Naoaki Akamatsu, Yoshito Itoh.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank all members of four facilities for reviewing this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability\u003c/strong\u003e\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll the data included in this study are available from the corresponding author upon request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eYoshimizu S, Hirasawa T, Horiuchi Y, et al. 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Patients and lesions characteristics\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"61%\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 151px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003en = 50\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 397px;\"\u003e\n \u003cp\u003eSex, n\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eMale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e29\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eFemale\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 189px;\"\u003e\n \u003cp\u003eAge average (range), year\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e65.1 (31-85)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" style=\"width: 189px;\"\u003e\n \u003cp\u003eSize, mean, mm (range)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e15.0 (2-75)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 397px;\"\u003e\n \u003cp\u003eLocation, n\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e1st portion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e11\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e2nd portion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e37\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e3rd portion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e2\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 397px;\"\u003e\n \u003cp\u003eMorphological type\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e0-I\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e0-IIa\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e25\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003e0-IIc\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e21\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 397px;\"\u003e\n \u003cp\u003eTreatment\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eUEMR\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e31\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eESD\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e19\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"3\" style=\"width: 397px;\"\u003e\n \u003cp\u003ePathological diagnosis\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 38px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eAdenoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e4\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 151px;\"\u003e\n \u003cp\u003eAdenocarcinoma\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 208px;\"\u003e\n \u003cp\u003e46\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eUEMR, underwater endoscopic mucosal resection; ESD, endoscopic submucosal dissection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 2. Visibility score for the three modes in both CO\u003csub\u003e2\u003c/sub\u003e insufflation and underwater conditions\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"662\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eVisibility Score\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eWLI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eNBI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eTXI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eWLI vs NBI,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eWLI vs TXI,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003eNBI vs TXI,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e2.5\u0026plusmn;0.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2.6\u0026plusmn;0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e2.7\u0026plusmn;0.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0.105\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e0.072\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eUnderwater\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e3.1\u0026plusmn;0.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e2.9\u0026plusmn;0.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e3.2\u0026plusmn;0.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eCO\u003csub\u003e2\u003c/sub\u003e vs\u003c/p\u003e\n \u003cp\u003eUnderwater,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e―\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e―\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 95px;\"\u003e\n \u003cp\u003e―\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWLI, white-light imaging; NBI, narrow-band imaging; TXI, texture and color-enhancement imaging.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3. Color value difference\u003c/strong\u003e\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"658\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eWLI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eNBI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eTXI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eWLI vs NBI,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003eWLI vs TXI,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003eNBI vs TXI,\u003c/p\u003e\n \u003cp\u003e\u003cem\u003eP\u003c/em\u003e value\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 658px;\"\u003e\n \u003cp\u003e\u0026Delta;E*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e13.1\u0026plusmn;7.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e15.7\u0026plusmn;7.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e14.2\u0026plusmn;7.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.125\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0.093\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eUnderwater\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e13.4\u0026plusmn;6.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e16.2\u0026plusmn;9.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e14.8\u0026plusmn;6.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.140\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0.222\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 658px;\"\u003e\n \u003cp\u003e\u0026Delta;C*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e5.9\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e5.7\u0026plusmn;2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e8.5\u0026plusmn;6.0\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.806\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eUnderwater\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e6.6\u0026plusmn;3.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e5.2\u0026plusmn;2.8\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e9.2\u0026plusmn;5.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.024\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 658px;\"\u003e\n \u003cp\u003e\u0026Delta;L*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e10.0\u0026plusmn;6.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e12.6\u0026plusmn;8.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e9.2\u0026plusmn;6.3\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.007\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.311\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eUnderwater\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e10.0\u0026plusmn;6.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e13.5\u0026plusmn;9.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e9.2\u0026plusmn;5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.265\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 658px;\"\u003e\n \u003cp\u003e\u0026Delta;a*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e5.9\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e6.5\u0026plusmn;3.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e8.1\u0026plusmn;5.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.419\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0.090\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eUnderwater\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e6.4\u0026plusmn;3.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e6.3\u0026plusmn;3.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e9.1\u0026plusmn;5.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.956\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" style=\"width: 658px;\"\u003e\n \u003cp\u003e\u0026Delta;b*\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eCO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e3.5\u0026plusmn;1.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e2.9\u0026plusmn;1.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e4.2\u0026plusmn;2.6\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd style=\"width: 98px;\"\u003e\n \u003cp\u003eUnderwater\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e3.6\u0026plusmn;2.7\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e2.7\u0026plusmn;1.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e4.0\u0026plusmn;2.4\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.016\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 93px;\"\u003e\n \u003cp\u003e0.464\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 94px;\"\u003e\n \u003cp\u003e0.003\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003eWLI, white-light imaging; NBI, narrow-band imaging; TXI, texture and color-enhancement imaging.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Narrow-band imaging, superficial non-ampullary duodenal epithelial tumor, texture and color enhancement imaging, visibility, white light imaging","lastPublishedDoi":"10.21203/rs.3.rs-8802398/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8802398/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003ePurpose\u003c/h2\u003e \u003cp\u003eAlthough image-enhanced endoscopy (IEE) is useful, its benefit over white light imaging (WLI) for the detection of superficial non-ampullary duodenal epithelial tumors (SNADETs) remains unclear. We evaluated whether narrow-band imaging (NBI) and texture and color enhancement imaging (TXI) could improve SNADET visibility compared to WLI under CO\u003csub\u003e2\u003c/sub\u003e insufflation and underwater conditions.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eWe conducted a post-hoc analysis using a prospectively collected image database from patients with SNADET enrolled in a multicenter observational study. We used the EVIS X1 system with a GIF-H290Z or GIF-EZ1500 endoscope to compare the visibility scores for the recognition of SNADETs. We also measured the color difference (ΔE*), saturation difference (ΔC*), and lightness difference(ΔL*) between the tumor and background mucosa.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eWe analyzed 50 lesions, comprising 46 intramucosal adenocarcinomas and 4 adenomas. Under CO\u003csub\u003e2\u003c/sub\u003e insufflation, TXI provided a significantly higher visibility score than the WLI (2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 vs 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.002); however, no significant differences were observed between TXI and NBI (2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 vs 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.072). Underwater conditions yielded significantly higher visibility scores than CO\u003csub\u003e2\u003c/sub\u003e insufflation across the three modes (WLI, 3.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.6 vs. 2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;0.9, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; NBI, 2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7 vs. 2.6\u0026thinsp;\u0026plusmn;\u0026thinsp;0.7, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001; TXI, 3.2\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 vs. 2.7\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The ΔC* in TXI was significantly higher than that in WLI under CO\u003csub\u003e2\u003c/sub\u003e insufflation (8.5\u0026thinsp;\u0026plusmn;\u0026thinsp;6.0 vs 5.9\u0026thinsp;\u0026plusmn;\u0026thinsp;3.9, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and underwater condition (9.2\u0026thinsp;\u0026plusmn;\u0026thinsp;5.6 vs 6.6\u0026thinsp;\u0026plusmn;\u0026thinsp;3.5, \u003cem\u003eP\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eTXI significantly improved SNADET visibility compared to WLI under CO\u003csub\u003e2\u003c/sub\u003e insufflation and underwater conditions, likely due to the increased saturation difference.\u003c/p\u003e","manuscriptTitle":"Texture and color enhancement imaging improves visibility of superficial non- ampullary duodenal epithelial tumors","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-16 17:18:30","doi":"10.21203/rs.3.rs-8802398/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"2a01b8f4-5a16-42cf-af10-1b61a5e72d84","owner":[],"postedDate":"February 16th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2026-02-18T08:42:02+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-16 17:18:30","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8802398","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8802398","identity":"rs-8802398","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}