Beyond White-Light Colonoscopy: Water Exchange, Image-Enhanced Endoscopy, and Artificial Intelligence for Colorectal Neoplasia Detection—From Single Tools to Combined Strategies: A Scoping Review

Background: Water exchange, image-enhanced endoscopy (IEE), and computer-aided detection (CADe) address different reasons why colorectal lesions may be missed. Whether their benefits add up when the techniques are combined remains unclear. Objective: We mapped clinical and video-based evidence on combinations of these techniques for colorectal neoplasia detection. Methods: We conducted a scoping review following JBI methodology and PRISMA-ScR, with a protocol registered on the Open Science Framework. We searched PubMed, Web of Science, Scopus, ClinicalTrials.gov, and reference lists through September 2026. Eligible studies evaluated at least two techniques together in adults and reported a detection outcome. Large language model tools assisted screening, with reviewer verification. We summarized findings descriptively and added a structured, domain-based critical appraisal during revision. Results: From 644 database records, we included 18 studies: 13 patient-level clinical studies, nine randomized, and five lesion- or video-level studies. Most examined IEE with CADe. One trial directly added CADe to water exchange; one tested all three technique groups. No included clinical study used water immersion. Randomized incremental comparisons showed inconsistent adenoma detection rate (ADR) gains, while multicomponent trials could not isolate component effects. Historical controls, discretionary technique selection, selected video material, and incomplete reporting constrained other comparisons. Evidence on advanced and serrated lesions, procedural burden, and patient-important outcomes was limited. Conclusions: Combined strategies improved detection in some settings, but comparative effectiveness and net clinical benefit remain uncertain. Trials should isolate component effects and measure clinically relevant detection alongside procedural burden.