Colorectal cancer (CRC) is one of the most common cancers worldwide [1]. Most CRCs develop from malignant potential polyps, especially adenomas, sessile serrated polyps (SSPs), and sessile serrated lesions (SSLs) [2]. Screening is associated with a reduction in CRC incidence through the detection and removal of precancerous polyps and with a decrease in CRC-related death through a reduction of the incidence and early detection of CRC [3]. Colonoscopy is the most widely used screening tool. Unfortunately, during colonoscopy, a substantial number of polyps are still being missed [4]. Those missed polyps are thought to be at least 50 % of interval CRCs [5], [6].

About 13 % of the internal colon surface is out of view during standard colonoscopy (SC) screening. [7], and up to a quarter of polyps may be missed in blind areas [8], [9], [10]. Thus, improved polyp detection is a primary focus of quality improvement measures in screening colonoscopy.

To improve mucosal visualization, behind-folds visualizing techniques have been developed to improve visualization of the proximal side of the folds, thereby reducing blind areas as an attempt to maximize the detection of polyps; these techniques include: Third-Eye Retroscope® allows a back view [11], and Full Spectrum Endoscopy™ provides a much more comprehensive view of 330 degrees compared to the 170 degrees with SC [12], but the two are a pricey investment. [13]. Transparent caps and EndoRings TM applied at the tip of the SC have been used. During colonoscopy withdrawal, these tools stretch the mucosa and flatten the colon folds, improving the visibility of these regions [14].

EndoCuff (Arc Medical Design Ltd., Leeds, England) is a device attached to the tip of the colonoscope. The first-generation, ENDOCUFF™, was introduced in 2012, a 2-cm long, disposable cuff with flexible fingerlike projections arranged in two rows that flatten towards the colonoscope during insertion but extend out against the colonic wall during withdrawal. This allows engagement of the cuff projections with the colonic folds, flattening them out and preventing accidental backward slipping of the scope at various flexures; it was initially developed to increase tip stability and improve access when performing endoscopic therapy [15]. The second generation ENDOCUFF VISION™ has been developed to decrease mucosal scratches, has only one row of longer and flexible fingerlike projections that do not project beyond the tip of the colonoscope [16], [17].

Parallel studies have shown controversial results. Some studies showed that EndoCuff-assisted colonoscopy (EAC) has a higher adenoma detection rate (ADR) compared to SC [18], [19], [20], [21]. However, other studies showed no statistical significance between EAC and SC [22], [23]. Therefore, cross-over back-to-back research studies are encouraged to assess the effectiveness of this novel endoscopic technique.