Post written by Roberto de Sire, MD, PhD, and Roberta Maselli, MD, PhD, FESGE, FJGES, from the the Endoscopy Unit, Gastroenterology Department, Humanitas Research Hospital IRCCS, Rozzano, Italy.

Third-space endoscopy is fundamentally a visual discipline. Whether it is endoscopic submucosal dissection or peroral endoscopic myotomy, every procedural decision depends on the operator’s ability to accurately recognize tissue planes and vascular structures in real time.

We designed this prospective video-based study to answer a simple but clinically relevant question: can amber-red color imaging (ACI), a novel image-enhanced modality, improve recognition of key anatomical structures compared with conventional white-light imaging (WLI)? 

Although image-enhanced endoscopy has transformed lesion detection and characterization, relatively little attention has been devoted to technologies specifically designed to assist therapeutic procedures. ACI was developed to enhance visualization of blood-rich and deep submucosal structures by exploiting longer light wavelengths. We wanted to evaluate whether these optical advantages translate into better anatomical recognition for both experienced and less-experienced endoscopists during complex endoscopic procedures. 

Our study demonstrated that ACI consistently improved recognition of submucosal vessels, the submucosal layer, and the muscularis propria compared with WLI. Importantly, the benefit was observed in both experts and nonexperts, with remarkably large effect sizes across all anatomical targets. Perhaps the most striking finding was that nonexpert endoscopists using ACI achieved, and in vessel recognition even surpassed, the performance of experts using conventional WLI. In addition, ACI reduced interobserver variability, suggesting a more standardized interpretation of anatomical planes. 

We believe these findings extend beyond simple image enhancement. Accurate identification of vessels and tissue planes underpins safe dissection, efficient hemostasis, and preservation of the correct surgical plane during endoscopic submucosal dissection and peroral endoscopic myotomy. Technologies that improve visual confidence may therefore not only optimize procedural performance but also facilitate training by helping narrow the gap between novice and expert operators.

More broadly, this work reflects an important evolution in therapeutic endoscopy. The next generation of innovation is unlikely to arrive solely from new devices or accessories, but increasingly from technologies that augment the endoscopist’s vision and decision-making in real time.

Rather than replacing operator expertise, enhanced imaging has the potential to amplify it, making complex procedures safer, more reproducible, and ultimately more accessible. Future clinical studies should now determine whether these improvements in anatomical recognition translate into tangible procedural benefits, including faster dissections, fewer adverse events, and improved clinical outcomes. 

A and B, Representative endoscopic video frames of third-space endoscopy procedures using white-light imaging and amber-red color imaging. C, Red, blue, and yellow lines indicate submucosal vessels, submucosal layer, and muscle layer, respectively.

Read the full article online.

The information presented in Endoscopedia reflects the opinions of the authors and does not represent the position of the American Society for Gastrointestinal Endoscopy (ASGE). ASGE expressly disclaims any warranties or guarantees, expressed or implied, and is not liable for damages of any kind in connection with the material, information, or procedures set forth.