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Trimodal imaging endoscopy reduces the risk of synchronous gastric neoplasia. BACKGROUND AND AIM: The accurate detection of synchronous neoplasia is important to reduce the risk of recurrence after endoscopic resection. Trimodal imaging endoscopy (TMIE) was developed for this purpose. Our aim was to compare the effects of TMIE and white-light imaging endoscopy (WLIE) in gastric neoplasia detection. PATIENTS AND METHODS: Six hundred and seventy-eight patients with gastric dysplasia or cancer initially treated by endoscopic resection and who underwent follow-up endoscopy were analyzed retrospectively. Gastric neoplasia detected within 1 year of endoscopic resection was defined as synchronous disease. WLIE or TMIE was used to detect another gastric neoplasia before endoscopic resection. RESULTS: Synchronous gastric neoplasia was observed in 41 patients (6%), and occurred more frequently after the resection of carcinoma than dysplasia (8.5 vs. 4.6%, P=0.04). TMIE significantly reduced the frequency of synchronous gastric lesions than WLIE (2.3 vs. 9.3%, P<0.01). TMIE was more effective than WLIE in reducing the risk of missing a synchronous gastric lesion after adjusting for lesion multiplicity, experience, and resected lesion pathology (hazard ratio, 0.32; 95% confidence interval, 0.108-0.762). CONCLUSION: The risk of missing synchronous gastric neoplasia is higher after endoscopic resection for gastric cancer than dysplasia, but is reduced by TMIE. TMIE before endoscopic treatment can be useful in decreasing the risk of synchronous gastric neoplasia.