Reviewer ’s report  
 
Title:  Gastroesophageal flap valve reflected EGJ morphology and correlated to acid reflux  
 
Version: 0 Date: 30 Jun 2017 
 
Reviewer:  Amit  Patel  
 
Reviewer’s report:  
 
In this report from Guangzhou, the authors examined 83 patients with typical GERD symp toms 
(heartburn and/or regurgitation), who underwent EGD, HRM, and pH -impedance testing, in 
order to evaluate the correlations between GEFV (per Hill classification), EGJ HRM metrics 
(including EGJ -CI, IRP, EGJP -exp, EGJP -insp, and EGJ morphology), LA Grad e esophagitis, 
and reflux metrics (particularly AET). Their primary findings include increased proportions of 
GEFV grades III -IV among esophagitis, lower AET in GEFV grade I, weak correlation between 
AET and GEFV, and an association of EGJ type III and GEF V grade IV. In sum, GEFV grades 
were associated with AET and esophagitis but NOT the studied HRM metrics of IRP, EGJP -exp, 
or EGJP -insp, suggesting that GEFV may assist in the anti -reflux barrier but not the primary. 
The authors should be congratulated on pursuing this study.  
 
As a whole, I would suggest tightening the prose to make the manuscript more readable 
(especially being consistent with past vs present tense).  
 
-Introduction: I like the concise description of the EGJ and brief review of prior literat ure, but 
you should focus more on what makes the present study unique (where it "fits" in the literature, 
especially given the prior work on GEFV -hiatus hernia -reflux associations) -- perhaps the focus 
on GEFV and/or EGJ -CI in these patients? Changes in EGJ -CI have been assessed with surgical 
intervention, which might be worth mentioning (NGM 2016 Wang).  
 
-Methods: you could include the Hill classification scheme as part of Figure 1 instead of in the 
text 
 
-Methods: I would suggest consistent nomenclature EGJ -CI (vs EGJ -DCI), and suggest a brief 
explanation of how this metric is calculated (can use the the EGJ -CI references to assist)  
 
-Methods: you appear to introduce the concepts of GERD phenotypes (such as reflux 
hypersensitivity) based on AET and SAP -- I sug gest you classify appropriately into GERD 
phenotypes to assess differences (in addition to the erosive esophagitis vs not). However, you 
mention in the discussion that FH patients were excluded from the study, but this is not clear in 
the methods -- please address. It might also be beneficial to include a flow chart (or in the text) 
how many patients were excluded from the study and for which exclusion criteria.  
 
-Methods: What was the concordance in GEFV grading between the endoscopist and other 
author? How was agreement obtained?  
 
-Results: I feel that higher GEFV grades should intuitively correlate with increased EGJ 
morphology (given that both are ultimately assessing hiatus hernia), so I'm unsure of the value of 
this association, especially as prior work h as already established the association between GEFV 
and reflux. However, I am intrigued by the potential importance of Hill grades II -III for GERD 
and its management.  
 
-Results: You could consider inter -group comparisons between 2 groups -- i.e., was the EGJ -CI 
for Hill IV different from EGJ -CI for the other Hill classes? I would also suggest explaining how 
the EGJ -CI was measured in patients with types II and III EGJ morphology (i.e., was the 
diaphragm included in the EGJ -CI box?).  
 
-Tables/Figures: Suggest c utting Table 3 values to tenths. Why not include HRM metrics in 
Table 3, as these results are only otherwise revealed in Figure 3? Figure 2 may be best conveyed 
as in the prior publications (it is a little cumbersome in the present fashion). For Figure 3, specify 
in the caption how the p values were calculated. Otherwise, good presentation of data via tables 
and figures.  
 
-Discussion: Focus on what the clinical implications of your findings are -- does Hill 
classification matter and can/should it guide manage ment of these patients? Most American 
gastroenterologists, for example, do not routinely report the Hill classification on endoscopy; 
should they?  
 
-Discussion: Would include in limitations the sample size, lack of standardized interpretation 
(concordance) of Hill classification, lack of symptom data. How can you conclude based on your 
data that "it seemed that symptom relief could be independent to the decrease of acid reflux."?  
 
Thank you for the opportunity to review your work!  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in  the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Qualit y of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any w ay gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or sal ary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer  no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the websi te along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title:  Gastroesophageal flap valve reflected EGJ morphology and correlated to acid reflux  
 
Version: 0 Date: 30 Jun 2017 
 
Reviewer:  Amit  Patel  
 
Reviewer’s report:  
 
In this report from Guangzhou, the authors examined 83 patients with typical GERD symp toms 
(heartburn and/or regurgitation), who underwent EGD, HRM, and pH -impedance testing, in 
order to evaluate the correlations between GEFV (per Hill classification), EGJ HRM metrics 
(including EGJ -CI, IRP, EGJP -exp, EGJP -insp, and EGJ morphology), LA Grad e esophagitis, 
and reflux metrics (particularly AET). Their primary findings include increased proportions of 
GEFV grades III -IV among esophagitis, lower AET in GEFV grade I, weak correlation between 
AET and GEFV, and an association of EGJ type III and GEF V grade IV. In sum, GEFV grades 
were associated with AET and esophagitis but NOT the studied HRM metrics of IRP, EGJP -exp, 
or EGJP -insp, suggesting that GEFV may assist in the anti -reflux barrier but not the primary. 
The authors should be congratulated on pursuing this study.  
 
As a whole, I would suggest tightening the prose to make the manuscript more readable 
(especially being consistent with past vs present tense).  
 
-Introduction: I like the concise description of the EGJ and brief review of prior literat ure, but 
you should focus more on what makes the present study unique (where it "fits" in the literature, 
especially given the prior work on GEFV -hiatus hernia -reflux associations) -- perhaps the focus 
on GEFV and/or EGJ -CI in these patients? Changes in EGJ -CI have been assessed with surgical 
intervention, which might be worth mentioning (NGM 2016 Wang).  
 
-Methods: you could include the Hill classification scheme as part of Figure 1 instead of in the 
text 
 
-Methods: I would suggest consistent nomenclature EGJ -CI (vs EGJ -DCI), and suggest a brief 
explanation of how this metric is calculated (can use the the EGJ -CI references to assist)  
 
-Methods: you appear to introduce the concepts of GERD phenotypes (such as reflux 
hypersensitivity) based on AET and SAP -- I sug gest you classify appropriately into GERD 
phenotypes to assess differences (in addition to the erosive esophagitis vs not). However, you 
mention in the discussion that FH patients were excluded from the study, but this is not clear in 
the methods -- please address. It might also be beneficial to include a flow chart (or in the text) 
how many patients were excluded from the study and for which exclusion criteria.  
 
-Methods: What was the concordance in GEFV grading between the endoscopist and other 
author? How was agreement obtained?  
 
-Results: I feel that higher GEFV grades should intuitively correlate with increased EGJ 
morphology (given that both are ultimately assessing hiatus hernia), so I'm unsure of the value of 
this association, especially as prior work h as already established the association between GEFV 
and reflux. However, I am intrigued by the potential importance of Hill grades II -III for GERD 
and its management.  
 
-Results: You could consider inter -group comparisons between 2 groups -- i.e., was the EGJ -CI 
for Hill IV different from EGJ -CI for the other Hill classes? I would also suggest explaining how 
the EGJ -CI was measured in patients with types II and III EGJ morphology (i.e., was the 
diaphragm included in the EGJ -CI box?).  
 
-Tables/Figures: Suggest c utting Table 3 values to tenths. Why not include HRM metrics in 
Table 3, as these results are only otherwise revealed in Figure 3? Figure 2 may be best conveyed 
as in the prior publications (it is a little cumbersome in the present fashion). For Figure 3, specify 
in the caption how the p values were calculated. Otherwise, good presentation of data via tables 
and figures.  
 
-Discussion: Focus on what the clinical implications of your findings are -- does Hill 
classification matter and can/should it guide manage ment of these patients? Most American 
gastroenterologists, for example, do not routinely report the Hill classification on endoscopy; 
should they?  
 
-Discussion: Would include in limitations the sample size, lack of standardized interpretation 
(concordance) of Hill classification, lack of symptom data. How can you conclude based on your 
data that "it seemed that symptom relief could be independent to the decrease of acid reflux."?  
 
Thank you for the opportunity to review your work!  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in  the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Qualit y of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any w ay gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or sal ary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer  no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the websi te along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title:  Gastroesophageal flap valve reflected EGJ morphology and correlated to acid reflux  
 
Version: 0 Date: 30 Jun 2017 
 
Reviewer:  Amit  Patel  
 
Reviewer’s report:  
 
In this report from Guangzhou, the authors examined 83 patients with typical GERD symp toms 
(heartburn and/or regurgitation), who underwent EGD, HRM, and pH -impedance testing, in 
order to evaluate the correlations between GEFV (per Hill classification), EGJ HRM metrics 
(including EGJ -CI, IRP, EGJP -exp, EGJP -insp, and EGJ morphology), LA Grad e esophagitis, 
and reflux metrics (particularly AET). Their primary findings include increased proportions of 
GEFV grades III -IV among esophagitis, lower AET in GEFV grade I, weak correlation between 
AET and GEFV, and an association of EGJ type III and GEF V grade IV. In sum, GEFV grades 
were associated with AET and esophagitis but NOT the studied HRM metrics of IRP, EGJP -exp, 
or EGJP -insp, suggesting that GEFV may assist in the anti -reflux barrier but not the primary. 
The authors should be congratulated on pursuing this study.  
 
As a whole, I would suggest tightening the prose to make the manuscript more readable 
(especially being consistent with past vs present tense).  
 
-Introduction: I like the concise description of the EGJ and brief review of prior literat ure, but 
you should focus more on what makes the present study unique (where it "fits" in the literature, 
especially given the prior work on GEFV -hiatus hernia -reflux associations) -- perhaps the focus 
on GEFV and/or EGJ -CI in these patients? Changes in EGJ -CI have been assessed with surgical 
intervention, which might be worth mentioning (NGM 2016 Wang).  
 
-Methods: you could include the Hill classification scheme as part of Figure 1 instead of in the 
text 
 
-Methods: I would suggest consistent nomenclature EGJ -CI (vs EGJ -DCI), and suggest a brief 
explanation of how this metric is calculated (can use the the EGJ -CI references to assist)  
 
-Methods: you appear to introduce the concepts of GERD phenotypes (such as reflux 
hypersensitivity) based on AET and SAP -- I sug gest you classify appropriately into GERD 
phenotypes to assess differences (in addition to the erosive esophagitis vs not). However, you 
mention in the discussion that FH patients were excluded from the study, but this is not clear in 
the methods -- please address. It might also be beneficial to include a flow chart (or in the text) 
how many patients were excluded from the study and for which exclusion criteria.  
 
-Methods: What was the concordance in GEFV grading between the endoscopist and other 
author? How was agreement obtained?  
 
-Results: I feel that higher GEFV grades should intuitively correlate with increased EGJ 
morphology (given that both are ultimately assessing hiatus hernia), so I'm unsure of the value of 
this association, especially as prior work h as already established the association between GEFV 
and reflux. However, I am intrigued by the potential importance of Hill grades II -III for GERD 
and its management.  
 
-Results: You could consider inter -group comparisons between 2 groups -- i.e., was the EGJ -CI 
for Hill IV different from EGJ -CI for the other Hill classes? I would also suggest explaining how 
the EGJ -CI was measured in patients with types II and III EGJ morphology (i.e., was the 
diaphragm included in the EGJ -CI box?).  
 
-Tables/Figures: Suggest c utting Table 3 values to tenths. Why not include HRM metrics in 
Table 3, as these results are only otherwise revealed in Figure 3? Figure 2 may be best conveyed 
as in the prior publications (it is a little cumbersome in the present fashion). For Figure 3, specify 
in the caption how the p values were calculated. Otherwise, good presentation of data via tables 
and figures.  
 
-Discussion: Focus on what the clinical implications of your findings are -- does Hill 
classification matter and can/should it guide manage ment of these patients? Most American 
gastroenterologists, for example, do not routinely report the Hill classification on endoscopy; 
should they?  
 
-Discussion: Would include in limitations the sample size, lack of standardized interpretation 
(concordance) of Hill classification, lack of symptom data. How can you conclude based on your 
data that "it seemed that symptom relief could be independent to the decrease of acid reflux."?  
 
Thank you for the opportunity to review your work!  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in  the manuscript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further 
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Qualit y of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any w ay gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you received reimbursements, fees, funding, or sal ary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests in relation to this paper?  
 
If you can answer  no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the websi te along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be included as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant