Title: Impact of the Body Mass Index on the Retention of the Anorectal Mucosa after Double-
stapled Ileal Pouch-anal Anastomosis for Ulcerative Colitis
Version: 4 Date: 26 Jan 2023
Reviewer's report:
Comments to the Author
It was a great pleasure to review your manuscript on Impact of the Body Mass Index on
the Retention of the Anorectal Mucosa after Double-stapled Ileal Pouch-anal Anastomosis for
Ulcerative Colitis.
The report has high clinical significance, as it showed that BMI was the factor most strongly
associated with the retention of a large amount of anorectal mucosa in IPAA.
Only minor comments in order to improve the paper.
1)The ECCO statement states that the maximum length of the anal mucosa from the dentate line
to the anastomosis should not exceed 20 mm. Please specify the reason that you defined having
a retained mucosal length of #30 mm in the anterior or posterior wall. Was it a quantile point?
Or did you quote from previous references?
In addition, since there were only 25 cases of high anastomosis defined as 30 mm or greater,
defining 20 mm or longer as high anastomosis and increasing the number of events may improve
the statistical reliability from the viewpoint of events per variable.
2) In the present results, the frequency of cuffitis was as low as 0.6% and there was no significant
difference between high and low anastomosis. However, a systematic review reported that
cuffitis occured in an estimated 10.2# to 30.1# of pouch patients, and possible risk factors
were rectal cuff length >20 mm, pouch-rectal anastomosis, stapled anastomosis, and J-pouch
configuration 1). I think that this is due to differences in the definition of cuffitis. But, if possible,
please follow the "International Ileal Pouch Consortium guidelines" for the definition 2).
1) Hembree AE, Scherl E. Diagnosis and Management of Cuffitis: A Systematic Review.
Dis Colon Rectum. 2022 Dec 1;65(S1):S85-S91. doi: 10.1097/DCR.0000000000002593. Epub
2022 Aug 25. PMID: 36399769.
2) Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita
A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S,
Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham
B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P,
McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S.
Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International
Ileal Pouch Consortium. Lancet Gastroenterol Hepatol. 2021 Oct;6(10):826-849. doi: 10.1016/
S2468-1253(21)00101-1. Epub 2021 Aug 18. PMID: 34416186.
Title: Impact of the Body Mass Index on the Retention of the Anorectal Mucosa after Double-
stapled Ileal Pouch-anal Anastomosis for Ulcerative Colitis
Version: 4 Date: 26 Jan 2023
Reviewer's report:
Comments to the Author
It was a great pleasure to review your manuscript on Impact of the Body Mass Index on
the Retention of the Anorectal Mucosa after Double-stapled Ileal Pouch-anal Anastomosis for
Ulcerative Colitis.
The report has high clinical significance, as it showed that BMI was the factor most strongly
associated with the retention of a large amount of anorectal mucosa in IPAA.
Only minor comments in order to improve the paper.
1)The ECCO statement states that the maximum length of the anal mucosa from the dentate line
to the anastomosis should not exceed 20 mm. Please specify the reason that you defined having
a retained mucosal length of #30 mm in the anterior or posterior wall. Was it a quantile point?
Or did you quote from previous references?
In addition, since there were only 25 cases of high anastomosis defined as 30 mm or greater,
defining 20 mm or longer as high anastomosis and increasing the number of events may improve
the statistical reliability from the viewpoint of events per variable.
2) In the present results, the frequency of cuffitis was as low as 0.6% and there was no significant
difference between high and low anastomosis. However, a systematic review reported that
cuffitis occured in an estimated 10.2# to 30.1# of pouch patients, and possible risk factors
were rectal cuff length >20 mm, pouch-rectal anastomosis, stapled anastomosis, and J-pouch
configuration 1). I think that this is due to differences in the definition of cuffitis. But, if possible,
please follow the "International Ileal Pouch Consortium guidelines" for the definition 2).
1) Hembree AE, Scherl E. Diagnosis and Management of Cuffitis: A Systematic Review.
Dis Colon Rectum. 2022 Dec 1;65(S1):S85-S91. doi: 10.1097/DCR.0000000000002593. Epub
2022 Aug 25. PMID: 36399769.
2) Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita
A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S,
Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham
B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P,
McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S.
Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International
Ileal Pouch Consortium. Lancet Gastroenterol Hepatol. 2021 Oct;6(10):826-849. doi: 10.1016/
S2468-1253(21)00101-1. Epub 2021 Aug 18. PMID: 34416186.
Please review this paper.
user
Title: Impact of the Body Mass Index on the Retention of the Anorectal Mucosa after Double-
stapled Ileal Pouch-anal Anastomosis for Ulcerative Colitis
Version: 4 Date: 26 Jan 2023
Reviewer's report:
Comments to the Author
It was a great pleasure to review your manuscript on Impact of the Body Mass Index on
the Retention of the Anorectal Mucosa after Double-stapled Ileal Pouch-anal Anastomosis for
Ulcerative Colitis.
The report has high clinical significance, as it showed that BMI was the factor most strongly
associated with the retention of a large amount of anorectal mucosa in IPAA.
Only minor comments in order to improve the paper.
1)The ECCO statement states that the maximum length of the anal mucosa from the dentate line
to the anastomosis should not exceed 20 mm. Please specify the reason that you defined having
a retained mucosal length of #30 mm in the anterior or posterior wall. Was it a quantile point?
Or did you quote from previous references?
In addition, since there were only 25 cases of high anastomosis defined as 30 mm or greater,
defining 20 mm or longer as high anastomosis and increasing the number of events may improve
the statistical reliability from the viewpoint of events per variable.
2) In the present results, the frequency of cuffitis was as low as 0.6% and there was no significant
difference between high and low anastomosis. However, a systematic review reported that
cuffitis occured in an estimated 10.2# to 30.1# of pouch patients, and possible risk factors
were rectal cuff length >20 mm, pouch-rectal anastomosis, stapled anastomosis, and J-pouch
configuration 1). I think that this is due to differences in the definition of cuffitis. But, if possible,
please follow the "International Ileal Pouch Consortium guidelines" for the definition 2).
1) Hembree AE, Scherl E. Diagnosis and Management of Cuffitis: A Systematic Review.
Dis Colon Rectum. 2022 Dec 1;65(S1):S85-S91. doi: 10.1097/DCR.0000000000002593. Epub
2022 Aug 25. PMID: 36399769.
2) Shen B, Kochhar GS, Kariv R, Liu X, Navaneethan U, Rubin DT, Cross RK, Sugita
A, D'Hoore A, Schairer J, Farraye FA, Kiran RP, Fleshner P, Rosh J, Shah SA, Chang S,
Scherl E, Pardi DS, Schwartz DA, Kotze PG, Bruining DH, Kane SV, Philpott J, Abraham
B, Segal J, Sedano R, Kayal M, Bentley-Hibbert S, Tarabar D, El-Hachem S, Sehgal P,
McCormick JT, Picoraro JA, Silverberg MS, Bernstein CN, Sandborn WJ, Vermeire S.
Diagnosis and classification of ileal pouch disorders: consensus guidelines from the International
Ileal Pouch Consortium. Lancet Gastroenterol Hepatol. 2021 Oct;6(10):826-849. doi: 10.1016/
S2468-1253(21)00101-1. Epub 2021 Aug 18. PMID: 34416186.
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