Title: Characterizing Reflux on High Resolution Esophageal Manometry with Impedance
Version: 1 Date: 09 Dec 2021
Reviewer's report:
The group from Temple University presents a case series of esophageal function tests in patients
and a small group of volunteers to correlate episodes of reflux during the esophageal manometry
and at the ambulatory pHmonitoring.
The idea behind the study is very interestingly; however, there are few points to be clarified
before the results can be well understood:
1)  Inclusion criteria: are these consecutive HRM for patients with clinically suspected GERD?
There is a myriad of manmetric diagnosis and some without the possibility of having GERD
(e.g., achalasia).  Why these patients were not excluded or used as "control"?
2) All patients underwent pHmonitoring? Why achalasia patients would undergo it? They may
have false reflux and confuse results
3)  The majority of patients were on PPIs. This is a SERIOUS limitation.
4)  Episodes of reflux are usually considered during LES relaxation during swallows (as a
common cavity). What the authors present at the figure 2 looks like a transient relaxation of
the LES. Is it what they were looking for? There are established criteria and protocols to search
for TRLES.
5) Statistical analysis is not appropriate. This is a diagnostic test analysis. A ROC curve could
provide a better reference value for pathologic reflux at HRM.
Minor comments:
1) Surgery is the name of a science not a procedure. Replace "surgeries" with "operations"
2) Tests can be reviewed and adapted to Chicago 4.0 version at least regarding the definition of
innefective motlity. Change in position was probably not performed to confirm EGJOO
3) "hiatal hernia" will lead the readers to interpretate it as an endoscopic finding. Please use
esophagogastric junction morphology classification instead
4) Why 12 swallows when the standard is 10?
Title: Characterizing Reflux on High Resolution Esophageal Manometry with Impedance
Version: 1 Date: 09 Dec 2021
Reviewer's report:
The group from Temple University presents a case series of esophageal function tests in patients
and a small group of volunteers to correlate episodes of reflux during the esophageal manometry
and at the ambulatory pHmonitoring.
The idea behind the study is very interestingly; however, there are few points to be clarified
before the results can be well understood:
1)  Inclusion criteria: are these consecutive HRM for patients with clinically suspected GERD?
There is a myriad of manmetric diagnosis and some without the possibility of having GERD
(e.g., achalasia).  Why these patients were not excluded or used as "control"?
2) All patients underwent pHmonitoring? Why achalasia patients would undergo it? They may
have false reflux and confuse results
3)  The majority of patients were on PPIs. This is a SERIOUS limitation.
4)  Episodes of reflux are usually considered during LES relaxation during swallows (as a
common cavity). What the authors present at the figure 2 looks like a transient relaxation of
the LES. Is it what they were looking for? There are established criteria and protocols to search
for TRLES.
5) Statistical analysis is not appropriate. This is a diagnostic test analysis. A ROC curve could
provide a better reference value for pathologic reflux at HRM.
Minor comments:
1) Surgery is the name of a science not a procedure. Replace "surgeries" with "operations"
2) Tests can be reviewed and adapted to Chicago 4.0 version at least regarding the definition of
innefective motlity. Change in position was probably not performed to confirm EGJOO
3) "hiatal hernia" will lead the readers to interpretate it as an endoscopic finding. Please use
esophagogastric junction morphology classification instead
4) Why 12 swallows when the standard is 10?
Please review this paper.
user
Title: Characterizing Reflux on High Resolution Esophageal Manometry with Impedance
Version: 1 Date: 09 Dec 2021
Reviewer's report:
The group from Temple University presents a case series of esophageal function tests in patients
and a small group of volunteers to correlate episodes of reflux during the esophageal manometry
and at the ambulatory pHmonitoring.
The idea behind the study is very interestingly; however, there are few points to be clarified
before the results can be well understood:
1)  Inclusion criteria: are these consecutive HRM for patients with clinically suspected GERD?
There is a myriad of manmetric diagnosis and some without the possibility of having GERD
(e.g., achalasia).  Why these patients were not excluded or used as "control"?
2) All patients underwent pHmonitoring? Why achalasia patients would undergo it? They may
have false reflux and confuse results
3)  The majority of patients were on PPIs. This is a SERIOUS limitation.
4)  Episodes of reflux are usually considered during LES relaxation during swallows (as a
common cavity). What the authors present at the figure 2 looks like a transient relaxation of
the LES. Is it what they were looking for? There are established criteria and protocols to search
for TRLES.
5) Statistical analysis is not appropriate. This is a diagnostic test analysis. A ROC curve could
provide a better reference value for pathologic reflux at HRM.
Minor comments:
1) Surgery is the name of a science not a procedure. Replace "surgeries" with "operations"
2) Tests can be reviewed and adapted to Chicago 4.0 version at least regarding the definition of
innefective motlity. Change in position was probably not performed to confirm EGJOO
3) "hiatal hernia" will lead the readers to interpretate it as an endoscopic finding. Please use
esophagogastric junction morphology classification instead
4) Why 12 swallows when the standard is 10?
assistant