Reviewer's report 
 Recurrent Barrett's Esophagus and Adenocarcinoma After Esophagectomy Title: 
 1  27 April 2004 Version: Date: 
 George Triadafilopoulos Reviewer: 
Reviewer's report: 
General 
This is a very well-written report of the experience of the Mayo Clinic Jacksonville group that brings 
to surface an important clinical issue, the recurrence of Barrett's esophagus after esophagectomy for 
Barrett's dysplasia and early cancer. Such experience will undoubtedly be helpful to clinicians in the 
future as esophageal adenocarcinoma is increasingly recognized earlier due to emphasis on 
screening and surveillance 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
The authors need to specifically note the following: 
1. Type of esophagectomy (transhiatal, trnasthoracic) 
2. Open, laparoscopic or thoracoscopic 3. Pyloroplasty or not, endoscopic gastric stasis or not 4. Number of surgeons or the same surgeon (unlikely) 
5. % of need for anastomotic dilation, number of dilation sessions and possible relationship between 
dysphagia, anastomotic stricture and subsequent Barrett's esophagus 
6. Use of ASA or NSAIDs (regular or not) 7. Use of PPIs (regular or not) 
The authors need to at least explore the relationship of the above and the recurrence rates. I 
suspect that the number of observations may not be adequate but it is important to see possible trends. 
On page 6, 22% represents the percentage of the 36 patients, not the 45 and this should be stated. 
This should also be clarified in the abstract. 
On page 7, the authors should report the presence of endoscopic esophagitis in the 3 patients with 
dysplastic Barrett's dysplasia and cancer. If the hypothesis of acid-induced injury is correct, such patients should have worse reflux changes as compared to the other 5. 
On page 9, add: In the study of Oberg et al, despite the use of potent.... 
In the table, the authors should change the word observation with PPI therapy (if indeed this is what 
they did) since this is a strategy that differs from observation and may play a role in ?inducing or 
?suppressing such recurrences. 
It would also be useful to conclude with more "specific" recommendations (albeit 
not-evidence-based): 
1. Yearly endoscopy? 
2. High-dose PPI, PPI for symptoms, or no PPI? 
3. Prokinetics? 
4. ASA, NSAIDs use? 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of importance in its field Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
No conflict 
Reviewer's report 
 Recurrent Barrett's Esophagus and Adenocarcinoma After Esophagectomy Title: 
 1  27 April 2004 Version: Date: 
 George Triadafilopoulos Reviewer: 
Reviewer's report: 
General 
This is a very well-written report of the experience of the Mayo Clinic Jacksonville group that brings 
to surface an important clinical issue, the recurrence of Barrett's esophagus after esophagectomy for 
Barrett's dysplasia and early cancer. Such experience will undoubtedly be helpful to clinicians in the 
future as esophageal adenocarcinoma is increasingly recognized earlier due to emphasis on 
screening and surveillance 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
The authors need to specifically note the following: 
1. Type of esophagectomy (transhiatal, trnasthoracic) 
2. Open, laparoscopic or thoracoscopic 3. Pyloroplasty or not, endoscopic gastric stasis or not 4. Number of surgeons or the same surgeon (unlikely) 
5. % of need for anastomotic dilation, number of dilation sessions and possible relationship between 
dysphagia, anastomotic stricture and subsequent Barrett's esophagus 
6. Use of ASA or NSAIDs (regular or not) 7. Use of PPIs (regular or not) 
The authors need to at least explore the relationship of the above and the recurrence rates. I 
suspect that the number of observations may not be adequate but it is important to see possible trends. 
On page 6, 22% represents the percentage of the 36 patients, not the 45 and this should be stated. 
This should also be clarified in the abstract. 
On page 7, the authors should report the presence of endoscopic esophagitis in the 3 patients with 
dysplastic Barrett's dysplasia and cancer. If the hypothesis of acid-induced injury is correct, such patients should have worse reflux changes as compared to the other 5. 
On page 9, add: In the study of Oberg et al, despite the use of potent.... 
In the table, the authors should change the word observation with PPI therapy (if indeed this is what 
they did) since this is a strategy that differs from observation and may play a role in ?inducing or 
?suppressing such recurrences. 
It would also be useful to conclude with more "specific" recommendations (albeit 
not-evidence-based): 
1. Yearly endoscopy? 
2. High-dose PPI, PPI for symptoms, or no PPI? 
3. Prokinetics? 
4. ASA, NSAIDs use? 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of importance in its field Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
No conflict 
Please review this paper.
user
Reviewer's report 
 Recurrent Barrett's Esophagus and Adenocarcinoma After Esophagectomy Title: 
 1  27 April 2004 Version: Date: 
 George Triadafilopoulos Reviewer: 
Reviewer's report: 
General 
This is a very well-written report of the experience of the Mayo Clinic Jacksonville group that brings 
to surface an important clinical issue, the recurrence of Barrett's esophagus after esophagectomy for 
Barrett's dysplasia and early cancer. Such experience will undoubtedly be helpful to clinicians in the 
future as esophageal adenocarcinoma is increasingly recognized earlier due to emphasis on 
screening and surveillance 
------------------------------------------------------------------------------- 
Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
The authors need to specifically note the following: 
1. Type of esophagectomy (transhiatal, trnasthoracic) 
2. Open, laparoscopic or thoracoscopic 3. Pyloroplasty or not, endoscopic gastric stasis or not 4. Number of surgeons or the same surgeon (unlikely) 
5. % of need for anastomotic dilation, number of dilation sessions and possible relationship between 
dysphagia, anastomotic stricture and subsequent Barrett's esophagus 
6. Use of ASA or NSAIDs (regular or not) 7. Use of PPIs (regular or not) 
The authors need to at least explore the relationship of the above and the recurrence rates. I 
suspect that the number of observations may not be adequate but it is important to see possible trends. 
On page 6, 22% represents the percentage of the 36 patients, not the 45 and this should be stated. 
This should also be clarified in the abstract. 
On page 7, the authors should report the presence of endoscopic esophagitis in the 3 patients with 
dysplastic Barrett's dysplasia and cancer. If the hypothesis of acid-induced injury is correct, such patients should have worse reflux changes as compared to the other 5. 
On page 9, add: In the study of Oberg et al, despite the use of potent.... 
In the table, the authors should change the word observation with PPI therapy (if indeed this is what 
they did) since this is a strategy that differs from observation and may play a role in ?inducing or 
?suppressing such recurrences. 
It would also be useful to conclude with more "specific" recommendations (albeit 
not-evidence-based): 
1. Yearly endoscopy? 
2. High-dose PPI, PPI for symptoms, or no PPI? 
3. Prokinetics? 
4. ASA, NSAIDs use? 
------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
------------------------------------------------------------------------------- 
Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of importance in its field Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
No conflict 
assistant