Reviewer ’s report  
 
Title: Risk of rebleeding from gastroesophageal varices after initial treatment with 
cyanoacrylate; a systematic review and pooled analysis.  
 
Version: 0 Date: 28 Mar 2020  
 
Reviewer's report:  
 
The au thor assessed the risk of rebleeding from gastroesophageal varices after initial treatment 
with cyanoacrylate (CA) with/without other treatment by a systematic review and pooled 
analysis. They concluded that CA with other treatment reduced the risk of rebl eeding than CA 
alone, and that the lowest risk treatment was CA with ethanolamine or with endoscopic 
ultrasound guided coils in esophageal and gastric varices, respectively.  
 
This detailed study showed very critical results, but there are some concerns need ed to be 
addressed or discussed to help understand the readers.  
 
 
Comments is as follows.  
 
1. Rebleeding from gastroesophageal varices after initial hemostatic treatment would be 
influenced by liver damage or hepatic venous pressure, as the author described in the 
introduction. How much there are heterogeneity in the liver function in 32 reports  analyzed in 
this study? In addition, whether initial treatment is emergent for ruptured varices or elective 
(prophylactic) would potentially impact an increased risk of rebleeding. Please reanalyze or 
discuss additionally.  
 
2. Hemodynamics with gastric va rices is different between solitary varices of the fundus (Lg -f) 
and cardia varices connecting to esophageal varices, leading to the different treatment strategy 
such as BRTO or endoscopic sclerotherapy. This would influence the risk of rebleeding. The 
author should discuss on the location of gastric varices.  
 
3. Follow -up duration in each study have a wide range from several weeks to over 10 years. The 
risk stratification of rebleeding should be conducted according to length of follow -up periods.  
 
4. Pleas e add percentage of participants rebleed in Table 1.  
 
Are the met hods 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 as sess 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additi onal statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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, f ees, funding, or salary 
from an organisation that may in any way gai n or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way 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 salary from an organization 
that holds or has applied for patents relating to the content o f 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 ac cepted f or publication, my named report 
including any attachments I upload will be posted on the website along w ith the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommo ns.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded 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: Risk of rebleeding from gastroesophageal varices after initial treatment with 
cyanoacrylate; a systematic review and pooled analysis.  
 
Version: 0 Date: 28 Mar 2020  
 
Reviewer's report:  
 
The au thor assessed the risk of rebleeding from gastroesophageal varices after initial treatment 
with cyanoacrylate (CA) with/without other treatment by a systematic review and pooled 
analysis. They concluded that CA with other treatment reduced the risk of rebl eeding than CA 
alone, and that the lowest risk treatment was CA with ethanolamine or with endoscopic 
ultrasound guided coils in esophageal and gastric varices, respectively.  
 
This detailed study showed very critical results, but there are some concerns need ed to be 
addressed or discussed to help understand the readers.  
 
 
Comments is as follows.  
 
1. Rebleeding from gastroesophageal varices after initial hemostatic treatment would be 
influenced by liver damage or hepatic venous pressure, as the author described in the 
introduction. How much there are heterogeneity in the liver function in 32 reports  analyzed in 
this study? In addition, whether initial treatment is emergent for ruptured varices or elective 
(prophylactic) would potentially impact an increased risk of rebleeding. Please reanalyze or 
discuss additionally.  
 
2. Hemodynamics with gastric va rices is different between solitary varices of the fundus (Lg -f) 
and cardia varices connecting to esophageal varices, leading to the different treatment strategy 
such as BRTO or endoscopic sclerotherapy. This would influence the risk of rebleeding. The 
author should discuss on the location of gastric varices.  
 
3. Follow -up duration in each study have a wide range from several weeks to over 10 years. The 
risk stratification of rebleeding should be conducted according to length of follow -up periods.  
 
4. Pleas e add percentage of participants rebleed in Table 1.  
 
Are the met hods 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 as sess 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additi onal statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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, f ees, funding, or salary 
from an organisation that may in any way gai n or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way 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 salary from an organization 
that holds or has applied for patents relating to the content o f 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 ac cepted f or publication, my named report 
including any attachments I upload will be posted on the website along w ith the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommo ns.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded 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: Risk of rebleeding from gastroesophageal varices after initial treatment with 
cyanoacrylate; a systematic review and pooled analysis.  
 
Version: 0 Date: 28 Mar 2020  
 
Reviewer's report:  
 
The au thor assessed the risk of rebleeding from gastroesophageal varices after initial treatment 
with cyanoacrylate (CA) with/without other treatment by a systematic review and pooled 
analysis. They concluded that CA with other treatment reduced the risk of rebl eeding than CA 
alone, and that the lowest risk treatment was CA with ethanolamine or with endoscopic 
ultrasound guided coils in esophageal and gastric varices, respectively.  
 
This detailed study showed very critical results, but there are some concerns need ed to be 
addressed or discussed to help understand the readers.  
 
 
Comments is as follows.  
 
1. Rebleeding from gastroesophageal varices after initial hemostatic treatment would be 
influenced by liver damage or hepatic venous pressure, as the author described in the 
introduction. How much there are heterogeneity in the liver function in 32 reports  analyzed in 
this study? In addition, whether initial treatment is emergent for ruptured varices or elective 
(prophylactic) would potentially impact an increased risk of rebleeding. Please reanalyze or 
discuss additionally.  
 
2. Hemodynamics with gastric va rices is different between solitary varices of the fundus (Lg -f) 
and cardia varices connecting to esophageal varices, leading to the different treatment strategy 
such as BRTO or endoscopic sclerotherapy. This would influence the risk of rebleeding. The 
author should discuss on the location of gastric varices.  
 
3. Follow -up duration in each study have a wide range from several weeks to over 10 years. The 
risk stratification of rebleeding should be conducted according to length of follow -up periods.  
 
4. Pleas e add percentage of participants rebleed in Table 1.  
 
Are the met hods 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 as sess 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additi onal statistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
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, f ees, funding, or salary 
from an organisation that may in any way gai n or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way 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 salary from an organization 
that holds or has applied for patents relating to the content o f 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 ac cepted f or publication, my named report 
including any attachments I upload will be posted on the website along w ith the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommo ns.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant