Title: A method of “Noninjecting Resection using Bipolar Soft coagulation mode; NIRBS” for
superficial non-ampullary duodenal epithelial tumor: A pilot study
Version: 5 Date: 21 Aug 2024
Reviewer's report:
Thank you for asking me to peer review this paper.
This paper is a retrospective pilot study reviewing a novel technique for removal of mucosal
lesions in the duodenum.
The premise for the normal technique is that existing mucosal resection techniques have
limitations with unacceptable adverse events. The opinion of the authors is that endoscopic
mucosal resection (cold and with cautery) and ESD are consistent with poor outcomes with a
high risk of adverse events.
The nature of the lesion was not confirmed with biopsy prior to endoscopic resection with the
novel technique. The technique essentially involved snare resection with non-injection using
soft coagulation.
The resected lesions were located in the bulbar duodenum 23%, proximal D2 54% and distal
D2 23%. 13 specimens demonstrated en bloc resection.
This is a small study including only 13 patients. One could question whether it is a true pilot
study if it is retrospective in nature.
The study is insufficiently powered to suggest that this technique is of any great benefit compared
to more widely accepted methods of endoscopic resection in the duodenum.
I would disagree with comments made about preinjection in the duodenum ("poor mucosal
lifting") although certainly this can be hindered in the first part of the duodenum. There are
no issues with mucosal lifting in the second part of the duodenum. The likelihood of a patient
having an adenoma in the bulbar duodenum amongst Brunner's glands is very low.
I would also disagree with the comments made about cold snare polypectomy, which is widely
utilised for small duodenal adenomas after preinjection. The risk of bleeding after cold snare
polypectomy of the duodenum after preinjection is negligible, particularly if prophylactic clip
placement is used.
I strongly agree with the comments made by the authors about performing ESD in the duodenum.
The authors do not mention the size of the snare. The size of the snare would be very important
particularly when suction is involved to engage tissue for resection. The size of the snare should
be included in the methods in case this technique is attempted with a different brand of snare
by readers.
Soft coagulation is not an innocuous current. It does have a significant depth of penetration,
although the relatively low power rating is noted. Despite the jiggling method, I would be
concerned about the potential risk of superficial or deep muscle injury  for lesions up to 20 mm
in diameter.
I disagree that conventional EMR is unsuitable for the duodenum "due to a perceived risk of
perforation caused by insufficient mucosal lifting. "This is inconsistent with published data.
I hope that my review is helpful to the authors.
Title: A method of “Noninjecting Resection using Bipolar Soft coagulation mode; NIRBS” for
superficial non-ampullary duodenal epithelial tumor: A pilot study
Version: 5 Date: 21 Aug 2024
Reviewer's report:
Thank you for asking me to peer review this paper.
This paper is a retrospective pilot study reviewing a novel technique for removal of mucosal
lesions in the duodenum.
The premise for the normal technique is that existing mucosal resection techniques have
limitations with unacceptable adverse events. The opinion of the authors is that endoscopic
mucosal resection (cold and with cautery) and ESD are consistent with poor outcomes with a
high risk of adverse events.
The nature of the lesion was not confirmed with biopsy prior to endoscopic resection with the
novel technique. The technique essentially involved snare resection with non-injection using
soft coagulation.
The resected lesions were located in the bulbar duodenum 23%, proximal D2 54% and distal
D2 23%. 13 specimens demonstrated en bloc resection.
This is a small study including only 13 patients. One could question whether it is a true pilot
study if it is retrospective in nature.
The study is insufficiently powered to suggest that this technique is of any great benefit compared
to more widely accepted methods of endoscopic resection in the duodenum.
I would disagree with comments made about preinjection in the duodenum ("poor mucosal
lifting") although certainly this can be hindered in the first part of the duodenum. There are
no issues with mucosal lifting in the second part of the duodenum. The likelihood of a patient
having an adenoma in the bulbar duodenum amongst Brunner's glands is very low.
I would also disagree with the comments made about cold snare polypectomy, which is widely
utilised for small duodenal adenomas after preinjection. The risk of bleeding after cold snare
polypectomy of the duodenum after preinjection is negligible, particularly if prophylactic clip
placement is used.
I strongly agree with the comments made by the authors about performing ESD in the duodenum.
The authors do not mention the size of the snare. The size of the snare would be very important
particularly when suction is involved to engage tissue for resection. The size of the snare should
be included in the methods in case this technique is attempted with a different brand of snare
by readers.
Soft coagulation is not an innocuous current. It does have a significant depth of penetration,
although the relatively low power rating is noted. Despite the jiggling method, I would be
concerned about the potential risk of superficial or deep muscle injury  for lesions up to 20 mm
in diameter.
I disagree that conventional EMR is unsuitable for the duodenum "due to a perceived risk of
perforation caused by insufficient mucosal lifting. "This is inconsistent with published data.
I hope that my review is helpful to the authors.
Please review this paper.
user
Title: A method of “Noninjecting Resection using Bipolar Soft coagulation mode; NIRBS” for
superficial non-ampullary duodenal epithelial tumor: A pilot study
Version: 5 Date: 21 Aug 2024
Reviewer's report:
Thank you for asking me to peer review this paper.
This paper is a retrospective pilot study reviewing a novel technique for removal of mucosal
lesions in the duodenum.
The premise for the normal technique is that existing mucosal resection techniques have
limitations with unacceptable adverse events. The opinion of the authors is that endoscopic
mucosal resection (cold and with cautery) and ESD are consistent with poor outcomes with a
high risk of adverse events.
The nature of the lesion was not confirmed with biopsy prior to endoscopic resection with the
novel technique. The technique essentially involved snare resection with non-injection using
soft coagulation.
The resected lesions were located in the bulbar duodenum 23%, proximal D2 54% and distal
D2 23%. 13 specimens demonstrated en bloc resection.
This is a small study including only 13 patients. One could question whether it is a true pilot
study if it is retrospective in nature.
The study is insufficiently powered to suggest that this technique is of any great benefit compared
to more widely accepted methods of endoscopic resection in the duodenum.
I would disagree with comments made about preinjection in the duodenum ("poor mucosal
lifting") although certainly this can be hindered in the first part of the duodenum. There are
no issues with mucosal lifting in the second part of the duodenum. The likelihood of a patient
having an adenoma in the bulbar duodenum amongst Brunner's glands is very low.
I would also disagree with the comments made about cold snare polypectomy, which is widely
utilised for small duodenal adenomas after preinjection. The risk of bleeding after cold snare
polypectomy of the duodenum after preinjection is negligible, particularly if prophylactic clip
placement is used.
I strongly agree with the comments made by the authors about performing ESD in the duodenum.
The authors do not mention the size of the snare. The size of the snare would be very important
particularly when suction is involved to engage tissue for resection. The size of the snare should
be included in the methods in case this technique is attempted with a different brand of snare
by readers.
Soft coagulation is not an innocuous current. It does have a significant depth of penetration,
although the relatively low power rating is noted. Despite the jiggling method, I would be
concerned about the potential risk of superficial or deep muscle injury  for lesions up to 20 mm
in diameter.
I disagree that conventional EMR is unsuitable for the duodenum "due to a perceived risk of
perforation caused by insufficient mucosal lifting. "This is inconsistent with published data.
I hope that my review is helpful to the authors.
assistant