Reviewer ’s report  
 
Title: Safety of endoscopic procedures with monopolar versus bi polar instruments in an ex vivo 
porcine model  
 
Version: 3 Date: 10 Dec 2019  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
PEER REVIEWER ASSESSMENTS:  
 
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research 
question(s) (brief or other article types: is there a clear objective)?  
Yes - there is a clear objecti ve 
 
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for the 
objective?  
No - there are minor issues  
 
EXECUTION - Are the experiments and analyses performed with technical rigor to allow 
confidence in the results?  
Yes - experiments and analyses were performed appropriately  
 
STATISTICS - Is the use of statistics in the manuscript appropriate?  
N/A - there are no statistics in this study  
 
INTERPRETATION - Is the current interpretation/discussion of the results reasonab le and not 
overstated?  
No - there are minor issues  
 
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically 
sound? If not, can revisions be made to make the work technically sound?  
Probably - with minor revisions  
 
PEER REVIEWER COMME NTS:  
 
GENERAL COMMENTS:  
Congratulations to the authors, because they have conducted a novel and interesting study, 
evaluating adverse effects of endoscopic resections with monopolar and bipolar devices. 
However, several points should be addressed to impr ove the quality of the manuscript:  
 
REQUESTED REVISIONS:  
Methods:  
"Before EMR,  sufficient volume of saline was injected into the submucosal layer located under 
the target lesion. The volume of saline injected were not measured". (line 138 -140). Given tha t 
the models aimed to be similar, the volume of saline should have been also similar. This could 
represent  a bias. The authors should explain it or add it into a Limitations section.  
 
The authors should explain ir all the endoscopic procedures were perfor med by one or many 
endoscopists and their experience. Similarly, explain if all the specimens were histologically 
evaluated by the same pathologist.  
 
"The institution review board (IRB) ordained that this study needed not be approved by IRB." 
Please explai n if the IRB has already approved the study. It should have been approved before 
the conduction of the study.  
 
 
 
 
Discussion:  
"The rate of perforation during polypectomy and EMR using a monopolar snare was 0 -0.1% [17, 
18] and 0.4 -1.5% [19, 20],respectively." (lines 188 -189) These reported perforation rates are 
clinical data. Thus, the results obtained in the present study indicat e a greater perforation rate, 
which is probably subclinical. This should be mentioned somewhere in the Discussion.  
 
The maximal temperature obtained at the tipo f the instrument with monopolar and bipolar 
devices must be reported (as described by the manuf acturer) and trying to correlate them with the 
adjacent tissue damage. Moreover, actual surgical devices include advanced bipolar instruments, 
with maximal temperature sensors and external cover to minimize the spread of high 
temperature. Please, discuss i f these kind of devices would add some benefit to the endoscopic 
resections.  
 
Figures:  
H&amp; E Figures are OK, but probably images at higher magnification would add more 
information to the reader.  
ADDITIONAL REQUESTS/SUGGESTIONS:  
The text should be revise d by a native English speaker.  
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your  comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statist ical review?  
If an additional 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:  
 
Needs some language corrections before being published  
 
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, fees, funding, or salary from an 
organisation that may in any way gain 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 
financi ally 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 organiz ation that 
holds or has applied for patents relating to the content of 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 th e above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declared or apparent competing interests are not utilized for t hese reviews. This reviewer has 
agreed to pub lication of their comments online under a Creat ive Commons Attribution License 
attributed to Research Square and was paid a small honorarium for  completing the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of t he reviewer  
recommendation.  
 
 
 
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY l icense ( http://creativecommons.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: Safety of endoscopic procedures with monopolar versus bi polar instruments in an ex vivo 
porcine model  
 
Version: 3 Date: 10 Dec 2019  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
PEER REVIEWER ASSESSMENTS:  
 
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research 
question(s) (brief or other article types: is there a clear objective)?  
Yes - there is a clear objecti ve 
 
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for the 
objective?  
No - there are minor issues  
 
EXECUTION - Are the experiments and analyses performed with technical rigor to allow 
confidence in the results?  
Yes - experiments and analyses were performed appropriately  
 
STATISTICS - Is the use of statistics in the manuscript appropriate?  
N/A - there are no statistics in this study  
 
INTERPRETATION - Is the current interpretation/discussion of the results reasonab le and not 
overstated?  
No - there are minor issues  
 
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically 
sound? If not, can revisions be made to make the work technically sound?  
Probably - with minor revisions  
 
PEER REVIEWER COMME NTS:  
 
GENERAL COMMENTS:  
Congratulations to the authors, because they have conducted a novel and interesting study, 
evaluating adverse effects of endoscopic resections with monopolar and bipolar devices. 
However, several points should be addressed to impr ove the quality of the manuscript:  
 
REQUESTED REVISIONS:  
Methods:  
"Before EMR,  sufficient volume of saline was injected into the submucosal layer located under 
the target lesion. The volume of saline injected were not measured". (line 138 -140). Given tha t 
the models aimed to be similar, the volume of saline should have been also similar. This could 
represent  a bias. The authors should explain it or add it into a Limitations section.  
 
The authors should explain ir all the endoscopic procedures were perfor med by one or many 
endoscopists and their experience. Similarly, explain if all the specimens were histologically 
evaluated by the same pathologist.  
 
"The institution review board (IRB) ordained that this study needed not be approved by IRB." 
Please explai n if the IRB has already approved the study. It should have been approved before 
the conduction of the study.  
 
 
 
 
Discussion:  
"The rate of perforation during polypectomy and EMR using a monopolar snare was 0 -0.1% [17, 
18] and 0.4 -1.5% [19, 20],respectively." (lines 188 -189) These reported perforation rates are 
clinical data. Thus, the results obtained in the present study indicat e a greater perforation rate, 
which is probably subclinical. This should be mentioned somewhere in the Discussion.  
 
The maximal temperature obtained at the tipo f the instrument with monopolar and bipolar 
devices must be reported (as described by the manuf acturer) and trying to correlate them with the 
adjacent tissue damage. Moreover, actual surgical devices include advanced bipolar instruments, 
with maximal temperature sensors and external cover to minimize the spread of high 
temperature. Please, discuss i f these kind of devices would add some benefit to the endoscopic 
resections.  
 
Figures:  
H&amp; E Figures are OK, but probably images at higher magnification would add more 
information to the reader.  
ADDITIONAL REQUESTS/SUGGESTIONS:  
The text should be revise d by a native English speaker.  
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your  comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statist ical review?  
If an additional 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:  
 
Needs some language corrections before being published  
 
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, fees, funding, or salary from an 
organisation that may in any way gain 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 
financi ally 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 organiz ation that 
holds or has applied for patents relating to the content of 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 th e above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declared or apparent competing interests are not utilized for t hese reviews. This reviewer has 
agreed to pub lication of their comments online under a Creat ive Commons Attribution License 
attributed to Research Square and was paid a small honorarium for  completing the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of t he reviewer  
recommendation.  
 
 
 
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY l icense ( http://creativecommons.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: Safety of endoscopic procedures with monopolar versus bi polar instruments in an ex vivo 
porcine model  
 
Version: 3 Date: 10 Dec 2019  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
PEER REVIEWER ASSESSMENTS:  
 
OBJECTIVE - Full research articles: is there a clear objective that addresses a testable research 
question(s) (brief or other article types: is there a clear objective)?  
Yes - there is a clear objecti ve 
 
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for the 
objective?  
No - there are minor issues  
 
EXECUTION - Are the experiments and analyses performed with technical rigor to allow 
confidence in the results?  
Yes - experiments and analyses were performed appropriately  
 
STATISTICS - Is the use of statistics in the manuscript appropriate?  
N/A - there are no statistics in this study  
 
INTERPRETATION - Is the current interpretation/discussion of the results reasonab le and not 
overstated?  
No - there are minor issues  
 
OVERALL MANUSCRIPT POTENTIAL - Is the current version of this work technically 
sound? If not, can revisions be made to make the work technically sound?  
Probably - with minor revisions  
 
PEER REVIEWER COMME NTS:  
 
GENERAL COMMENTS:  
Congratulations to the authors, because they have conducted a novel and interesting study, 
evaluating adverse effects of endoscopic resections with monopolar and bipolar devices. 
However, several points should be addressed to impr ove the quality of the manuscript:  
 
REQUESTED REVISIONS:  
Methods:  
"Before EMR,  sufficient volume of saline was injected into the submucosal layer located under 
the target lesion. The volume of saline injected were not measured". (line 138 -140). Given tha t 
the models aimed to be similar, the volume of saline should have been also similar. This could 
represent  a bias. The authors should explain it or add it into a Limitations section.  
 
The authors should explain ir all the endoscopic procedures were perfor med by one or many 
endoscopists and their experience. Similarly, explain if all the specimens were histologically 
evaluated by the same pathologist.  
 
"The institution review board (IRB) ordained that this study needed not be approved by IRB." 
Please explai n if the IRB has already approved the study. It should have been approved before 
the conduction of the study.  
 
 
 
 
Discussion:  
"The rate of perforation during polypectomy and EMR using a monopolar snare was 0 -0.1% [17, 
18] and 0.4 -1.5% [19, 20],respectively." (lines 188 -189) These reported perforation rates are 
clinical data. Thus, the results obtained in the present study indicat e a greater perforation rate, 
which is probably subclinical. This should be mentioned somewhere in the Discussion.  
 
The maximal temperature obtained at the tipo f the instrument with monopolar and bipolar 
devices must be reported (as described by the manuf acturer) and trying to correlate them with the 
adjacent tissue damage. Moreover, actual surgical devices include advanced bipolar instruments, 
with maximal temperature sensors and external cover to minimize the spread of high 
temperature. Please, discuss i f these kind of devices would add some benefit to the endoscopic 
resections.  
 
Figures:  
H&amp; E Figures are OK, but probably images at higher magnification would add more 
information to the reader.  
ADDITIONAL REQUESTS/SUGGESTIONS:  
The text should be revise d by a native English speaker.  
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your  comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statist ical review?  
If an additional 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:  
 
Needs some language corrections before being published  
 
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, fees, funding, or salary from an 
organisation that may in any way gain 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 
financi ally 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 organiz ation that 
holds or has applied for patents relating to the content of 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 th e above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declared or apparent competing interests are not utilized for t hese reviews. This reviewer has 
agreed to pub lication of their comments online under a Creat ive Commons Attribution License 
attributed to Research Square and was paid a small honorarium for  completing the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of t he reviewer  
recommendation.  
 
 
 
 
I agree to the open peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the authors' 
responses. I agree for my report to be made available under an Open Access Creative Commons  
CC-BY l icense ( http://creativecommons.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