Title: Timing of endoscopy in patients with acute variceal bleeding in cirrhosis: An updated
systematic review and meta-analysis
Version: 0 Date: 30 Apr 2025
Reviewer's report:
This study investigates the impact of endoscopy timing on outcomes in cirrhotic patients with
acute variceal bleeding (AVB) through a systematic review and meta-analysis. The topic holds
significant clinical relevance. The authors included recent studies and expanded the sample size,
with a rigorous methodological design. The conclusions provide valuable insights for clinical
practice. Specific comments are as follows:
1.The meta-analysis should adhere to the latest PRISMA guidelines and include a completed
checklist.
2.The search dates should be mentioned in the abstract.
The original conclusion states:" Endoscopy within 6 may be associated with higher mortality,
while endoscopy within 6-24 h had no significant impact on clinical outcomes in AVB patients.
Therefore, the timing for endoscopy would be more appropriate based on each patient's condition
within 24 h than an urgent endoscopy." This conclusion is problematic. The results indicate that
the subgroup analysis (6–24 hours) showed significantly lower mortality compared to the <6-
hour group, but this was based on only 2 studies (n=3,631). Overall, no significant differences
were observed between urgent endoscopy and early endoscopy groups in primary outcomes
(mortality, rebleeding) or secondary outcomes (hospital stay, rescue therapy, transfusion units).
The study does not demonstrate the superiority of "individualized timing within 24 hours" over
"urgent endoscopy," but rather shows no significant difference between the two. This conclusion
may mislead clinical practice.
3.Significant heterogeneity was observed in the analysis of primary outcomes, particularly for
mortality (I² = 69%). Potential sources of heterogeneity include variations in definitions of
endoscopy timing, inconsistencies in baseline patient characteristics (e.g., liver function scores,
bleeding severity), and differences in treatment protocols. Although subgroup analyses were
performed, the study failed to thoroughly explore the root causes of heterogeneity or conduct
sensitivity analyses to assess its impact on result stability.
4.Result Interpretation and Discussion:The <6-hour group showed significantly higher mortality
(OR = 2.05, 95% CI: 1.29–3.26, P = 0.002), but this was derived from only 2 studies (n=3,631).
When endoscopy timing was defined as a 12-hour interval, no significant mortality difference
was observed. The robustness of these findings and potential mechanisms (e.g., critically ill
patients being prioritized for urgent endoscopy, procedural risks) should be discussed. The
discussion should explicitly address the lack of significant differences in primary outcomes
across endoscopy timing groups and compare these findings with similar studies in the field.
Title: Timing of endoscopy in patients with acute variceal bleeding in cirrhosis: An updated
systematic review and meta-analysis
Version: 0 Date: 30 Apr 2025
Reviewer's report:
This study investigates the impact of endoscopy timing on outcomes in cirrhotic patients with
acute variceal bleeding (AVB) through a systematic review and meta-analysis. The topic holds
significant clinical relevance. The authors included recent studies and expanded the sample size,
with a rigorous methodological design. The conclusions provide valuable insights for clinical
practice. Specific comments are as follows:
1.The meta-analysis should adhere to the latest PRISMA guidelines and include a completed
checklist.
2.The search dates should be mentioned in the abstract.
The original conclusion states:" Endoscopy within 6 may be associated with higher mortality,
while endoscopy within 6-24 h had no significant impact on clinical outcomes in AVB patients.
Therefore, the timing for endoscopy would be more appropriate based on each patient's condition
within 24 h than an urgent endoscopy." This conclusion is problematic. The results indicate that
the subgroup analysis (6–24 hours) showed significantly lower mortality compared to the <6-
hour group, but this was based on only 2 studies (n=3,631). Overall, no significant differences
were observed between urgent endoscopy and early endoscopy groups in primary outcomes
(mortality, rebleeding) or secondary outcomes (hospital stay, rescue therapy, transfusion units).
The study does not demonstrate the superiority of "individualized timing within 24 hours" over
"urgent endoscopy," but rather shows no significant difference between the two. This conclusion
may mislead clinical practice.
3.Significant heterogeneity was observed in the analysis of primary outcomes, particularly for
mortality (I² = 69%). Potential sources of heterogeneity include variations in definitions of
endoscopy timing, inconsistencies in baseline patient characteristics (e.g., liver function scores,
bleeding severity), and differences in treatment protocols. Although subgroup analyses were
performed, the study failed to thoroughly explore the root causes of heterogeneity or conduct
sensitivity analyses to assess its impact on result stability.
4.Result Interpretation and Discussion:The <6-hour group showed significantly higher mortality
(OR = 2.05, 95% CI: 1.29–3.26, P = 0.002), but this was derived from only 2 studies (n=3,631).
When endoscopy timing was defined as a 12-hour interval, no significant mortality difference
was observed. The robustness of these findings and potential mechanisms (e.g., critically ill
patients being prioritized for urgent endoscopy, procedural risks) should be discussed. The
discussion should explicitly address the lack of significant differences in primary outcomes
across endoscopy timing groups and compare these findings with similar studies in the field.
Please review this paper.
user
Title: Timing of endoscopy in patients with acute variceal bleeding in cirrhosis: An updated
systematic review and meta-analysis
Version: 0 Date: 30 Apr 2025
Reviewer's report:
This study investigates the impact of endoscopy timing on outcomes in cirrhotic patients with
acute variceal bleeding (AVB) through a systematic review and meta-analysis. The topic holds
significant clinical relevance. The authors included recent studies and expanded the sample size,
with a rigorous methodological design. The conclusions provide valuable insights for clinical
practice. Specific comments are as follows:
1.The meta-analysis should adhere to the latest PRISMA guidelines and include a completed
checklist.
2.The search dates should be mentioned in the abstract.
The original conclusion states:" Endoscopy within 6 may be associated with higher mortality,
while endoscopy within 6-24 h had no significant impact on clinical outcomes in AVB patients.
Therefore, the timing for endoscopy would be more appropriate based on each patient's condition
within 24 h than an urgent endoscopy." This conclusion is problematic. The results indicate that
the subgroup analysis (6–24 hours) showed significantly lower mortality compared to the <6-
hour group, but this was based on only 2 studies (n=3,631). Overall, no significant differences
were observed between urgent endoscopy and early endoscopy groups in primary outcomes
(mortality, rebleeding) or secondary outcomes (hospital stay, rescue therapy, transfusion units).
The study does not demonstrate the superiority of "individualized timing within 24 hours" over
"urgent endoscopy," but rather shows no significant difference between the two. This conclusion
may mislead clinical practice.
3.Significant heterogeneity was observed in the analysis of primary outcomes, particularly for
mortality (I² = 69%). Potential sources of heterogeneity include variations in definitions of
endoscopy timing, inconsistencies in baseline patient characteristics (e.g., liver function scores,
bleeding severity), and differences in treatment protocols. Although subgroup analyses were
performed, the study failed to thoroughly explore the root causes of heterogeneity or conduct
sensitivity analyses to assess its impact on result stability.
4.Result Interpretation and Discussion:The <6-hour group showed significantly higher mortality
(OR = 2.05, 95% CI: 1.29–3.26, P = 0.002), but this was derived from only 2 studies (n=3,631).
When endoscopy timing was defined as a 12-hour interval, no significant mortality difference
was observed. The robustness of these findings and potential mechanisms (e.g., critically ill
patients being prioritized for urgent endoscopy, procedural risks) should be discussed. The
discussion should explicitly address the lack of significant differences in primary outcomes
across endoscopy timing groups and compare these findings with similar studies in the field.
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