Title: Three-to-Six Month Post-POEM Timed Barium Esophagram Can Predict Esophageal
Contents and May Stratify Aspiration Risk on Follow-up EGD
Version: 2 Date: 04 Mar 2025
Reviewer's report:
I thank the editors for the opportunity to review this interesting article.  In it the authors assessed
the utility of TBE in post-POEM patients to predict the presence of residual food/liquid in the
esophagus on EGD.  I have some comments.
Major points:
1. The authors write that intubation is "typically" (lines 82, 112) or "frequently" (lines 84, 120)
performed for EGDs in patients with achalasia.  What is the evidence for this?  Are there any
studies showing this?  This may be the practice at the authors' institution, but I've never seen
this to be standard of care.  Please support this assertion.  And add it to the limitations that this
may not be applicable in all locales.
2. This study assesses the improvement in TBE findings after achalasia treatment.  This is a
subject that has been extensively written about (and is not novel here), but does not appear to be
cited or discussed in this paper.  Line 123 states that "The timed barium esophagram is useful
in evaluating POEM response." without citing a source, and none of the studies showing how
TBE is useful are discussed.     This should be discussed.
3.  "Esophagram" and "TBE" are not the same.   TBE is a specific type of esophgram so I would
change all uses of the term to timed barium esophagram or TBE, including in the title.
4.  For the conclusion, I think it should be changed to something more on the lines of: This study
adds to our knowledge that TBE findings are a good predictor of esophageal emptying post-
POEM. This may be used to predict which patients may be at risk of having residual esophageal
contents and therefore need intubation.
Smaller points:
1. I would not call POEM "non-invasive" (line 111).  Perhaps change to "minimally invasive"
or "non-surgical"
2.  Some definitions of terms/outcomes are not given.  How was residual food or liquid in the
esophagus on EGD defined?  How much was needed?  If suction was performed?  Was this
defined a priori or retrospectively taken from EGD reports?
3. Line 165 mentions that Eckardt scores significantly improved.  Please provide a p-value.  The
statistical test used should be mentioned in the Methods.
4. Line 166: passed tablets and transiently delayed tablets were combined.  Was this a priori?
How was "transiently" passed defined?
5. Line 170. Some patients were intubated and others were not.  Why?  What factors went into
this decision?
6. Table.  Many rows start with "median Q1 Q3" and then list the variable.  It would be much
easier to read if the variable was always first, then median Q1 Q3.  For example would change
it to: Age at POEM, median, Q1 Q3.  BMI, median, Q1 Q3.
Title: Three-to-Six Month Post-POEM Timed Barium Esophagram Can Predict Esophageal
Contents and May Stratify Aspiration Risk on Follow-up EGD
Version: 2 Date: 04 Mar 2025
Reviewer's report:
I thank the editors for the opportunity to review this interesting article.  In it the authors assessed
the utility of TBE in post-POEM patients to predict the presence of residual food/liquid in the
esophagus on EGD.  I have some comments.
Major points:
1. The authors write that intubation is "typically" (lines 82, 112) or "frequently" (lines 84, 120)
performed for EGDs in patients with achalasia.  What is the evidence for this?  Are there any
studies showing this?  This may be the practice at the authors' institution, but I've never seen
this to be standard of care.  Please support this assertion.  And add it to the limitations that this
may not be applicable in all locales.
2. This study assesses the improvement in TBE findings after achalasia treatment.  This is a
subject that has been extensively written about (and is not novel here), but does not appear to be
cited or discussed in this paper.  Line 123 states that "The timed barium esophagram is useful
in evaluating POEM response." without citing a source, and none of the studies showing how
TBE is useful are discussed.     This should be discussed.
3.  "Esophagram" and "TBE" are not the same.   TBE is a specific type of esophgram so I would
change all uses of the term to timed barium esophagram or TBE, including in the title.
4.  For the conclusion, I think it should be changed to something more on the lines of: This study
adds to our knowledge that TBE findings are a good predictor of esophageal emptying post-
POEM. This may be used to predict which patients may be at risk of having residual esophageal
contents and therefore need intubation.
Smaller points:
1. I would not call POEM "non-invasive" (line 111).  Perhaps change to "minimally invasive"
or "non-surgical"
2.  Some definitions of terms/outcomes are not given.  How was residual food or liquid in the
esophagus on EGD defined?  How much was needed?  If suction was performed?  Was this
defined a priori or retrospectively taken from EGD reports?
3. Line 165 mentions that Eckardt scores significantly improved.  Please provide a p-value.  The
statistical test used should be mentioned in the Methods.
4. Line 166: passed tablets and transiently delayed tablets were combined.  Was this a priori?
How was "transiently" passed defined?
5. Line 170. Some patients were intubated and others were not.  Why?  What factors went into
this decision?
6. Table.  Many rows start with "median Q1 Q3" and then list the variable.  It would be much
easier to read if the variable was always first, then median Q1 Q3.  For example would change
it to: Age at POEM, median, Q1 Q3.  BMI, median, Q1 Q3.
Please review this paper.
user
Title: Three-to-Six Month Post-POEM Timed Barium Esophagram Can Predict Esophageal
Contents and May Stratify Aspiration Risk on Follow-up EGD
Version: 2 Date: 04 Mar 2025
Reviewer's report:
I thank the editors for the opportunity to review this interesting article.  In it the authors assessed
the utility of TBE in post-POEM patients to predict the presence of residual food/liquid in the
esophagus on EGD.  I have some comments.
Major points:
1. The authors write that intubation is "typically" (lines 82, 112) or "frequently" (lines 84, 120)
performed for EGDs in patients with achalasia.  What is the evidence for this?  Are there any
studies showing this?  This may be the practice at the authors' institution, but I've never seen
this to be standard of care.  Please support this assertion.  And add it to the limitations that this
may not be applicable in all locales.
2. This study assesses the improvement in TBE findings after achalasia treatment.  This is a
subject that has been extensively written about (and is not novel here), but does not appear to be
cited or discussed in this paper.  Line 123 states that "The timed barium esophagram is useful
in evaluating POEM response." without citing a source, and none of the studies showing how
TBE is useful are discussed.     This should be discussed.
3.  "Esophagram" and "TBE" are not the same.   TBE is a specific type of esophgram so I would
change all uses of the term to timed barium esophagram or TBE, including in the title.
4.  For the conclusion, I think it should be changed to something more on the lines of: This study
adds to our knowledge that TBE findings are a good predictor of esophageal emptying post-
POEM. This may be used to predict which patients may be at risk of having residual esophageal
contents and therefore need intubation.
Smaller points:
1. I would not call POEM "non-invasive" (line 111).  Perhaps change to "minimally invasive"
or "non-surgical"
2.  Some definitions of terms/outcomes are not given.  How was residual food or liquid in the
esophagus on EGD defined?  How much was needed?  If suction was performed?  Was this
defined a priori or retrospectively taken from EGD reports?
3. Line 165 mentions that Eckardt scores significantly improved.  Please provide a p-value.  The
statistical test used should be mentioned in the Methods.
4. Line 166: passed tablets and transiently delayed tablets were combined.  Was this a priori?
How was "transiently" passed defined?
5. Line 170. Some patients were intubated and others were not.  Why?  What factors went into
this decision?
6. Table.  Many rows start with "median Q1 Q3" and then list the variable.  It would be much
easier to read if the variable was always first, then median Q1 Q3.  For example would change
it to: Age at POEM, median, Q1 Q3.  BMI, median, Q1 Q3.
assistant