Reviewer ’s report  
 
Title: A case of type 1 multiple endocrine neoplasia with  esophageal stricture successfully 
treated with endoscopic balloon dilation and local steroid injection combined with surgical 
resection of gastrinomas  
 
Version: 0 Date: 04 May 2016  
 
Reviewer: Yen-Po Wang  
 
Reviewer's report:  
 
This is a case report talking about MEN -I/ZES related esophageal stricture treated by repeated 
esophageal  dilatation + steroid injection. The authors did lots effort to diagnose and treat the 
patient with adequate result. About the endoscopic procedure, the author should describe it more 
in detail to guide the readers to treat their patients. In discussion, t here should be more feedback 
reviewing this protocol and talk about the potential weakness and easy making errors about the 
management. Could this method be replicated or standardized in some way? Also, management 
of the patient should be discussed with cu rrent guidelines since there are still uncertain areas in 
this field. Some English editing about words use is also welcome.  
 
Major issues  
1. According to your reference, MEN -I /ZES is more likely to be  related to esopahgeal disease 
and stricture over ZES patient. Though not as common as heartburn,  it is still 3 times more 
freqent in MEN1/ZES patients up to 9%. Rare will cause misunderstand ings to the readers. (J 
Clin Endocrinol Metab. 2006 Jan;91(1):204 -12. ).   
 
2. Did you injection steroid before dilatation or after dilatation? In (Gastrointest Endosc. 2002 
Dec; 56(6):829 -34.), it was suggested to inject steroid whenever possible before di latation, 
will the difference influence the result?  
 
2. How did you manage about anti -acid therapy during your 16th balloon dilation?  
 
3. How did the gastric and duodenal lesions change during your 16th balloon dilation, did they 
disappear soon  after surger y or also persisted?  
 
4. Is other medical therapy toward gastrinoma given, such as octreotide analog?  
 
5. About MEN -I gastrinoma surgical management in discussion, the authors opinion is different 
from the current consensus. Please refer to (Neuroendocrinol ogy 2016;103:153 -171 ) to 
make a balanced discussion.  
 
6. Is there any previous reported result including efficacy and complication about steorid + 
dilatation in ZES related esophageal stricture? If so, what is the reported dilatation times and 
complication  rate? If no, what is your suggestion about the times in repeated dilatation, when 
you will suggest alternative treatment, or you suggest that you can try until it work?  
 
7. Is the balloon size differ?  
 
8. Will EUS help in pre -dilatation evaluation of the stricture?  
 
Minor issues  
1. Lesional corticosteroid injection may be intralesional corticosteroid injection.  
 
2. What is your concentration of kenacort -A, high or low? Why you choose 50ug? in how much 
shots? 8 shots as previously reported?  
 
3. Background, lin e 6,  gastric hypersecretion is better than hypersecrete.  
 
4. line 7, Zollinger -Ellison syndrome(ZES) seems redundant  
 
5. line 10 , the author used "conversely", in  describing dysphagia due to esophageal strictures. 
However, reflux disease are less reporte d with strictures nowadays. What does MEN -1 with 
ZES converse with? Please modify the term.  
 
6. Case presentation , 1st paragraph, Was the pancreatic mass seen in image during SASI test? 
Since the patients had some other lesions in duodenum, is any other v essels signal showed 
possitive? How many and what vessels did you test?  
 
7. Paragraph 2, with the largest pancreatic tumor being 20 mm may be modified to with up to 
20 mm in pancreas  
 
8. Did the patient received total pancreatctomy only , or pancreaticoduoden ectomy(Whipple's 
operation). Since the authors mentioned about duodenal lesion also.  
 
9. p.6, line 5 "was" is redundant.  
 
Are the methods appropriate and well described?  
If not, please specify wha t 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.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require fu rther  
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 financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the fut ure? 
 
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 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 the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
No 
 
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 accepted for 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 license ( 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 included 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: A case of type 1 multiple endocrine neoplasia with  esophageal stricture successfully 
treated with endoscopic balloon dilation and local steroid injection combined with surgical 
resection of gastrinomas  
 
Version: 0 Date: 04 May 2016  
 
Reviewer: Yen-Po Wang  
 
Reviewer's report:  
 
This is a case report talking about MEN -I/ZES related esophageal stricture treated by repeated 
esophageal  dilatation + steroid injection. The authors did lots effort to diagnose and treat the 
patient with adequate result. About the endoscopic procedure, the author should describe it more 
in detail to guide the readers to treat their patients. In discussion, t here should be more feedback 
reviewing this protocol and talk about the potential weakness and easy making errors about the 
management. Could this method be replicated or standardized in some way? Also, management 
of the patient should be discussed with cu rrent guidelines since there are still uncertain areas in 
this field. Some English editing about words use is also welcome.  
 
Major issues  
1. According to your reference, MEN -I /ZES is more likely to be  related to esopahgeal disease 
and stricture over ZES patient. Though not as common as heartburn,  it is still 3 times more 
freqent in MEN1/ZES patients up to 9%. Rare will cause misunderstand ings to the readers. (J 
Clin Endocrinol Metab. 2006 Jan;91(1):204 -12. ).   
 
2. Did you injection steroid before dilatation or after dilatation? In (Gastrointest Endosc. 2002 
Dec; 56(6):829 -34.), it was suggested to inject steroid whenever possible before di latation, 
will the difference influence the result?  
 
2. How did you manage about anti -acid therapy during your 16th balloon dilation?  
 
3. How did the gastric and duodenal lesions change during your 16th balloon dilation, did they 
disappear soon  after surger y or also persisted?  
 
4. Is other medical therapy toward gastrinoma given, such as octreotide analog?  
 
5. About MEN -I gastrinoma surgical management in discussion, the authors opinion is different 
from the current consensus. Please refer to (Neuroendocrinol ogy 2016;103:153 -171 ) to 
make a balanced discussion.  
 
6. Is there any previous reported result including efficacy and complication about steorid + 
dilatation in ZES related esophageal stricture? If so, what is the reported dilatation times and 
complication  rate? If no, what is your suggestion about the times in repeated dilatation, when 
you will suggest alternative treatment, or you suggest that you can try until it work?  
 
7. Is the balloon size differ?  
 
8. Will EUS help in pre -dilatation evaluation of the stricture?  
 
Minor issues  
1. Lesional corticosteroid injection may be intralesional corticosteroid injection.  
 
2. What is your concentration of kenacort -A, high or low? Why you choose 50ug? in how much 
shots? 8 shots as previously reported?  
 
3. Background, lin e 6,  gastric hypersecretion is better than hypersecrete.  
 
4. line 7, Zollinger -Ellison syndrome(ZES) seems redundant  
 
5. line 10 , the author used "conversely", in  describing dysphagia due to esophageal strictures. 
However, reflux disease are less reporte d with strictures nowadays. What does MEN -1 with 
ZES converse with? Please modify the term.  
 
6. Case presentation , 1st paragraph, Was the pancreatic mass seen in image during SASI test? 
Since the patients had some other lesions in duodenum, is any other v essels signal showed 
possitive? How many and what vessels did you test?  
 
7. Paragraph 2, with the largest pancreatic tumor being 20 mm may be modified to with up to 
20 mm in pancreas  
 
8. Did the patient received total pancreatctomy only , or pancreaticoduoden ectomy(Whipple's 
operation). Since the authors mentioned about duodenal lesion also.  
 
9. p.6, line 5 "was" is redundant.  
 
Are the methods appropriate and well described?  
If not, please specify wha t 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.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require fu rther  
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 financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the fut ure? 
 
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 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 the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
No 
 
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 accepted for 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 license ( 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 included 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: A case of type 1 multiple endocrine neoplasia with  esophageal stricture successfully 
treated with endoscopic balloon dilation and local steroid injection combined with surgical 
resection of gastrinomas  
 
Version: 0 Date: 04 May 2016  
 
Reviewer: Yen-Po Wang  
 
Reviewer's report:  
 
This is a case report talking about MEN -I/ZES related esophageal stricture treated by repeated 
esophageal  dilatation + steroid injection. The authors did lots effort to diagnose and treat the 
patient with adequate result. About the endoscopic procedure, the author should describe it more 
in detail to guide the readers to treat their patients. In discussion, t here should be more feedback 
reviewing this protocol and talk about the potential weakness and easy making errors about the 
management. Could this method be replicated or standardized in some way? Also, management 
of the patient should be discussed with cu rrent guidelines since there are still uncertain areas in 
this field. Some English editing about words use is also welcome.  
 
Major issues  
1. According to your reference, MEN -I /ZES is more likely to be  related to esopahgeal disease 
and stricture over ZES patient. Though not as common as heartburn,  it is still 3 times more 
freqent in MEN1/ZES patients up to 9%. Rare will cause misunderstand ings to the readers. (J 
Clin Endocrinol Metab. 2006 Jan;91(1):204 -12. ).   
 
2. Did you injection steroid before dilatation or after dilatation? In (Gastrointest Endosc. 2002 
Dec; 56(6):829 -34.), it was suggested to inject steroid whenever possible before di latation, 
will the difference influence the result?  
 
2. How did you manage about anti -acid therapy during your 16th balloon dilation?  
 
3. How did the gastric and duodenal lesions change during your 16th balloon dilation, did they 
disappear soon  after surger y or also persisted?  
 
4. Is other medical therapy toward gastrinoma given, such as octreotide analog?  
 
5. About MEN -I gastrinoma surgical management in discussion, the authors opinion is different 
from the current consensus. Please refer to (Neuroendocrinol ogy 2016;103:153 -171 ) to 
make a balanced discussion.  
 
6. Is there any previous reported result including efficacy and complication about steorid + 
dilatation in ZES related esophageal stricture? If so, what is the reported dilatation times and 
complication  rate? If no, what is your suggestion about the times in repeated dilatation, when 
you will suggest alternative treatment, or you suggest that you can try until it work?  
 
7. Is the balloon size differ?  
 
8. Will EUS help in pre -dilatation evaluation of the stricture?  
 
Minor issues  
1. Lesional corticosteroid injection may be intralesional corticosteroid injection.  
 
2. What is your concentration of kenacort -A, high or low? Why you choose 50ug? in how much 
shots? 8 shots as previously reported?  
 
3. Background, lin e 6,  gastric hypersecretion is better than hypersecrete.  
 
4. line 7, Zollinger -Ellison syndrome(ZES) seems redundant  
 
5. line 10 , the author used "conversely", in  describing dysphagia due to esophageal strictures. 
However, reflux disease are less reporte d with strictures nowadays. What does MEN -1 with 
ZES converse with? Please modify the term.  
 
6. Case presentation , 1st paragraph, Was the pancreatic mass seen in image during SASI test? 
Since the patients had some other lesions in duodenum, is any other v essels signal showed 
possitive? How many and what vessels did you test?  
 
7. Paragraph 2, with the largest pancreatic tumor being 20 mm may be modified to with up to 
20 mm in pancreas  
 
8. Did the patient received total pancreatctomy only , or pancreaticoduoden ectomy(Whipple's 
operation). Since the authors mentioned about duodenal lesion also.  
 
9. p.6, line 5 "was" is redundant.  
 
Are the methods appropriate and well described?  
If not, please specify wha t 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.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require fu rther  
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 financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the fut ure? 
 
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 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 the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
No 
 
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 accepted for 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 license ( 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 included as confidential comments  
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant