Title: London Protocol under water-perfused HRM in a healthy population, towards novel 3D
manometric parameters in an evaluation of anorectal functional disorders
Version: 0 Date: 06 Feb 2024
Reviewer's report:
This is an interesting study showing how much a water-perfused anorectal manometry system
can do.  3D-reconstruction was nice. Results will be useful for a place where the solid-state
catheter is now available.  Here are some questions and comments to consider.
1) Should the upper limit of inclusion "age" be addressed? The lower limit was 18. However,
there was no upper limit.
2) Does the  term "London protocol" in this study refer to the anorectal manometry protocol that
is used in the "London classification"? If this is so, there is no need to find the feasibility because
it is only the description of steps of the procedure.  London classification is not demonstrated
in this study  as the population is normal.
3) 3D-manometric parameters (Endurance complementary parameters: fatigue rate, and
capability to sustain) were interesting. However, these data were derived from calculation  and
clinical relevance are not known. Further study in clinical settings and comparison to the existing
parameter from conventional manometry, such as duration of squeeze and  saline retention would
clarify their role.
4) Included female had vaginal delivery up to 68%. Thus, it was possible that these subjects had
anal sphincter defect to some degree. For this reason, the obtained "normative data" here might
not be normal enough to be a standard comparison to the "diseased patient" who presents with
anal incontinence  or anal sphincter injury.  However, it is understandable that the COVID period
might preclude enrollment of enough number of subjects. Thus, this point should be addressed
in the discussion.
5) From the reason in 4), it could be a reason why  other parameters , e.g. squeeze pressure, and
change during cough, is significantly impaired in female compared to male subjects.
6) Form the reason 4), it could be explained why "asymmetry" was more in female.
7) Table 6: the number of M and F in each study should be addressed only once, may be in
the first row.
7) Under "statistical analysis", t-test ... is more appropriate than T-test.
8) Although, the  water-perfused system is affordable and the authors had demonstrated robusted
information obtained. The "wetness" during procedure, especially a long procedural time with
36-channels water running would lead to discomfort and uncertainty in measurement which
should also be addressed in the discussion.
8) The strenght of this study is the 3D-reconstruction from the 36-channel manometry which
was not frequently showed in the previous literature. Additional description on this point may
elaborate the article.
Title: London Protocol under water-perfused HRM in a healthy population, towards novel 3D
manometric parameters in an evaluation of anorectal functional disorders
Version: 0 Date: 06 Feb 2024
Reviewer's report:
This is an interesting study showing how much a water-perfused anorectal manometry system
can do.  3D-reconstruction was nice. Results will be useful for a place where the solid-state
catheter is now available.  Here are some questions and comments to consider.
1) Should the upper limit of inclusion "age" be addressed? The lower limit was 18. However,
there was no upper limit.
2) Does the  term "London protocol" in this study refer to the anorectal manometry protocol that
is used in the "London classification"? If this is so, there is no need to find the feasibility because
it is only the description of steps of the procedure.  London classification is not demonstrated
in this study  as the population is normal.
3) 3D-manometric parameters (Endurance complementary parameters: fatigue rate, and
capability to sustain) were interesting. However, these data were derived from calculation  and
clinical relevance are not known. Further study in clinical settings and comparison to the existing
parameter from conventional manometry, such as duration of squeeze and  saline retention would
clarify their role.
4) Included female had vaginal delivery up to 68%. Thus, it was possible that these subjects had
anal sphincter defect to some degree. For this reason, the obtained "normative data" here might
not be normal enough to be a standard comparison to the "diseased patient" who presents with
anal incontinence  or anal sphincter injury.  However, it is understandable that the COVID period
might preclude enrollment of enough number of subjects. Thus, this point should be addressed
in the discussion.
5) From the reason in 4), it could be a reason why  other parameters , e.g. squeeze pressure, and
change during cough, is significantly impaired in female compared to male subjects.
6) Form the reason 4), it could be explained why "asymmetry" was more in female.
7) Table 6: the number of M and F in each study should be addressed only once, may be in
the first row.
7) Under "statistical analysis", t-test ... is more appropriate than T-test.
8) Although, the  water-perfused system is affordable and the authors had demonstrated robusted
information obtained. The "wetness" during procedure, especially a long procedural time with
36-channels water running would lead to discomfort and uncertainty in measurement which
should also be addressed in the discussion.
8) The strenght of this study is the 3D-reconstruction from the 36-channel manometry which
was not frequently showed in the previous literature. Additional description on this point may
elaborate the article.
Please review this paper.
user
Title: London Protocol under water-perfused HRM in a healthy population, towards novel 3D
manometric parameters in an evaluation of anorectal functional disorders
Version: 0 Date: 06 Feb 2024
Reviewer's report:
This is an interesting study showing how much a water-perfused anorectal manometry system
can do.  3D-reconstruction was nice. Results will be useful for a place where the solid-state
catheter is now available.  Here are some questions and comments to consider.
1) Should the upper limit of inclusion "age" be addressed? The lower limit was 18. However,
there was no upper limit.
2) Does the  term "London protocol" in this study refer to the anorectal manometry protocol that
is used in the "London classification"? If this is so, there is no need to find the feasibility because
it is only the description of steps of the procedure.  London classification is not demonstrated
in this study  as the population is normal.
3) 3D-manometric parameters (Endurance complementary parameters: fatigue rate, and
capability to sustain) were interesting. However, these data were derived from calculation  and
clinical relevance are not known. Further study in clinical settings and comparison to the existing
parameter from conventional manometry, such as duration of squeeze and  saline retention would
clarify their role.
4) Included female had vaginal delivery up to 68%. Thus, it was possible that these subjects had
anal sphincter defect to some degree. For this reason, the obtained "normative data" here might
not be normal enough to be a standard comparison to the "diseased patient" who presents with
anal incontinence  or anal sphincter injury.  However, it is understandable that the COVID period
might preclude enrollment of enough number of subjects. Thus, this point should be addressed
in the discussion.
5) From the reason in 4), it could be a reason why  other parameters , e.g. squeeze pressure, and
change during cough, is significantly impaired in female compared to male subjects.
6) Form the reason 4), it could be explained why "asymmetry" was more in female.
7) Table 6: the number of M and F in each study should be addressed only once, may be in
the first row.
7) Under "statistical analysis", t-test ... is more appropriate than T-test.
8) Although, the  water-perfused system is affordable and the authors had demonstrated robusted
information obtained. The "wetness" during procedure, especially a long procedural time with
36-channels water running would lead to discomfort and uncertainty in measurement which
should also be addressed in the discussion.
8) The strenght of this study is the 3D-reconstruction from the 36-channel manometry which
was not frequently showed in the previous literature. Additional description on this point may
elaborate the article.
assistant