Title: Long-term outcomes of refractory esophageal strictures after endoscopic submucosal
dissection of superficial esophageal neoplasms
Version: 2 Date: 21 Nov 2021
Reviewer's report:
General comments:
This study showed the natural history of refractory esophageal strictures (RES) after endoscopic
submucosal dissection (ESD) of superficial esophageal neoplasms. An average of more than
10 dilatations finally resulted in endoscopic therapy success in 60% of cases. Once a RES had
occurred, prophylactic steroid therapy could not reduce the frequency of dilations or change the
long-term outcomes. Although this study is informative, it has several points that require further
attention as described below.
Major and specific comments:
1. Of the total number of ESD cases for superficial esophageal neoplasms, how many had large
circumferential resections and what percentage of them resulted in RES? What kind of stenosis
prevention measures were taken in each case? Please show the flow chart of this study because
we cannot understand.
2. It would be misleading to show only that prophylactic steroid medication had no effect on
completed RES. Please show the role of prophylactic steroid medication played in reducing the
incidence of RES. In which cases was prophylactic oral steroids chosen, and in what proportion
of these cases did RES occur?
3. The analysis method in Table 1 is not clear. What does the note " &: P indicates a significant
relationship between characteristics of patients and endoscopic therapy in univariate analysis."
in table1 mean? Did the authors compare endoscopic therapy successes and failures? Or did
the authors perform a logistic regression analysis with each factor as an explanatory variable
with the objective variable being endoscopic therapy success? Please show the percentage of
endoscopic therapy successes and failures and their characteristics.
4. Why is there a longer period of time without dysphagia in the balloon dilation alone group
compared to the steroid prophylaxis group? Isn't there a strong selection bias in favor of steroid
prophylaxis in patients at high risk for RES? The authors should discuss this point.
5. Why did the elderly and female patients have shorter dysphagia-free periods compared with
young and male patients? What mechanism could have influenced this result? Please discuss
the reasons as possible.
6. In table 3, did the authors perform the multivariate analysis using the 5 risk factors presented
as explanatory variables? 5 explanatory variables might be a bit overfitting for 30 cases with
endoscopic therapy successes as the event. Please state this in the limitations.
7. Before using RES as an abbreviation, please provide the definition and full spelling of RES
first.
8. In the definition section, provide a definition for each of the dysphagia scores.
9. Please show the R0 resection rate for these RES cases. Furthermore, please show that the
residual recurrence was not involved in these RES cases.
Title: Long-term outcomes of refractory esophageal strictures after endoscopic submucosal
dissection of superficial esophageal neoplasms
Version: 2 Date: 21 Nov 2021
Reviewer's report:
General comments:
This study showed the natural history of refractory esophageal strictures (RES) after endoscopic
submucosal dissection (ESD) of superficial esophageal neoplasms. An average of more than
10 dilatations finally resulted in endoscopic therapy success in 60% of cases. Once a RES had
occurred, prophylactic steroid therapy could not reduce the frequency of dilations or change the
long-term outcomes. Although this study is informative, it has several points that require further
attention as described below.
Major and specific comments:
1. Of the total number of ESD cases for superficial esophageal neoplasms, how many had large
circumferential resections and what percentage of them resulted in RES? What kind of stenosis
prevention measures were taken in each case? Please show the flow chart of this study because
we cannot understand.
2. It would be misleading to show only that prophylactic steroid medication had no effect on
completed RES. Please show the role of prophylactic steroid medication played in reducing the
incidence of RES. In which cases was prophylactic oral steroids chosen, and in what proportion
of these cases did RES occur?
3. The analysis method in Table 1 is not clear. What does the note " &: P indicates a significant
relationship between characteristics of patients and endoscopic therapy in univariate analysis."
in table1 mean? Did the authors compare endoscopic therapy successes and failures? Or did
the authors perform a logistic regression analysis with each factor as an explanatory variable
with the objective variable being endoscopic therapy success? Please show the percentage of
endoscopic therapy successes and failures and their characteristics.
4. Why is there a longer period of time without dysphagia in the balloon dilation alone group
compared to the steroid prophylaxis group? Isn't there a strong selection bias in favor of steroid
prophylaxis in patients at high risk for RES? The authors should discuss this point.
5. Why did the elderly and female patients have shorter dysphagia-free periods compared with
young and male patients? What mechanism could have influenced this result? Please discuss
the reasons as possible.
6. In table 3, did the authors perform the multivariate analysis using the 5 risk factors presented
as explanatory variables? 5 explanatory variables might be a bit overfitting for 30 cases with
endoscopic therapy successes as the event. Please state this in the limitations.
7. Before using RES as an abbreviation, please provide the definition and full spelling of RES
first.
8. In the definition section, provide a definition for each of the dysphagia scores.
9. Please show the R0 resection rate for these RES cases. Furthermore, please show that the
residual recurrence was not involved in these RES cases.
Please review this paper.
user
Title: Long-term outcomes of refractory esophageal strictures after endoscopic submucosal
dissection of superficial esophageal neoplasms
Version: 2 Date: 21 Nov 2021
Reviewer's report:
General comments:
This study showed the natural history of refractory esophageal strictures (RES) after endoscopic
submucosal dissection (ESD) of superficial esophageal neoplasms. An average of more than
10 dilatations finally resulted in endoscopic therapy success in 60% of cases. Once a RES had
occurred, prophylactic steroid therapy could not reduce the frequency of dilations or change the
long-term outcomes. Although this study is informative, it has several points that require further
attention as described below.
Major and specific comments:
1. Of the total number of ESD cases for superficial esophageal neoplasms, how many had large
circumferential resections and what percentage of them resulted in RES? What kind of stenosis
prevention measures were taken in each case? Please show the flow chart of this study because
we cannot understand.
2. It would be misleading to show only that prophylactic steroid medication had no effect on
completed RES. Please show the role of prophylactic steroid medication played in reducing the
incidence of RES. In which cases was prophylactic oral steroids chosen, and in what proportion
of these cases did RES occur?
3. The analysis method in Table 1 is not clear. What does the note " &: P indicates a significant
relationship between characteristics of patients and endoscopic therapy in univariate analysis."
in table1 mean? Did the authors compare endoscopic therapy successes and failures? Or did
the authors perform a logistic regression analysis with each factor as an explanatory variable
with the objective variable being endoscopic therapy success? Please show the percentage of
endoscopic therapy successes and failures and their characteristics.
4. Why is there a longer period of time without dysphagia in the balloon dilation alone group
compared to the steroid prophylaxis group? Isn't there a strong selection bias in favor of steroid
prophylaxis in patients at high risk for RES? The authors should discuss this point.
5. Why did the elderly and female patients have shorter dysphagia-free periods compared with
young and male patients? What mechanism could have influenced this result? Please discuss
the reasons as possible.
6. In table 3, did the authors perform the multivariate analysis using the 5 risk factors presented
as explanatory variables? 5 explanatory variables might be a bit overfitting for 30 cases with
endoscopic therapy successes as the event. Please state this in the limitations.
7. Before using RES as an abbreviation, please provide the definition and full spelling of RES
first.
8. In the definition section, provide a definition for each of the dysphagia scores.
9. Please show the R0 resection rate for these RES cases. Furthermore, please show that the
residual recurrence was not involved in these RES cases.
assistant