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: 03 Mar 2025
Reviewer:  Ippei Tanaka
Reviewer's report:
This study aims to determine if timed barium esophagram findings after POEM can predict
esophageal contents at the time of follow-up endoscopy. However, there are several concerns
that the authors should address.
Major Concerns
1, Among the 48 patients, 5 (10.4%) had solid content remaining. However, how much solid
content was present? At the authors' institution, patients are instructed to fast from solid foods for
two days before the procedure, which is generally considered a sufficient fasting period. Under
such conditions, one would typically expect the esophagus to contain no solid or liquid content.
If the fasting protocol at the authors' institution ensures this, would endotracheal intubation even
be necessary in the first place?
If such a pre-procedural protocol is difficult to implement at other institutions, wouldn't it
be more appropriate to conduct this study under the same pre-procedural conditions as those
commonly used at other hospitals? For example, if patients were instructed to fast only on the
day of the procedure, the study could examine whether endotracheal intubation was actually
necessary in those cases.
2, This study aims to reduce the need for endotracheal intubation and concludes that if the 5-
minute barium column height is 7 cm or more, endotracheal intubation should be performed
during EGD.
How many patients had a 5-minute barium column height of 7 cm after POEM? Additionally, if
aspiration did not occur even in the group that did not undergo endotracheal intubation, wouldn't
that suggest that intubation is unnecessary in the first place?
3, In order to elaborate this study, how about grading the amount of remaining solid content?
For example:
Grade 1: Small amount
Grade 2: Moderate amount
Grade 3: Large amount, with a significantly high aspiration risk during endoscopy
Minor Concerns
1, Was there any correlation between barium column height at 3-6 months follow-up esophagram
and post-POEM symptoms?
2, Please describe in the Methods section how the passage of the 13 mm barium tablet was
evaluated in post-POEM esophagram, as well as how cases where the tablet did not pass were
managed.
3, The study states that the median column height at 5 minutes was 0 in post-POEM esophagram.
Please provide additional details on how many patients had specific barium column heights. For
example, how many patients had:
1 cm: X patients
2 cm: Y patients
etc.
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: 03 Mar 2025
Reviewer:  Ippei Tanaka
Reviewer's report:
This study aims to determine if timed barium esophagram findings after POEM can predict
esophageal contents at the time of follow-up endoscopy. However, there are several concerns
that the authors should address.
Major Concerns
1, Among the 48 patients, 5 (10.4%) had solid content remaining. However, how much solid
content was present? At the authors' institution, patients are instructed to fast from solid foods for
two days before the procedure, which is generally considered a sufficient fasting period. Under
such conditions, one would typically expect the esophagus to contain no solid or liquid content.
If the fasting protocol at the authors' institution ensures this, would endotracheal intubation even
be necessary in the first place?
If such a pre-procedural protocol is difficult to implement at other institutions, wouldn't it
be more appropriate to conduct this study under the same pre-procedural conditions as those
commonly used at other hospitals? For example, if patients were instructed to fast only on the
day of the procedure, the study could examine whether endotracheal intubation was actually
necessary in those cases.
2, This study aims to reduce the need for endotracheal intubation and concludes that if the 5-
minute barium column height is 7 cm or more, endotracheal intubation should be performed
during EGD.
How many patients had a 5-minute barium column height of 7 cm after POEM? Additionally, if
aspiration did not occur even in the group that did not undergo endotracheal intubation, wouldn't
that suggest that intubation is unnecessary in the first place?
3, In order to elaborate this study, how about grading the amount of remaining solid content?
For example:
Grade 1: Small amount
Grade 2: Moderate amount
Grade 3: Large amount, with a significantly high aspiration risk during endoscopy
Minor Concerns
1, Was there any correlation between barium column height at 3-6 months follow-up esophagram
and post-POEM symptoms?
2, Please describe in the Methods section how the passage of the 13 mm barium tablet was
evaluated in post-POEM esophagram, as well as how cases where the tablet did not pass were
managed.
3, The study states that the median column height at 5 minutes was 0 in post-POEM esophagram.
Please provide additional details on how many patients had specific barium column heights. For
example, how many patients had:
1 cm: X patients
2 cm: Y patients
etc.
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: 03 Mar 2025
Reviewer:  Ippei Tanaka
Reviewer's report:
This study aims to determine if timed barium esophagram findings after POEM can predict
esophageal contents at the time of follow-up endoscopy. However, there are several concerns
that the authors should address.
Major Concerns
1, Among the 48 patients, 5 (10.4%) had solid content remaining. However, how much solid
content was present? At the authors' institution, patients are instructed to fast from solid foods for
two days before the procedure, which is generally considered a sufficient fasting period. Under
such conditions, one would typically expect the esophagus to contain no solid or liquid content.
If the fasting protocol at the authors' institution ensures this, would endotracheal intubation even
be necessary in the first place?
If such a pre-procedural protocol is difficult to implement at other institutions, wouldn't it
be more appropriate to conduct this study under the same pre-procedural conditions as those
commonly used at other hospitals? For example, if patients were instructed to fast only on the
day of the procedure, the study could examine whether endotracheal intubation was actually
necessary in those cases.
2, This study aims to reduce the need for endotracheal intubation and concludes that if the 5-
minute barium column height is 7 cm or more, endotracheal intubation should be performed
during EGD.
How many patients had a 5-minute barium column height of 7 cm after POEM? Additionally, if
aspiration did not occur even in the group that did not undergo endotracheal intubation, wouldn't
that suggest that intubation is unnecessary in the first place?
3, In order to elaborate this study, how about grading the amount of remaining solid content?
For example:
Grade 1: Small amount
Grade 2: Moderate amount
Grade 3: Large amount, with a significantly high aspiration risk during endoscopy
Minor Concerns
1, Was there any correlation between barium column height at 3-6 months follow-up esophagram
and post-POEM symptoms?
2, Please describe in the Methods section how the passage of the 13 mm barium tablet was
evaluated in post-POEM esophagram, as well as how cases where the tablet did not pass were
managed.
3, The study states that the median column height at 5 minutes was 0 in post-POEM esophagram.
Please provide additional details on how many patients had specific barium column heights. For
example, how many patients had:
1 cm: X patients
2 cm: Y patients
etc.
assistant