Title: Endoscopic Iatrogenic Esophageal Perforation and Management: A Retrospective
Outcome Analysis in the Modern Era
Version: 3 Date: 25 Sep 2023
Reviewer:  Kazuhiro Ota
Reviewer's report:
This manuscript showed retrospectivity the characteristics and outcomes of iatrogenic
esophageal perforation from the endoscopist's perspective. It is understandable that iatorogenic
esophageal perforation is an extremely rare incident during endoscopic procedures. The number
of cases is so small that no statistical considerations in detail have been conducted. From the
above, it is important to consider each case in more detail. The following modifications are
necessary to accept this paper.
Major comments
1. It is understandable that iatrogenic esophageal perforation requires immediate attention.  The
conclusion of this paper is that SEMS is effective. Please consider whether it is necessary to
consider the location and size of the lesion, the patient's background, and the procedure that
caused the prior condition in developing a treatment strategy for the IEP.
2. Please consider the background of patients to iatrogenic esophageal perforation and also
consider proactive measures for high-risk patients of IEP.
3. Please suggest a way to detect IEPs early. What were the symptoms and laboratory findings
of the patients you collected?
Minor comments
1. There is a case report of the esophageal perforation during endoscopic submucosal dissection
resulting in pyothorax. In this case, the esophagus and thoracic cavity had become entangled,
requiring not only closure with SEMS but also chest pain drainage (Ota K, et al. Temporary
insertion of a covered self-expandable metal stent to treat esophageal perforation due to
endoscopic submucosal dissection. Intern Med. 2015;54(9):1049-1052.). On the other hand,
in the case of delayed perforation of endoscopic submucosal dissection, the patient had a
mediastinal abscess, so surgical treatment was the treatment of choice (Iwatsubo T, et al. Very
Delayed Perforation after Esophageal Endoscopic Submucosal Dissection and Intralesional
Triamcinolone Injection. Case Rep Gastroenterol. 2022;16(2):462-468). As mentioned above,
each patient is likely to have a different treatment strategy, and each case should be fully
considered.
2. The supplementary file named “Raw Data" contains personal information.  Necessity of
deletion.
3. Please provide some images of typical cases.
Title: Endoscopic Iatrogenic Esophageal Perforation and Management: A Retrospective
Outcome Analysis in the Modern Era
Version: 3 Date: 25 Sep 2023
Reviewer:  Kazuhiro Ota
Reviewer's report:
This manuscript showed retrospectivity the characteristics and outcomes of iatrogenic
esophageal perforation from the endoscopist's perspective. It is understandable that iatorogenic
esophageal perforation is an extremely rare incident during endoscopic procedures. The number
of cases is so small that no statistical considerations in detail have been conducted. From the
above, it is important to consider each case in more detail. The following modifications are
necessary to accept this paper.
Major comments
1. It is understandable that iatrogenic esophageal perforation requires immediate attention.  The
conclusion of this paper is that SEMS is effective. Please consider whether it is necessary to
consider the location and size of the lesion, the patient's background, and the procedure that
caused the prior condition in developing a treatment strategy for the IEP.
2. Please consider the background of patients to iatrogenic esophageal perforation and also
consider proactive measures for high-risk patients of IEP.
3. Please suggest a way to detect IEPs early. What were the symptoms and laboratory findings
of the patients you collected?
Minor comments
1. There is a case report of the esophageal perforation during endoscopic submucosal dissection
resulting in pyothorax. In this case, the esophagus and thoracic cavity had become entangled,
requiring not only closure with SEMS but also chest pain drainage (Ota K, et al. Temporary
insertion of a covered self-expandable metal stent to treat esophageal perforation due to
endoscopic submucosal dissection. Intern Med. 2015;54(9):1049-1052.). On the other hand,
in the case of delayed perforation of endoscopic submucosal dissection, the patient had a
mediastinal abscess, so surgical treatment was the treatment of choice (Iwatsubo T, et al. Very
Delayed Perforation after Esophageal Endoscopic Submucosal Dissection and Intralesional
Triamcinolone Injection. Case Rep Gastroenterol. 2022;16(2):462-468). As mentioned above,
each patient is likely to have a different treatment strategy, and each case should be fully
considered.
2. The supplementary file named “Raw Data" contains personal information.  Necessity of
deletion.
3. Please provide some images of typical cases.
Please review this paper.
user
Title: Endoscopic Iatrogenic Esophageal Perforation and Management: A Retrospective
Outcome Analysis in the Modern Era
Version: 3 Date: 25 Sep 2023
Reviewer:  Kazuhiro Ota
Reviewer's report:
This manuscript showed retrospectivity the characteristics and outcomes of iatrogenic
esophageal perforation from the endoscopist's perspective. It is understandable that iatorogenic
esophageal perforation is an extremely rare incident during endoscopic procedures. The number
of cases is so small that no statistical considerations in detail have been conducted. From the
above, it is important to consider each case in more detail. The following modifications are
necessary to accept this paper.
Major comments
1. It is understandable that iatrogenic esophageal perforation requires immediate attention.  The
conclusion of this paper is that SEMS is effective. Please consider whether it is necessary to
consider the location and size of the lesion, the patient's background, and the procedure that
caused the prior condition in developing a treatment strategy for the IEP.
2. Please consider the background of patients to iatrogenic esophageal perforation and also
consider proactive measures for high-risk patients of IEP.
3. Please suggest a way to detect IEPs early. What were the symptoms and laboratory findings
of the patients you collected?
Minor comments
1. There is a case report of the esophageal perforation during endoscopic submucosal dissection
resulting in pyothorax. In this case, the esophagus and thoracic cavity had become entangled,
requiring not only closure with SEMS but also chest pain drainage (Ota K, et al. Temporary
insertion of a covered self-expandable metal stent to treat esophageal perforation due to
endoscopic submucosal dissection. Intern Med. 2015;54(9):1049-1052.). On the other hand,
in the case of delayed perforation of endoscopic submucosal dissection, the patient had a
mediastinal abscess, so surgical treatment was the treatment of choice (Iwatsubo T, et al. Very
Delayed Perforation after Esophageal Endoscopic Submucosal Dissection and Intralesional
Triamcinolone Injection. Case Rep Gastroenterol. 2022;16(2):462-468). As mentioned above,
each patient is likely to have a different treatment strategy, and each case should be fully
considered.
2. The supplementary file named “Raw Data" contains personal information.  Necessity of
deletion.
3. Please provide some images of typical cases.
assistant