Title: Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric
cardiofundal variceal bleeding in liver cirrhosis
Version: 3 Date: 09 May 2022
Reviewer's report:
This study is a retrospective observational study comparing the effects of EVO and RTO in
patients with gastric variceal bleeding. Both EVO and RTO have very good therapeutic effects
on gastric variceal bleeding, which is a fatal condition, have few complications, and can be
evaluated as excellent treatments. In this study, it was concluded that RTO is more curative in
terms of eradication of gastric varices, as previously reported. Although the conclusions of this
study are not novel, the results of the analysis are credible using the two groups with a very
uniform number of cases and background. However, there are some problems to be confirmed.
Major comments
1. Although this study design looks like a retrospective observational study, it neatly divides
emergency patients with gastric variceal bleeding into two groups and is suspected to be a
prospective interventional study. Isn’t it a prospective controlled study?
2. In addition, it is necessary to clarify what kind of adaptation was decided to perform EVO or
RTO. We request that you clarify how to make one of the two treatment options (for example,
"EVO was performed at facility A and RTO was performed at facility B", "the treatment was
changed depending on the period", "alternatively changed treatment methods," etc.).
Minor comments
1. Even when the authors find bleeding endoscopically, do they give no treatment to patients
in the RTO group?
(Examples: endoscopic clipping, EVL, compression with SB tube, etc.)
2. Was EVO puncture performed under EUS?
Was the injection of glue (NBCA-Lipiodol) performed under fluoroscopy?
What was the end point of glue injection?
3. RTO includes BRTO (using STS) and PARTO (using gelatin sponge). Both showed good
results equally and were highly evaluated. STS is a sclerosant that causes vascular endothelial
damage, but gelatin sponge is just a physical embolic material without endothelial damage. The
differences between BRTO and PARTO should be considered, including the differences with
and without sclerosant.
4. BRTO occludes major portosystemic shunts and is often used as a treatment for hepatic
encephalopathy. In this study, the onset of hepatic encephalopathy after RTO was seen in 2
cases. Why?
Title: Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric
cardiofundal variceal bleeding in liver cirrhosis
Version: 3 Date: 09 May 2022
Reviewer's report:
This study is a retrospective observational study comparing the effects of EVO and RTO in
patients with gastric variceal bleeding. Both EVO and RTO have very good therapeutic effects
on gastric variceal bleeding, which is a fatal condition, have few complications, and can be
evaluated as excellent treatments. In this study, it was concluded that RTO is more curative in
terms of eradication of gastric varices, as previously reported. Although the conclusions of this
study are not novel, the results of the analysis are credible using the two groups with a very
uniform number of cases and background. However, there are some problems to be confirmed.
Major comments
1. Although this study design looks like a retrospective observational study, it neatly divides
emergency patients with gastric variceal bleeding into two groups and is suspected to be a
prospective interventional study. Isn’t it a prospective controlled study?
2. In addition, it is necessary to clarify what kind of adaptation was decided to perform EVO or
RTO. We request that you clarify how to make one of the two treatment options (for example,
"EVO was performed at facility A and RTO was performed at facility B", "the treatment was
changed depending on the period", "alternatively changed treatment methods," etc.).
Minor comments
1. Even when the authors find bleeding endoscopically, do they give no treatment to patients
in the RTO group?
(Examples: endoscopic clipping, EVL, compression with SB tube, etc.)
2. Was EVO puncture performed under EUS?
Was the injection of glue (NBCA-Lipiodol) performed under fluoroscopy?
What was the end point of glue injection?
3. RTO includes BRTO (using STS) and PARTO (using gelatin sponge). Both showed good
results equally and were highly evaluated. STS is a sclerosant that causes vascular endothelial
damage, but gelatin sponge is just a physical embolic material without endothelial damage. The
differences between BRTO and PARTO should be considered, including the differences with
and without sclerosant.
4. BRTO occludes major portosystemic shunts and is often used as a treatment for hepatic
encephalopathy. In this study, the onset of hepatic encephalopathy after RTO was seen in 2
cases. Why?
Please review this paper.
user
Title: Endoscopic variceal obturation and retrograde transvenous obliteration for acute gastric
cardiofundal variceal bleeding in liver cirrhosis
Version: 3 Date: 09 May 2022
Reviewer's report:
This study is a retrospective observational study comparing the effects of EVO and RTO in
patients with gastric variceal bleeding. Both EVO and RTO have very good therapeutic effects
on gastric variceal bleeding, which is a fatal condition, have few complications, and can be
evaluated as excellent treatments. In this study, it was concluded that RTO is more curative in
terms of eradication of gastric varices, as previously reported. Although the conclusions of this
study are not novel, the results of the analysis are credible using the two groups with a very
uniform number of cases and background. However, there are some problems to be confirmed.
Major comments
1. Although this study design looks like a retrospective observational study, it neatly divides
emergency patients with gastric variceal bleeding into two groups and is suspected to be a
prospective interventional study. Isn’t it a prospective controlled study?
2. In addition, it is necessary to clarify what kind of adaptation was decided to perform EVO or
RTO. We request that you clarify how to make one of the two treatment options (for example,
"EVO was performed at facility A and RTO was performed at facility B", "the treatment was
changed depending on the period", "alternatively changed treatment methods," etc.).
Minor comments
1. Even when the authors find bleeding endoscopically, do they give no treatment to patients
in the RTO group?
(Examples: endoscopic clipping, EVL, compression with SB tube, etc.)
2. Was EVO puncture performed under EUS?
Was the injection of glue (NBCA-Lipiodol) performed under fluoroscopy?
What was the end point of glue injection?
3. RTO includes BRTO (using STS) and PARTO (using gelatin sponge). Both showed good
results equally and were highly evaluated. STS is a sclerosant that causes vascular endothelial
damage, but gelatin sponge is just a physical embolic material without endothelial damage. The
differences between BRTO and PARTO should be considered, including the differences with
and without sclerosant.
4. BRTO occludes major portosystemic shunts and is often used as a treatment for hepatic
encephalopathy. In this study, the onset of hepatic encephalopathy after RTO was seen in 2
cases. Why?
assistant