Title: Animal Study of Adhesiolysis via Transumbilical Endoscopic Surgery with Gastric
Endoscopy: An Exploration
Version: 0 Date: 02 Jun 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
1. Sample Size and Generalizability
The study's sample size of eight beagles is relatively small, limiting the statistical power and
generalizability of the results. A larger cohort would provide more robust data and allow for
more definitive conclusions regarding the safety and efficacy of the E-NOTES procedure.
2. Duration of Follow-Up
A three-month follow-up period may not be sufficient to assess the long-term outcomes and
potential recurrence of adhesions. Adhesion-related complications can manifest beyond this
timeframe, and longer follow-ups would provide a more comprehensive understanding of the
procedure's durability.
3. Severity and Complexity of Adhesions
The adhesions induced in the beagle models ranged from grade 1 to 3, indicating mild to
moderate severity. This may not fully represent the complexity of adhesions encountered in
human clinical scenarios, where dense and extensive adhesions are common. Further studies
involving more severe adhesion models would better simulate clinical conditions.
4. Lack of Control Group
The absence of a control group undergoing standard laparoscopic or open adhesiolysis
procedures limits the ability to compare the outcomes and advantages of the E-NOTES approach
directly. Including such control groups in future studies would strengthen the comparative
analysis.
5. Technical Challenges and Learning Curve
The study acknowledges the technical challenges associated with the E-NOTES procedure,
particularly the maneuverability and stability of the gastric endoscope within the abdominal
cavity. The reliance on a single access point may also limit instrument triangulation, potentially
complicating the procedure. Addressing these technical limitations and assessing the learning
curve for surgeons are important considerations for clinical adoption.
6. Risk of Adhesion Reformation
While the study reports no new adhesions at the three-month follow-up, the risk of adhesion
reformation remains a concern. Literature indicates that adhesions can reform after adhesiolysis,
with rates varying depending on the surgical technique and patient factors. Long-term studies
are necessary to evaluate the recurrence rates associated with the E-NOTES approach.
7. Translation to Human Clinical Practice
The anatomical and physiological differences between beagle models and humans may affect
the translatability of the findings. Human clinical trials are essential to assess the feasibility,
safety, and efficacy of the E-NOTES procedure in the target patient population.
8. Ethical and Regulatory Considerations
As with any novel surgical technique, ethical considerations regarding patient selection,
informed consent, and regulatory approvals are paramount. Future studies should address these
aspects to ensure responsible clinical implementation.
Title: Animal Study of Adhesiolysis via Transumbilical Endoscopic Surgery with Gastric
Endoscopy: An Exploration
Version: 0 Date: 02 Jun 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
1. Sample Size and Generalizability
The study's sample size of eight beagles is relatively small, limiting the statistical power and
generalizability of the results. A larger cohort would provide more robust data and allow for
more definitive conclusions regarding the safety and efficacy of the E-NOTES procedure.
2. Duration of Follow-Up
A three-month follow-up period may not be sufficient to assess the long-term outcomes and
potential recurrence of adhesions. Adhesion-related complications can manifest beyond this
timeframe, and longer follow-ups would provide a more comprehensive understanding of the
procedure's durability.
3. Severity and Complexity of Adhesions
The adhesions induced in the beagle models ranged from grade 1 to 3, indicating mild to
moderate severity. This may not fully represent the complexity of adhesions encountered in
human clinical scenarios, where dense and extensive adhesions are common. Further studies
involving more severe adhesion models would better simulate clinical conditions.
4. Lack of Control Group
The absence of a control group undergoing standard laparoscopic or open adhesiolysis
procedures limits the ability to compare the outcomes and advantages of the E-NOTES approach
directly. Including such control groups in future studies would strengthen the comparative
analysis.
5. Technical Challenges and Learning Curve
The study acknowledges the technical challenges associated with the E-NOTES procedure,
particularly the maneuverability and stability of the gastric endoscope within the abdominal
cavity. The reliance on a single access point may also limit instrument triangulation, potentially
complicating the procedure. Addressing these technical limitations and assessing the learning
curve for surgeons are important considerations for clinical adoption.
6. Risk of Adhesion Reformation
While the study reports no new adhesions at the three-month follow-up, the risk of adhesion
reformation remains a concern. Literature indicates that adhesions can reform after adhesiolysis,
with rates varying depending on the surgical technique and patient factors. Long-term studies
are necessary to evaluate the recurrence rates associated with the E-NOTES approach.
7. Translation to Human Clinical Practice
The anatomical and physiological differences between beagle models and humans may affect
the translatability of the findings. Human clinical trials are essential to assess the feasibility,
safety, and efficacy of the E-NOTES procedure in the target patient population.
8. Ethical and Regulatory Considerations
As with any novel surgical technique, ethical considerations regarding patient selection,
informed consent, and regulatory approvals are paramount. Future studies should address these
aspects to ensure responsible clinical implementation.
Please review this paper.
user
Title: Animal Study of Adhesiolysis via Transumbilical Endoscopic Surgery with Gastric
Endoscopy: An Exploration
Version: 0 Date: 02 Jun 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
1. Sample Size and Generalizability
The study's sample size of eight beagles is relatively small, limiting the statistical power and
generalizability of the results. A larger cohort would provide more robust data and allow for
more definitive conclusions regarding the safety and efficacy of the E-NOTES procedure.
2. Duration of Follow-Up
A three-month follow-up period may not be sufficient to assess the long-term outcomes and
potential recurrence of adhesions. Adhesion-related complications can manifest beyond this
timeframe, and longer follow-ups would provide a more comprehensive understanding of the
procedure's durability.
3. Severity and Complexity of Adhesions
The adhesions induced in the beagle models ranged from grade 1 to 3, indicating mild to
moderate severity. This may not fully represent the complexity of adhesions encountered in
human clinical scenarios, where dense and extensive adhesions are common. Further studies
involving more severe adhesion models would better simulate clinical conditions.
4. Lack of Control Group
The absence of a control group undergoing standard laparoscopic or open adhesiolysis
procedures limits the ability to compare the outcomes and advantages of the E-NOTES approach
directly. Including such control groups in future studies would strengthen the comparative
analysis.
5. Technical Challenges and Learning Curve
The study acknowledges the technical challenges associated with the E-NOTES procedure,
particularly the maneuverability and stability of the gastric endoscope within the abdominal
cavity. The reliance on a single access point may also limit instrument triangulation, potentially
complicating the procedure. Addressing these technical limitations and assessing the learning
curve for surgeons are important considerations for clinical adoption.
6. Risk of Adhesion Reformation
While the study reports no new adhesions at the three-month follow-up, the risk of adhesion
reformation remains a concern. Literature indicates that adhesions can reform after adhesiolysis,
with rates varying depending on the surgical technique and patient factors. Long-term studies
are necessary to evaluate the recurrence rates associated with the E-NOTES approach.
7. Translation to Human Clinical Practice
The anatomical and physiological differences between beagle models and humans may affect
the translatability of the findings. Human clinical trials are essential to assess the feasibility,
safety, and efficacy of the E-NOTES procedure in the target patient population.
8. Ethical and Regulatory Considerations
As with any novel surgical technique, ethical considerations regarding patient selection,
informed consent, and regulatory approvals are paramount. Future studies should address these
aspects to ensure responsible clinical implementation.
assistant