Title: Esophageal motility disorders in symptomatic patients and its relation to age
Version: 3 Date: 28 Jan 2023
Reviewer's report:
The authors present an analysis of the different rates of motility disorders, particularly achalasia,
in older patients ( >65 years) compared with younger patients referred for esophageal motility
based on symptoms of heartburn, regurgitation, and/or dysphagia.  They found that the rate of
achalasia in older patients were significantly higher than that of the younger group, and that
these patients were more likely to be malnourished.
This paper does make some interesting points in what is a relatively straightforward study.  There
are a number of issues that need either clarification or could be improved, outlined by section
below:
1. In the Introduction, there is a lengthy section covering cognitive decline in the elderly which
is not directly related to the study in the manuscript.  This can be condensed for more clarity
in the overall paper.
2. In the Methods, the detail of which manometric system was used needs to be more toward
the beginning of the Methods section.  Notably, this is an outdated manometric measurement
system and what is described should be referred to as “conventional manometry” to distinguish
it from high resolution manometry.
3. In the Methods it would also be helpful to indicate the time period during which these 385
manometric studies were performed.
4. Also in the Methods, there is detail of older definitions of esophageal motility disorders that
are currently considered out of date. There is a brief mention of high resolution manometry in
the Discussion, but since the definitions have changed relatively dramatically since 2008 as high
resolution manometry has become widely used, there needs to be some acknowledgement of
this and the implications on the results.
5. In the Results the authors indicate that the rate of achalasia in the patients of the older
group was 43%, and that of the younger group was 29%.  These rates are extremely high,
particularly given that these patients were not all referred for the symptom of dysphagia.  The
overall incidence of achalasia around the world is generally considered to be 1 to 2 individuals
per 100,000, with a prevalence of approximately 1 in 10,000.  Among patients referred to
our esophageal manometry lab over the last approximately 20 years, only 1 in 20 or so has a
manometric diagnosis of achalasia.  Further, achalasia tends to be more easily recognized with
high resolution manometry techniques, since conventional manometry can sometimes misread
axial LES movement as pseudo-relaxation.  Therefore it will be important to for the authors to
comment on this very high incidence of achalasia in their referred patients in the Discussion
section of the paper.
Title: Esophageal motility disorders in symptomatic patients and its relation to age
Version: 3 Date: 28 Jan 2023
Reviewer's report:
The authors present an analysis of the different rates of motility disorders, particularly achalasia,
in older patients ( >65 years) compared with younger patients referred for esophageal motility
based on symptoms of heartburn, regurgitation, and/or dysphagia.  They found that the rate of
achalasia in older patients were significantly higher than that of the younger group, and that
these patients were more likely to be malnourished.
This paper does make some interesting points in what is a relatively straightforward study.  There
are a number of issues that need either clarification or could be improved, outlined by section
below:
1. In the Introduction, there is a lengthy section covering cognitive decline in the elderly which
is not directly related to the study in the manuscript.  This can be condensed for more clarity
in the overall paper.
2. In the Methods, the detail of which manometric system was used needs to be more toward
the beginning of the Methods section.  Notably, this is an outdated manometric measurement
system and what is described should be referred to as “conventional manometry” to distinguish
it from high resolution manometry.
3. In the Methods it would also be helpful to indicate the time period during which these 385
manometric studies were performed.
4. Also in the Methods, there is detail of older definitions of esophageal motility disorders that
are currently considered out of date. There is a brief mention of high resolution manometry in
the Discussion, but since the definitions have changed relatively dramatically since 2008 as high
resolution manometry has become widely used, there needs to be some acknowledgement of
this and the implications on the results.
5. In the Results the authors indicate that the rate of achalasia in the patients of the older
group was 43%, and that of the younger group was 29%.  These rates are extremely high,
particularly given that these patients were not all referred for the symptom of dysphagia.  The
overall incidence of achalasia around the world is generally considered to be 1 to 2 individuals
per 100,000, with a prevalence of approximately 1 in 10,000.  Among patients referred to
our esophageal manometry lab over the last approximately 20 years, only 1 in 20 or so has a
manometric diagnosis of achalasia.  Further, achalasia tends to be more easily recognized with
high resolution manometry techniques, since conventional manometry can sometimes misread
axial LES movement as pseudo-relaxation.  Therefore it will be important to for the authors to
comment on this very high incidence of achalasia in their referred patients in the Discussion
section of the paper.
Please review this paper.
user
Title: Esophageal motility disorders in symptomatic patients and its relation to age
Version: 3 Date: 28 Jan 2023
Reviewer's report:
The authors present an analysis of the different rates of motility disorders, particularly achalasia,
in older patients ( >65 years) compared with younger patients referred for esophageal motility
based on symptoms of heartburn, regurgitation, and/or dysphagia.  They found that the rate of
achalasia in older patients were significantly higher than that of the younger group, and that
these patients were more likely to be malnourished.
This paper does make some interesting points in what is a relatively straightforward study.  There
are a number of issues that need either clarification or could be improved, outlined by section
below:
1. In the Introduction, there is a lengthy section covering cognitive decline in the elderly which
is not directly related to the study in the manuscript.  This can be condensed for more clarity
in the overall paper.
2. In the Methods, the detail of which manometric system was used needs to be more toward
the beginning of the Methods section.  Notably, this is an outdated manometric measurement
system and what is described should be referred to as “conventional manometry” to distinguish
it from high resolution manometry.
3. In the Methods it would also be helpful to indicate the time period during which these 385
manometric studies were performed.
4. Also in the Methods, there is detail of older definitions of esophageal motility disorders that
are currently considered out of date. There is a brief mention of high resolution manometry in
the Discussion, but since the definitions have changed relatively dramatically since 2008 as high
resolution manometry has become widely used, there needs to be some acknowledgement of
this and the implications on the results.
5. In the Results the authors indicate that the rate of achalasia in the patients of the older
group was 43%, and that of the younger group was 29%.  These rates are extremely high,
particularly given that these patients were not all referred for the symptom of dysphagia.  The
overall incidence of achalasia around the world is generally considered to be 1 to 2 individuals
per 100,000, with a prevalence of approximately 1 in 10,000.  Among patients referred to
our esophageal manometry lab over the last approximately 20 years, only 1 in 20 or so has a
manometric diagnosis of achalasia.  Further, achalasia tends to be more easily recognized with
high resolution manometry techniques, since conventional manometry can sometimes misread
axial LES movement as pseudo-relaxation.  Therefore it will be important to for the authors to
comment on this very high incidence of achalasia in their referred patients in the Discussion
section of the paper.
assistant