Review for 10.1186/s12876-025-03758-6 (2025)

Title: Endoscopic treatment for gastroesophageal varices in patients with cirrhosis: a survey
comparing between developed and developing countries
Version: 2 Date: 26 Dec 2024
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-The inclusion of both developed and developing countries is a strength, but the methodology
would benefit from more detailed information about how participants were selected. For
instance, were the endoscopists invited randomly or based on specific criteria? -Did the authors
account for potential biases in the selection of participants from each country? Clarifying this
would strengthen the generalizability of the findings.
-It would be beneficial to report the number of endoscopists from each country separately, as
the sample sizes and practice patterns might vary significantly across countries.
-While the manuscript states that the questionnaire was developed by a collaborative group of
experts (gastroenterologists, hepatologists, and endoscopists), there is no information on the
validity and reliability of the survey instrument. It would be helpful to include a statement
regarding the pre-testing or pilot-testing of the questionnaire, as well as any validation measures
taken to ensure the clarity and accuracy of the questions.
-The manuscript describes the questionnaire as being divided into five parts, but it would be
helpful to provide a more detailed description of the specific questions asked in each part. While
the supplementary file is referenced, including some examples of key questions in the manuscript
itself would give readers a clearer understanding of the scope and focus of the survey.
-While the authors mention the role of medical resources, technology, and training in shaping
treatment decisions, this could be discussed in more detail. For example, the authors could
elaborate on how specific resource limitations in developing countries (e.g., availability of
cyanoacrylate for gastric varices treatment) may influence clinical decision-making. They could
also discuss regional variations in medical education and access to updated guidelines, which
could further explain the differences observed between the two regions.
-Furthermore, it would be helpful to explore whether economic factors (e.g., the cost of
treatment) influence the decision-making process in developing countries. For instance, the
choice between medication versus endoscopy in primary prophylaxis could be influenced by
financial constraints in certain healthcare settings.
-The discussion touches on the efficacy of various treatment options, such as endoscopic ligation,
cyanoacrylate injection, and sclerotherapy, but the authors do not fully address the potential
impact of these treatments on patient outcomes. How might the regional differences in treatment
choices lead to variations in patient prognosis? For instance, could the preference for medication
over endoscopic intervention in developing countries result in higher rates of rebleeding or
mortality? While this is speculative, exploring these potential outcomes could strengthen the
discussion and provide a clearer picture of the clinical implications of the findings.
-While the authors briefly mention cultural differences in medical practice, a more detailed
exploration of how cultural factors might influence treatment decisions in different regions
could add a valuable dimension to the discussion. For example, are there cultural attitudes
toward invasive procedures, such as endoscopy, in certain regions that might influence treatment
choices? Are there differences in how patients in different regions are involved in treatment
decision-making?