Review for 10.1186/s12876-019-1104-z (2019)

Reviewer’s report  
 
Title: Durability of pneumatic dilation monotherapy in treatment -naïve achalasia patients  
 
Version: 1 Date: 01 Aug 2019  
 
Reviewer: Pietro Familiari  
 
Reviewer's report:  
 
 
I read the revision with a lot of interest and curiosity.  
Authors edited the manuscript according to my suggestions or, at leas t, gave me some 
explanations regarding the methods of their study.  
 
Nevertheless I must admit that, even after this revision, the methods of the study (in the way they 
are written in the manuscript) remain someway confused and a little controversial and, a s a 
consequence, the results are equivocal.  
 
1) Please clearly state in the methods, who are exactly the patients in the x2PD and x3PD 
groups. How the patients were included in a group or another? What are the "inclusion criteria" 
for each group?  
 
I am so rry, but again I am confused when a read the manuscript.  
The indication for a second or third dilation, according to the current methods of the study, was 
ALWAYS symptoms persistence or recurrence. Authors replied to my queries: "we do not 
perform repeat scheduled repeat dilations". Furthermore, in accordance to the definition of 
success and failure in the methods section, if a patient was re -treated within 1 year he should be 
considered as a clinical failure (and exclude by the following subgroup analysis ). 
However,  in the group of patients who underwent two dilations the time interval between the 
two procedures varied between 14 and 2,335 days.   
In patients who underwent 3 PDs, the time interval between the first and second dilation and 
between the seco nd and third dilation was 19 -210 days and 49 -1,841 days, respectively.  
It means that many many patients underwent the second and third procedure before one year.  
It really seems that part of the patients included in the X2PD group were actually patients of the 
X1PD who had a clinical failure within 1 year and that were retreated with a second PD. Even 
worse: all the patients of the X3PD group experienced a clinical failure after the first dilation (the 
second one was performed between 19 and 210 days!!!).  … therefore ALL the following results 
should be reconsidered and recalculated, and the success -rate of a single PD, probably, is not 
anymore 87.5%. The flow -chard should be changed accordingly.  
 
2) Usually, in other groups of physicians that use the  gra ded dilator approach (that is 
currently recommended by many other experts!), a second or third dilation within 1 year of 
treatment is not a clinical failure, but part of the treatment. The failure would occur if the patient 
has not clinical improvement des pite the repeated dilations, or if he has a recurrence after more 
than 1 year.  
In this study you have a complete different definition of success and failure, and you consider the 
treatment modalities in an opposite way.  
Of course a different point of vie w is well accepted,  but it should be at least explained better and 
in detail in the discussion.  
 
3) In the abstract, the study population is still 103 patients  
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
No 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or  shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
 
4. Have you re ceived reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing interests i n relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
 
I declare that I have no competing interests  
 
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