Review for 10.1186/s12876-025-03838-7 (2025)

Title: Three-to-Six Month Post-POEM Timed Barium Esophagram Can Predict Esophageal
Contents and May Stratify Aspiration Risk on Follow-up EGD
Version: 2 Date: 05 Mar 2025
Reviewer's report:
This study explores the predictive value of esophagram parameters at 3-6 months post-POEM
for esophageal contents and aspiration risk, addressing a clinically significant topic. However,
from the perspective of esophageal manometry, the manuscript requires further elaboration and
improvement in the following areas:
1. Insufficient Presentation and Analysis of Esophageal Manometry Data
-Lack of Postoperative Manometry Data: While the authors mention pre- and post-POEM
high-resolution manometry (HRM), the results section lacks specific postoperative manometric
parameters (e.g., LES resting pressure, relaxation rate, esophageal body contraction patterns).
These metrics are critical for evaluating POEM efficacy and should be correlated with
esophagram findings (e.g., barium column height) and endoscopic esophageal contents. For
instance: Does postoperative LES pressure correlate with barium retention? Does recovery of
esophageal body peristalsis influence the passage of a 13mm barium tablet?
-Insufficient Subtype Analysis: Achalasia subtypes (I/II/III) exhibit distinct manometric
characteristics (e.g., spastic contractions in type III), which may impact postoperative emptying.
Although subtype distribution is listed in Table 1, the manuscript lacks analysis of how
manometric outcomes differ across subtypes and their relationship with esophagram/endoscopy
findings. Subtype-stratified analyses are recommended.
2. Synergistic Analysis of EndoFLIP and Esophageal Manometry
-The study uses EndoFLIP to assess the distensibility index (DI) of the LES but does not explore
correlations between DI and HRM parameters (e.g., LES pressure). Combining these modalities
would provide a more comprehensive evaluation of LES function. A joint analysis of DI and
manometric parameters is suggested to clarify their combined predictive value for esophageal
emptying.
3. Temporal Consistency and Longitudinal Data
-The intervals between postoperative manometry, esophagram, and endoscopy are not clearly
stated. If manometry and esophagram/endoscopy were performed at different time points (e.g.,
manometry at 3 months vs. esophagram at 6 months), this could introduce bias. Clarify the
temporal alignment of these assessments or analyze the impact of time gaps on outcomes.
4. Potential Clinical Value of Esophageal Manometry in Decision-Making
-The conclusion suggests that esophagram results may guide avoidance of endotracheal
intubation but does not address whether manometry adds predictive value. For example, does
postoperative LES relaxation rate synergize with barium column height in risk stratification?
Discuss the potential role of manometric parameters in optimizing clinical decision-making to
enhance practical relevance.
5. Methodological Details Require Clarification
- Specify HRM protocols (e.g., Chicago Classification version), analyzed parameters (e.g.,
integrated relaxation pressure \[IRP\], contraction pattern classification), and EndoFLIP
protocols (e.g., infusion volume, measurement location). Additionally, clarify whether patients
with overlapping motility disorders (e.g., EGJOO) were excluded.
This study provides valuable insights into post-POEM management but requires deeper
integration and analysis of esophageal manometry data to comprehensively elucidate the
relationship between motility recovery and emptying function. Strengthening these aspects will
enhance the rigor and clinical applicability of the conclusions.