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: 03 Mar 2025
Reviewer's report:
This manuscript evaluates whether timed barium esophagram (TBE) at 3–6 months post-POEM
can predict the presence of esophageal contents on follow-up esophagogastroduodenoscopy
(EGD), which may have implications for aspiration risk and the need for endotracheal
intubation (EI) during endoscopy. The authors retrospectively analyzed 48 achalasia patients
who underwent POEM, assessing TBE findings such as barium column height and tablet passage
as predictors of residual esophageal contents on EGD.
The study is clinically relevant, as it provides real-world data on the post-POEM functional
assessment and its role in reducing unnecessary EI. However, the manuscript appears overly
concise, lacking depth in several key areas such as comparisons with existing literature, a more
nuanced discussion of limitations, and clinical applicability in various patient subgroups. Given
these limitations, I recommend major revisions before acceptance.
Major Concerns and Areas for Improvement
While the study is methodologically sound, the manuscript is relatively short and lacks depth,
particularly in the discussion and clinical implications sections. There is minimal discussion
on how these findings compare to prior studies evaluating post-POEM functional assessment.
What are the specific advantages of using TBE over other functional assessments, such as high-
resolution manometry (HRM) or EndoFLIP? A more thorough discussion is needed to highlight
the clinical impact of this study.
The study concludes that certain esophagram findings predict the presence of esophageal
contents on EGD, but how should this influence clinical practice? Would these findings justify
omitting EI in certain patients? Are there specific subgroups (e.g., type I vs. type II achalasia)
in which this predictive model is more reliable? Would a validation cohort be necessary before
implementing this approach in clinical practice? Expanding the discussion on how these findings
can be translated into real-world practice would improve the manuscript significantly.
The manuscript does not compare the predictive ability of TBE with other post-POEM
assessments, such as: High-resolution manometry (HRM), which provides information on
esophageal peristalsis and outflow obstruction. Functional lumen imaging probe (EndoFLIP),
which evaluates distensibility at the GEJ. How does TBE compare to these modalities in terms
of predicting functional success post-POEM? The authors should include a brief discussion on
why TBE may be preferable in certain clinical scenarios.
The study does not evaluate whether achalasia subtype (Type I, II, or III) influences the
predictive value of TBE. Would the predictive ability of barium column height and tablet passage
differ between patients with different achalasia subtypes? Would patients with post-POEM
reflux or those requiring PPI therapy demonstrate different outcomes?
A stratified analysis could provide further insights and make the conclusions more clinically
useful.
The limitations section is somewhat superficial and does not adequately address potential
confounders. Did all patients undergo the same pre-EGD fasting protocol? If not, this could
introduce variability in findings. What was the interobserver variability in TBE interpretation?
The authors should also discuss whether the relatively short follow-up period (3–6 months) is
sufficient to assess long-term functional outcomes post-POEM.