Review for 10.1186/s12876-025-04225-y (2025)

Title: A Real-world Study of Balloon dilation vs. Self-Expandable Metal Stents for Benign
Gastric Outlet Obstruction
Version: 0 Date: 20 Jul 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following poimts below
1. Study Design Limitations
* Retrospective and single-center nature: The retrospective design inherently introduces biases
such as selection bias and information bias. The lack of randomization limits the strength of
causal inference.
* Small sample size: The cohort of 70 patients, further divided into three groups, reduces
statistical power and limits generalizability.
* Heterogeneous groups: The three-group division by both etiology and intervention is not
standardized and may confound interpretation. Groups B and C differ not only by etiology but
also by baseline characteristics that are not clearly reported.
2. Methodological and Reporting Issues
* No clear baseline comparison: There is insufficient information regarding baseline
demographics, severity of strictures, nutritional status, and comorbidities between groups.
These are important potential confounders that could influence outcomes and are necessary for
balanced comparison.
* Incomplete procedural details:
* Balloon dilation protocols (diameter, inflation duration, number of sessions) are not adequately
described.
* Stent selection rationale is unclear, especially regarding the use of uncovered SEMS in benign
conditions, which is generally not recommended.
* No standardized follow-up protocol: Although imaging was scheduled at 4–6 week intervals,
no standardized protocol or patient-reported outcomes are detailed. Symptom resolution criteria
also lack quantification.
3. Statistical Analysis Flaws
* Inappropriate statistical tests for some variables: One-way ANOVA is used for comparing
groups, but assumptions of normality and homogeneity of variance are not addressed. Non-
parametric alternatives (e.g., Kruskal-Wallis) might be more suitable given the small group sizes.
* No multivariate analysis: Only univariate comparisons are performed. Multivariate logistic
regression or Cox regression should have been conducted to adjust for potential confounders.
* Time-to-event analysis underreported: Although the log-rank test was mentioned, survival
analysis curves (e.g., Kaplan-Meier) were not shown for recurrence-free survival, which would
have added valuable information.
4. Data Interpretation Concerns
* Conclusions are overstated: The statement that SEMSs “appear safe and effective” contradicts
the reported high rates of complications and reinterventions. The conclusion should be more
conservative.
* Inappropriate use of uncovered SEMSs: This contradicts current guidelines for benign GOO
and undermines the external validity of findings.
* EUS-GJ not directly studied: Much of the discussion compares SEMSs and balloon dilation
with EUS-guided gastrojejunostomy and surgical bypass, despite not including them in the
study. This comparison is speculative and distracts from the actual data.
5. Literature Context and Referencing
* Outdated or weak references: Some citations are outdated or do not reflect the current standard
of care (e.g., use of uncovered SEMS in benign GOO).
* Lack of guideline references: The manuscript should include current guidelines or consensus
statements (e.g., ASGE, ESGE) for the management of benign GOO.
6. Language and Structural Issues
* Poor grammar and syntax throughout the manuscript hinder readability and clarity. Some
examples include:
* “GOO was confirmed via computerized tomography… regardless of symptomatic
symptoms…” – redundant phrasing.
* "can not" should be "cannot"
* Overuse of passive voice and awkward phrasing, e.g., “Patients were divided into three groups
according to the etiology of stenosis and different treatments.”