Review for 10.1186/s12876-025-03893-0 (2025)

Title: Safety of Early Feeding after Endoscopic Ultrasound-Guided Fine Needle Biopsy: A
Retrospective Study.
Version: 0 Date: 15 Mar 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-As a retrospective study, there are inherent limitations in the ability to establish causality.
The reliance on existing patient records and retrospective data may introduce bias, especially
regarding the consistency and accuracy of documentation of complications and feeding timing.
Prospective randomized controlled trials (RCTs) would provide stronger evidence.
-Since this is a case-control study with no random assignment to the early feeding or 24-hour
fasting group, there may be confounding factors that affect the outcomes. For instance, patients
who are less likely to have complications may be more likely to receive early feeding. This may
lead to bias in the comparison groups.
-Although the study mentions complications like pancreatitis, bleeding, and infection, it lacks
a detailed breakdown of the specific types and severity of complications that occurred in each
group. This detail could help assess whether early feeding impacts more severe or specific
complications differently.
-The study does not provide information on the sample size calculation or power analysis.
Without this information, it is difficult to evaluate whether the sample size was large enough to
detect clinically significant differences between the groups. A small sample size could lead to
type II errors (failing to detect differences that exist).
-The study collects data on procedure-related variables, such as needle size, number of
punctures, and procedure time. However, it doesn't seem to fully account for how these variables
could influence the outcomes. For example, a more complicated or prolonged procedure may
increase the likelihood of complications, which could confound the effects of early feeding.
-The study is conducted in a single-center setting, which may limit the generalizability of
the results to other centers, especially those with different practices, expertise, or patient
populations. Furthermore, since the study only includes patients with pancreatic diseases, the
findings may not apply to other patient groups undergoing EUS-FNA.
-While the study compares early feeding with 24-hour fasting, it does not seem to provide
much detail on other factors that could have affected the outcomes. For instance, medications,
particularly antiplatelets or anticoagulants, could have influenced the risk of complications like
bleeding. The retrospective nature of the study makes it difficult to fully control for these
confounding factors.
-The discussion mentions that all adverse events in the early feeding group were mild, but
it would be more informative to include specific information about how adverse events were
managed and if there were any long-term effects or subsequent hospital readmissions. The lack
of in-depth analysis of the severity of complications may weaken the ability to fully assess the
safety of early feeding in certain patient populations.
-The authors mention the absence of an objectively established dietary protocol as a limitation,
but they don’t explore in depth how this could have affected the study outcomes. Given that the
timing and type of early feeding could vary, the lack of a standardized protocol means that the
findings are not entirely reproducible in other clinical settings. A detailed protocol would help
clarify whether early feeding timing and content (e.g., clear liquids vs. solid food) have different
effects on patient outcomes.
-While the authors mention that adverse events occurred only in patients with malignant disease,
they do not explore how this subgroup may have influenced the generalizability of the study's
results. Given that pancreatic cancer patients often have distinct clinical characteristics, it would
be important to further assess whether the findings are applicable to other types of pancreatic
disease or whether malignant disease patients respond differently to early feeding.