Review for 10.1186/s12876-025-03690-9 (2025)

Title: Systematic Review and Meta-Analysis: No Evidence That Low-dose Non-Steroidal Anti-
Inflammatory Drugs (NSAIDs) Reduce the Risk of Pancreatitis After Endoscopic Retrograde
Cholangiopancreatography (ERCP)
Version: 2 Date: 03 Dec 2024
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-The methodology indicates that "18 articles were initially identified" through the use of
propensity score matching; however, it would be advantageous to elucidate the reasons for
excluding the other studies. Specifically, what criteria guided the final inclusion of only 3
studies? Were these studies classified as randomized controlled trials (RCTs), cohort studies,
or of another design? Providing detailed information regarding the inclusion and exclusion
criteria, such as study design, patient demographics, or quality, would significantly enhance the
transparency and reproducibility of the meta-analysis.
-The introduction and materials sections lack comprehensive detail about the characteristics of
the 3 studies incorporated into the meta-analysis. For instance, did these studies originate from
diverse geographical regions? Were there any differences in the ERCP procedures or NSAID
dosages employed across the studies? A succinct overview of these aspects would furnish
essential context for the reader and facilitate an assessment of the generalizability of the findings.
-The Results section states that Table 1 summarizes the characteristics of the selected studies;
however, the specific attributes of the studies—such as patient demographics, NSAID types,
dosages, and country of origin—are not thoroughly detailed within the text. While Table 1 may
present this information, incorporating a brief summary of the key study characteristics within
the text itself would provide valuable context. This would enhance readers’ comprehension of
the clinical relevance of the studies and elucidate how they may differ from one another.
-The authors acknowledge the potential for regional bias, given that the included studies
are predominantly from Japan. While this consideration is significant, additional discussion
is warranted regarding how regional factors—such as healthcare practices and patient
demographics—might have influenced the results. Furthermore, the authors could expand their
analysis to consider whether studies from other regions, such as Europe or North America, might
yield different insights and how generalizable the findings are across varied populations.
-Although the authors discuss the potential impact of low NSAID doses on the observed lack
of efficacy, they fail to provide specific details regarding the dosages utilized in the included
studies. If effective dosage ranges are known, it would be pertinent to highlight these ranges
and their implications for treatment. Moreover, additional information regarding the specific
NSAIDs employed, such as diclofenac or indomethacin, would be beneficial for assessing the
consistency and comparability of interventions across the studies.
-The Discussion section briefly addresses the issue of inadequate NSAID dosing, suggesting
that higher doses may be more effective. However, there is no mention of whether higher-
quality studies—characterized by larger sample sizes or more rigorous methodologies—have
investigated higher NSAID doses. Providing context on the quality of studies excluded from the
analysis, particularly those that focused on different dosages, would add considerable value.
Addressing these concerns would significantly improve the clarity and robustness of the
conclusions drawn, thereby enhancing the impact and informativeness of the study for clinicians
and researchers in the field.