Review for 10.1186/s12876-022-02140-0 (2022)

Title: Safety and efficacy of non-fluoroscopic endoscopic dilatation of gastrointestinal
tuberculosis related strictures
Version: 2 Date: 30 Jul 2021
Reviewer's report:
With great interest the study has been reviewd. Here are few comments.
1) The authors have mentioned that target dilatation diameter is 15mm, which maybe arbitrary.
Symptom resolution maybe seen with lesser diameter or persistence of symptoms even with
15mm dilatation. Is there any difference between different regions (duodenum, colon, rectum)?
Does all patients with 15mm dilatation have resolution of symptoms?
2) It was mentioned by the authors that all strictures are nonnegotiable by endoscopy.
Almost two thirds of the study cases are ileal or ileocecal strictures. Any scopes other than
colonoscope(12.8mm) were used to negotiate the stricture?
3)Clinical success is defined by the authors as only symptomatic resolution irrespective of
radiological or endoscopic resolution. Can the authors explain whether there is any control group
– radiological and endoscopic (non-negotiable) stricture but no symptoms? If not, why not?  If
so, how many developed symptoms later?
4) The authors have mentioned clinical success is symptomatic relief after one or MORE
dilatation sessions. Can the authors clarify more means how many? Is there any specific number?
5) Need for reintervention or need for surgery later after initial success – Is it taken as success
or failure by the authors? What is the effectiveness of endoscopic therapy short term and long
term? Are there any predictive factors for effectiveness?
6) In the manuscript it was written that only 7 patients were having microbiological diagnosis.
Rest (27) are diagnosed as tuberculosis based on the response to ATT. Four patients of crohns
disease were included in the study. Maybe few others, in the remaining cases, might have
been proved as crohns disease later in the long term follow up beyond study period. What are
the authors comments regarding this? Why they (crohns disease diagnosed later) shouldn’t be
excluded from the study?
7) Dilatation was done as early as 2 months post ATT and while on ATT. One case had
perforation. Ulceration at the time of dilatation was not mentioned in the study. Previous studies
report ulceration as contraindication for dilatation. Can the authors clarify whether any one was
denied dilatation due to the presence ulceration at index dilatation or 2wkly dilatation during
the study ?
8) How the authors account for confounding factor of antituberculous treatment in symptom
or stricture resolution in patients taken up for dilatation before completion of antitubercuous
treatment ?
9) A case of post dilatation perforation was diagnosed two weeks later and surgery was done
as mentined by the authors. Presence of fluoroscopy during dilatation might have diagnosed the
case earlier, is it not? How safe  is the dilatation without fluoroscopy? Any radiological studies
done for  cases post dilatation  by the authors to look for any pneumoperitoneum?
10) Technical failure is defined by the authors as non passage of guidewire or wire guided CRE
which was later taken up for  surgery. What about  the cases   where dilatation is not done upto
optimum diameter or unable to maintain optimum diameter with defined number of dilatations ?
seven cases underwent surgery.
11) The conclusion by the authors that non fluoroscopic endoscopic balloon dilatation is an
effective and safe modality appears a little far stretched with small sample size and retrospective
nature of the study. Can the authors modify this ?