Review for 10.1186/s12876-025-04129-x (2025)

Title: Serrated Polyps in Colorectal Cancer Prevention: Prevalence, Characteristics, and Clinical
Insights from a Large Retrospective Cohort Study
Version: 1 Date: 05 Jun 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
1. Introduction Section
a. Overuse of Historical Narrative Without Direct Clinical Relevance
While the historical context (e.g., Torlakovic et al., WHO classification) is informative, it could
be condensed. The extensive background somewhat delays the transition to the study’s core
rationale.Tighten the background to focus more directly on current knowledge gaps in detection,
prevalence, and clinical impact of serrated polyps.
b. Lack of Clear Study Objective Statement
The last paragraph hints at the goal but does not offer a clear, concise aim or hypothesis.
Include a definitive research objective, e.g., “This study aimed to determine the prevalence and
endoscopic-histologic characteristics of serrated polyps compared to conventional adenomas
and hyperplastic polyps in a large cohort.”
c. Terminology and Definition Ambiguities
The term “hyperplastic (non-serrated) polyps” is misleading, as hyperplastic polyps are typically
considered part of the serrated pathway.Clarify terminology and consider using standard
classifications per WHO (e.g., HPs, SSLs, TSAs).
d. Insufficient Emphasis on Clinical Relevance
While the text discusses diagnostic challenges, it does not clearly explain the clinical
implications of missed or misclassified serrated lesions (e.g., interval cancers, surveillance
errors). Expand on why this knowledge gap matters for patient outcomes and surveillance
guidelines.
2. Methods Section
a. Ethnic Categorization Lacks Justification
The binary ethnic classification (Arabs vs. Jews) is mentioned but not justified or contextualized.
It's unclear whether this variable was used in subgroup analyses or whether differences were
expected or found. Clarify the rationale for including ethnicity and whether it influenced
outcomes.
b. Bowel Prep Definition Inconsistency
Adequate prep is defined via the Aronchick Scale, but the exact criteria used (e.g., what rating
qualifies as adequate) are not specified.Provide thresholds used (e.g., “good” and “excellent”
scores classified as adequate).
c. Unclear Grouping of Polyps
The study states that polyps were grouped as “adenomas, hyperplastic (non-serrated), and
serrated,” but this categorization may overlap or contradict WHO definitions.Use standard
classification and clarify how lesions like TSAs and SSLs were handled.
d. Missing Sample Size Justification or Power Analysis
There’s no information on whether a power analysis was conducted to ensure adequate sample
size for meaningful comparison.Include a post hoc or a priori power calculation.
f. Potential for Interobserver Variability
Histological diagnosis of serrated lesions is known to be subjective. No mention of whether
multiple pathologists reviewed slides or whether interobserver agreement was assessed.
Describe measures taken to reduce diagnostic variability.
3)RESULTS
-Overly Detailed Descriptive Statistics Without Prioritization
The Results section is data-heavy, reporting exhaustive breakdowns of morphology, location,
and size without guiding the reader through the most clinically relevant findings.Focus on key
comparisons and clinical implications rather than exhaustive numeric details in the main text.
Move detailed breakdowns to tables or supplementary material.
-Lack of Multivariable Analysis
The results rely heavily on univariate comparisons (e.g., age, sex, ethnicity), but no multivariate
analysis is provided to adjust for potential confounders.Include multivariable logistic regression
to identify independent predictors of serrated polyp detection (e.g., age, sex, ethnicity, bowel
prep quality, indication).
-Ambiguous Definitions
Important terms such as “serrated polyps” are not clearly subclassified (e.g., sessile serrated
lesions (SSL), traditional serrated adenomas (TSA), or hyperplastic polyps).Clarify which
serrated subtypes are included and distinguish them clearly in the analysis.
-Inconsistent Morphology Numbers
The total percentages for morphologic subtypes (sessile, flat, pedunculated) sometimes appear
inconsistent or overlapping, raising concern about classification clarity.Ensure consistency in
terminology and totals, and provide definitions for each category used.
4)DISCUSSION
-Repetitive and Overlong
The Discussion is lengthy, repetitive, and occasionally restates results without adding
interpretive insight.Streamline by focusing on interpretation, implications, and linking findings
to broader literature.
-Lack of Clear Structure
The narrative lacks a clear logical flow (e.g., results interpretation # comparison with
prior studies # strengths/limitations # implications).Use a structured approach (e.g., START:
Summary of findings, Then: Context, Afterwards: Strengths/Limitations, Finally: Clinical
Implications).
-Speculative Without Data Support
The claim that differences in detection between Jewish and Arab patients may reflect biological
or access-related disparities is speculative and not supported by the study design. Clearly state
this as a hypothesis-generating observation and emphasize the need for targeted studies.
-Insufficient Discussion of HGD
The relatively high rate of high-grade dysplasia in serrated polyps (21.3%) is mentioned but
not thoroughly contextualized or explored.Discuss the potential impact of this finding on
surveillance guidelines or clinical practice.
-No Assessment of Inter-Observer Variability
The influence of endoscopist experience is mentioned, but no data is shown on inter-operator
variability or trainee vs. consultant detection rates. Include or request such data, or acknowledge
it as a limitation.
-Weak Justification for FIT Limitations
The discussion on FIT’s limitations in detecting serrated polyps is valid but overemphasized
without a dedicated FIT vs. non-FIT comparative analysis in this cohort.Avoid overextending
conclusions; instead, frame the FIT limitation as an area for future targeted research.
-No Mention of Bowel Preparation Quality
Although it’s stated that bowel prep may affect detection, no data or stratified analysis is
presented. Include a subgroup analysis if data available or clearly state this limitation.
-AI Discussion is Incomplete and Unreferenced
The AI-based detection is briefly mentioned at the end but lacks citations, specifics, or
integration into the earlier discussion.Either expand meaningfully on the AI literature with
references or remove it to maintain focus.