Issues and Prospects of Current Endoscopic Treatment Strategy for Superficial Non-Ampullary Duodenal Epithelial Tumors
Round 1
Reviewer 1 Report
The manuscript presented by Suwa et al. is an opinion letter about current endoscopic treatment strategies for superficial non-ampullary duodenal epithelial tumors (SNADET), which have increasing incidences due to improved endoscopic techniques. The scientific attention and interest is also reflected by steadily increasing publication numbers on this topic during the last 5 years. Thus, the topic is timely and addresses an important issue with relevance to the readership.
The manuscript is overall well written and consistent. Although the total numbers of documented cases for this pathologic finding are still limited, there is a mounting body of literature over the last five years which is nicely collected and presented according to different endoscopic treatment strategies (cEMR, CSP, UEMR, ESD, EFTR and LECS). Here, the authors also present profound numbers and experience from their institution.
However, the conclusion section is limited to 4 lines referring to the sections before and pointing out to the future and accumulation of further cases to come. The final figure representing their institutional algorithm leaves the reader alone with different treatment options. There is no doubt that due to the heterogeneity of SNADETs and individual patient risk profiles, there cannot be one univocal recommendation (one size fits all), but one would wish to have at least a graduation of techniques based on personal evidence. Furthermore, the figure for carcinoma cases is missing a surgical approach at all, which is a very risky message based on less than twenty cases with one month follow-up as presented.
Author Response
Response to the Reviewers' comments:
We appreciate you taking the time to offer us your comments and insights related to the paper. We found your feedback very constructive, and we have responded to each of your concerns. We hope that these revisions will meet your expectations.
To facilitate your review of our revisions, we are providing a response specific to each comment.
Reviewer #1 comment:
The manuscript presented by Suwa et al. is an opinion letter about current endoscopic treatment strategies for superficial non-ampullary duodenal epithelial tumors (SNADET), which have increasing incidences due to improved endoscopic techniques. The scientific attention and interest is also reflected by steadily increasing publication numbers on this topic during the last 5 years. Thus, the topic is timely and addresses an important issue with relevance to the readership.
The manuscript is overall well written and consistent. Although the total numbers of documented cases for this pathologic finding are still limited, there is a mounting body of literature over the last five years which is nicely collected and presented according to different endoscopic treatment strategies (cEMR, CSP, UEMR, ESD, EFTR and LECS). Here, the authors also present profound numbers and experience from their institution.
However, the conclusion section is limited to 4 lines referring to the sections before and pointing out to the future and accumulation of further cases to come. The final figure representing their institutional algorithm leaves the reader alone with different treatment options. There is no doubt that due to the heterogeneity of SNADETs and individual patient risk profiles, there cannot be one univocal recommendation (one size fits all), but one would wish to have at least a graduation of techniques based on personal evidence. Furthermore, the figure for carcinoma cases is missing a surgical approach at all, which is a very risky message based on less than twenty cases with one month follow-up as presented.
Answer:
Thank you for your valuable suggestions. First, we describe endoscopic treatment for SNADETs but not surgical resection, although the description of laparoscopic and endoscopic cooperative surgery for duodenal tumors is included.To avoid the risk of misleading the reader, we would like to make it clear that the recommendation is not intended to discourage surgical resection. In addition, the treatment strategies shown in the final figure are based on our institutional data but also include the guidelines from other countries and previous reports. Although we understand that it is difficult to standardize the treatment strategies depending on the system of each institution and other factors, we have presented several endoscopic resection methods for each tissue type and size. As you mentioned, the conclusion section was limited to 4 lines; we have added the following sentences to the conclusion section:
“Here, it is important to note that the present review is related to endoscopic treatment and does not include surgical resection. Additionally, since each institution is in a different situation, with varying endoscopists’ skills and and surgical backup systems and since the heterogeneity of SNADETs needs to be considered, we should be aware that not all patients would benefit from this strategy.”
Reviewer 2 Report
The article discusses current endoscopic treatment options for SNADETs, a challenging and not-yet standardized pathology with a high potential for complications due to the particularities of the duodenum.
Guidelines (American, European and Japanese) are currently either unclear regarding the choice of resection technique or which method is best for which tumor size. Therefore, a review of current issues and treatment possibilities is welcome and valuable.
However, the Methods section must be improved and authors should describe how they chose the articles included in the Results section.
Small adenomas (especially those measuring less than 10 mm, but also those between 10-20 mm) benefit from several types of resection that can be performed by experienced endoscopists, but do not necessarily require an expert, as shown by the authors, although there is still a relatively small number of articles and an insufficient number of enrolled patients to definitively outline indications even in such cases.
Treatment of adenomas larger than 30 mm is still insufficiently discussed.
I would like to read a bit more about this issue, and the conclusions could be expanded a bit more.
The article has valuable information, but the authors should aim to explain a bit more of the outcomes of their extensive study in the conclusions section.
Author Response
Response to the Reviewers' comments:
We appreciate you taking the time to offer us your comments and insights related to the paper. We found your feedback very constructive, and we have responded to each of your concerns. We hope that these revisions will meet your expectations.
To facilitate your review of our revisions, we are providing a response specific to each comment.
Reviewer #2 comment:
The article discusses current endoscopic treatment options for SNADETs, a challenging and not-yet standardized pathology with a high potential for complications due to the particularities of the duodenum.
Guidelines (American, European and Japanese) are currently either unclear regarding the choice of resection technique or which method is best for which tumor size. Therefore, a review of current issues and treatment possibilities is welcome and valuable.
However, the Methods section must be improved and authors should describe how they chose the articles included in the Results section.
Small adenomas (especially those measuring less than 10 mm, but also those between 10-20 mm) benefit from several types of resection that can be performed by experienced endoscopists, but do not necessarily require an expert, as shown by the authors, although there is still a relatively small number of articles and an insufficient number of enrolled patients to definitively outline indications even in such cases.
Treatment of adenomas larger than 30 mm is still insufficiently discussed.
I would like to read a bit more about this issue, and the conclusions could be expanded a bit more.
The article has valuable information, but the authors should aim to explain a bit more of the outcomes of their extensive study in the conclusions section.
Answer:
Thank you for your valuable suggestions. As you mentioned, no description was included regarding the papers cited in this article. We used PubMed to search for each treatment method and preferentially cited a higher level of evidence as much as possible. However, there are few published reports in the field of SNADET; therefore, we have also chosen case series and other reports with a certain number of cases for our review. This information has been added to the introduction section as follows:
“Although there are not many high-quality reports in the field of SNADET treatment, we searched databases, including PubMed, and cited previous reports with a higher level of evidence as much as possible.”
In addition, this article should be useful not only for experts but also for non-experts, and it is necessary to present which lesions require consultation with a high-volume center. Of course, there is not enough evidence to support this information, but we have added it based on the adverse event rates and procedural proficiency. There are a few reported cases for large lesions > 30 mm, and the evidence is significantly less. The lack of reported SNADET cases itself is a major concern and remains a challenge for the future. Considering these, we added the following part in the conclusions section:
“Further, although endoscopic resection for SNADETs is not widely accepted, it should be noted that most of the previous reports are published from so-called high-volume centers. Since the indications of CSP, cEMR, and UEMR for adenomas could not be stated in detail, particularly CSP and cEMR—also familiar for colorectal polyps—should be acceptable, including those at non-expert institutions. CSP might be a manageable procedure even for non-experts, considering that the delayed complication is almost 0%. However, severe complications may occur even with CSP; consultation with a high-volume center should be considered if it is difficult to manage such cases [31,32]. Furthermore, several issues need to be solved regarding whether en-bloc resection is really required (piecemeal EMR and CSP are acceptable) and whether endoscopic treatment alone is necessary (indications for ESD/EFTR vs. D-LECS). Currently, piecemeal EMR, ESD, EFTR, and D-LECS are described together as treatment options for large lesions (> 20 mm); we believe that the treatment strategy will become clearer with the accumulation of further cases and technological development.”
- Masunaga, T.; Kato, M.; Takatori, Y. Spurting delayed bleeding on postoperative day six after cold snare polypectomy for small superficial duodenal epithelial tumor. Dig. Endosc. 2021, 33, 1198; DOI:10.1111/den.14123.
- Akimoto T, Kato M, Yahagi N. Severe acute pancreatitis following cold polypectomy of the minor duodenal papilla in a case with pancreas divisum. Dig. Endosc. 2020, 32, 151; DOI:10.1111/den.13570.
Round 2
Reviewer 1 Report
The authors provided a sufficient reply and changed the manuscript accordingly.
