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1 Reviewer s code: Reviewer s country: United States Date reviewed: :21 [ ] Grade A: Priority publishing [ ] Grade B: Very good [ Y] Grade B: Minor language [ Y] Grade C: Good [ ] Grade D: Fair language [ Y] Minor revision [ ] Major revision The article is interesting and provides somee important informationn about the incidence, risk r factors for developing dysphagia following laparoscopic sleeve gastrectomy and some useful information about the endoscopic treatment for f this complication. The do not consider c technical reasons for this complication for spiraling and angulation off the gastric sleeve. Previous studies have reported the correlation between prior gastroesophageal reflux disease and dysphagia following bariatric surgery. They do provide good information on the incidence of dysphagia and the efficiency of endoscopic balloon dilation. 1

2 Reviewer s code: Reviewer s country: France Date reviewed: :11 [ ] Grade A: Priority publishing [ Y] Grade B: Very good [ Y] Grade B: Minor language [ ] Grade C: Good [ ] Grade D: Fair language [ Y] Minor revision [ ] Major revision I thank the oppurtunity to review this article. The article addresses an important entity and many newly qualified surgeons may find this article interesting, but:? It I includes too many grammatical errors.? This study is limited by its retrospective analysis One O of the challenges with this manuscript is that it does ask the question of whether there are anyy modifiablee risk factors. It seems that a poor quality of recovery may be onn the causal pathway between factors that are present pre-operatively (which are potentially modifiable) thatt then lead to poor quality of recovery and prolonged convalescence. Identifying modifiable factors may potentially increase the relevance of this work. Please delete Dr Tung in "Statistical analysiss was performed by a biomedical statistician (Dr. Tung Tran) " Not all statements have references. The objective the t authors set out to achieve was not met. The retrospective nature of the analysis prevents us from identifying a causative relationship. Definitionn of "stenosis of the gastric sleeve" was not clear in methods section how you detect a stenosis of the gastric sleeve Please provide SD for all continuous and % for all categorical variables. I would suggest including "Endoscopic dilation of the pylorus could have promoted healing by 2

3 reducing pressure in the gastricc tube " (reference: Abscess after sleeve gastrectomy: conservative treatment by endoscopic dilation. Kassir R, Piqueres S, Blanc P. Surg Obes Relat Dis Nov-Dec;10(6):e67-9.) 3

4 Reviewer s code: Reviewer s country: United States Date reviewed: :34 [ ] Grade A: Priority publishing [ ] Grade B: Very good [ Y] Grade B: Minor language [ ] Grade C: Good [ Y] Grade D: Fair language [ ] Minor revision [ Y] Major revision Reviewer Comments: I would like l to congratulate the authors on trying to shed some light on one of the complications of Sleeve gastrectomy y as it is becoming a more m common operation for the treatment of morbid obesity. I have the following comments: - In thee AIM, the authors are mixing two etiologies of potential risk of dysphagia intoo one paper; one is non-mechanicaland angulation of the VSG. It would be more cause, ie. the medical issues; the other is mechanical causes, ie. the narrowing meaningful to separate these two causes and compare them in terms of the prevalence of the other comorbidities. The mechanical cause could be a technical issue. - If I the AIM from this study was to link the reason of narrowing to the medical condition, then this is a failed attempt since the results do not support that. - The authors reportedd a 22.7% incidents of dysphagia after sleeve gastrectomy. This is definitely a high numberr that I don t see in my practice. Probably P that using only 2 weeks post-op as the cut offf date is one of the reasons for this high number. Edema and swelling normally takes more than 2 weeks to resolve post-operatively. What wouldd be the incidence if the authors expanded the exclusion to 6-8 weeks post-operatively which is moree likely when these post operative 4

5 changes are resolved? - If the number is still high, then the problemm would be technical in nature and review of the surgical technique should s be inn question for this high incidence especially that 33 of the 55 (60%) of those who had EGD had a stricture, spiral or sharp angels which all are technical issues. - In the abstract the study group was reported as 253 patients whilee in the article it was 352 patients. Need correction. - The Results in i the abstract are confusing and need n to be re-warded to reflect the finding. It only concentrates on the mechanical aspect of dysphagia and the mechanical aspect of treating it. - The authors had 80 patients with dysphagia: o Howw many would the number be by eliminating the first 6-8 weeks onset? The authors had 6 weeks visit which iss easy to go back and fined the number. Would eliminating these patients change the results of the co-morbidities prevalence? o Of the 55 patientss who had EGD there were 33 patients with mechanicall cause for dysphagia. What was the outcome of the other 22 patients? How was w the dysphagia treated and did it resolve? o In the other 25 patients with dysphagia, who did not under go EGD, weree there any other testing done such as an upper GI contrast x-ray to evaluate for possible mechanical narrowing? If not how can the authors be sure that narrowing wasn t a factor? How were these patients treated? Did their dysphagia resolve? o Iff we add the 22 patients with negative EGD to the 25 patients who refused EGD (assuming that they had an UGI contrast x-ray showing no stricture) this makes a group of 47 patients or 59.8% of those with dysphagia, what would be their other risk factors compared to the 33 patients who had mechanical causes?? o In the narrowing group g was the surgicall technique the same? Which staplers were used duringg this period of study? Was there a change of staplers in some patients? In our experience when wee used the Duet staplerr we had spiral sleeves. o Were there any repairs of hiatal hernia or were these in the excluded patients? o Was there a difference in the surgical techniquee between the surgeonss in the group who performed thesee operations? Was this a single surgeon study? Did any of these patients with narrowing had bleeding intra-operatively where suturing of the staple line done? o The 36 Fr bougie is a narrow n bougie and stretching the stomach can create a potential narrowing. Did the authors consider changing the bougie size and see if the incidence of this complication changes? Can the author compare his results with the literature in regard to the use of bougie size and dysphagia or stricture? o Can the authors break down the dysphagiaa group i 5

6 Reviewer s code: Reviewer s country: United Kingdom Date reviewed: :38 [ Y] Grade A: Priority publishing [ ] Grade B: Very good [ ] Grade B: Minor language [ Y] Grade C: Good [ ] Grade D: Fair language [ Y] Minor revision [ ] Major revision This is an informative retrospective studyy of the effects of endoscopic balloon dilatation after dysphagiaa from vertical sleeve gastrectomy. Major points 1 Whyy did the authors selectt 352 of the 400 patients for the study. Why were the others not available? 2 Did the authors use a scoring system to stage dysphagia? 3 Why did only 55 of 80 patients with w dysphagia have endoscopy? Did this relate to the unit's policy and if so how were the 55 selected? What happened to the other 25? Did they resolve spontaneously or with other intervention? 4 Was staple line reinforcement used for the operation? Was radiology done as a routine for all patients postoperatively? Did dysphagiaa correlate with radiological appearances? 5 Were patients p routinely given vitamin supplementation preoperatively or postoperatively? If not, why was w this? Minor point 1 There is no clinicall benefit in quoting more than 3 significant figures. 2 What happened to the patients in whom dilatation did not help? 3 At over 6 pages, the discussion is far too long for the amount of new material presented and should be shortened to around 3-3 1/2. 6