Endoscopic Ultrasound-Lavage Technique for Pancreatic Cancer: An In Vivo Pilot Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors,

This manuscript introduces a new and highly innovative technical concept of an endoscopic ultrasound-guided lavage technique (EUS-LT) that might offer a minimally invasive approach to staging laparoscopy for pancreatic cancer. The description of technical improvements, procedure description, and analysis of technical feasibility and safety of this method in a pig model is highly appreciable. This clinical work is very well conducted with a high relevance to addressing an existing need. Some points need to be clarified for better technical validity.

Points need clarification:

1- The Introduction is comprehensive but somewhat lengthy. Condensing background material and more clearly highlighting the novelty of EUS-LT would improve readability.

2- The text constantly uses the term “porcine pancreatic cancer models,” but no cancer implantation or simulation was done. The text uses potentially misleading terminology. They need to change this terminology throughout the text to porcine feasibility or peritoneal lavage model.

3- The conclusion holds that EUS-LT is “diagnostically feasible,” but it did not perform an assessment of cytological or molecular diagnosis. It is appropriate to draw only conclusions on technical feasibility and the safety of the procedure.

4- The rationale for selecting 800 mL of saline for lavage requires clarification. Please justify this volume with reference to existing staging laparoscopy or percutaneous lavage literature, or explain the empirical basis for this choice.

5- Although procedural refinements improved recovery, the retrieved volume remained a small fraction of the infused saline. The authors should discuss whether adequate cytological yield depends on the absolute recovered volume and what minimum volume may be clinically sufficient.

6- Group sizes are very small (n = 2, 4, and 4), limiting the robustness of statistical comparisons. While non-parametric testing is appropriate, claims suggesting equivalence between refined techniques should be interpreted cautiously and framed as exploratory.

7- Follow-up was limited to one week. Longer-term complications such as gastric leak, peritonitis, or adhesion formation cannot be excluded. This limitation should be emphasized more clearly.

8- The absence of fluoroscopic guidance is noted. A brief comment on how fluoroscopy or contrast confirmation would be incorporated in future clinical studies would be helpful.

9- Using more precise terms in the interpretation of feasibility results data, a refinement in conclusions based on the results provided in the study, the manuscript would be a valuable preclinical work for future first-in-human studies of EUS-guided peritoneal lavage.

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

The article is of interest andf well written. My comments:

1) Probably, the journal diagnostics is not a good fit for this paper. This is not a diagnostic procedure but a therapeutic approach to these patients

2) The rationale to this procedure should be better detailed. It is indicated for the peritoneal carcinomatosis?

3) Could the authors better explain the translational aspects of this research?

4) The authors should mention that also other EUS-guided therapies are available for PC patients, in this regard cite the series PMID: 27356212)

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Dear authors, 

Thanks for addressing the issues meticulously. 

Reviewer 2 Report

Comments and Suggestions for Authors

The revised manuscript is OK. Thank you!