Spontaneous Hyperinflation of Intragastric Balloons: A Systematic Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This systematic review summarized clinical presentation, management, complications, and hypothesized pathology of Spontaneous intragastric balloon hyperinflation (SIBH). The most common clinical presentation was gastric outlet obstruction. Emergency endoscopy was required in most of the cases. Reported complications mainly included acute pancreatitis and mucosal erosions. And the authors concluded that Gas-producing microbial colonization of the balloon is the predominant reason. In general, it is comprehensive and well-written.

1) For a systematic review, the PRISMA statement should be provided, at least in the supplementary Materials.

2) A typical endoscope image or a pathological section of SIBH should be shown.

3) In Table 1, a single word should not be separated by two lines. And there should be a blank between the number and the unit.

4) What does the symbol "#" mean? For example, "Barola, 2017 #49" means the Ref. 49?

5) Putative inflammatory cytokines involved in SIBH should be listed.

6) Possible relationship between dietary habit and SIBH should be discussed.

Author Response

1) For a systematic review, the PRISMA statement should be provided, at least in the supplementary Materials.

Prisma statement has been added as a supplementary material.

2) A typical endoscope image or a pathological section of SIBH should be shown.

A single endoscopic image of a hyperinflated balloon has been included and attributed to its original source.

3) In Table 1, a single word should not be separated by two lines. And there should be a blank between the number and the unit.

I am not sure what you mean by a single word should not be separated by two lines, I'm assuming it is an error in the formatting, as there are no additional lines in table 1, it has been formatted that way to allow for all required columns and rows. Spaces have been inserted between numbers and units.

4) What does the symbol "#" mean? For example, "Barola, 2017 #49" means the Ref. 49?

The # indicates the volume number on my reference tabulating software.

5) Putative inflammatory cytokines involved in SIBH should be listed.

None of the published reports directly identify specific inflammatory cytokines, in relation to SIBH.

6) Possible relationship between dietary habit and SIBH should be discussed.

None of the published reports discuss a possible relationship between dietary habits and SIBH, the literature generally focuses on device-related factors than attributing SIBH to specific eating patterns.

Reviewer 2 Report

Comments and Suggestions for Authors

Title: Spontaneous Hyperinflation of Intragastric Balloons: A Systematic Review

The manuscript by Guirgis et al. evaluated the literature updates on spontaneous hyperinflation of intragastric balloons and their clinical presentation, management, complications, and hypothesised aetiologies. Overall, the manuscript is interesting, and it requires revisions as follows:

Comments:

1. The introduction is too general; it can be minor improved and updated with desirable information and mechanisms of manifestation in broad perspectives.
2. Results can be elaborated with a few detailed quantitative data points of key findings from the literature.
3. In discussion, does any role of inflammatory mediators and microbial sepsis play in aetiology? i.e. https://doi.org/10.3390/biomedicines11030765. In addition, the role of gut microbiota in different stages of manifestation can be discussed for better understanding.
4. The scientific names of organisms should be in “italics”.
5. The authors should provide an illustration of the summary of findings, limitations/challenges, and perspectives.

Author Response

1. The introduction is too general; it can be minor improved and updated with desirable information and mechanisms of manifestation in broad perspectives.

I'm not sure what is meant by desirable information and mechanisms of manifestation in broad perspectives. The introduction includes all relevant information to outline why this is an important topic, it's clinical presentation and the hypothesised aetiologies. 

2. Results can be elaborated with a few detailed quantitative data points of key findings from the literature.

The key findings from the literature, are detailed in Table 1, and the summary of data points. Do you mean you would prefer more tabled data than short form paragraphs?

3. In discussion, does any role of inflammatory mediators and microbial sepsis play in aetiology? i.e. https://doi.org/10.3390/biomedicines11030765. In addition, the role of gut microbiota in different stages of manifestation can be discussed for better understanding

There is a negligible role to discuss inflammatory mediators and microbial sepsis in the setting of SIBH, as most of the literature indicates on/in-device translocation of pathogens, which only very rarely results in sepsis which this type of therapy may be beneficial, most presentations are due to GOO, not sepsis.

4. The scientific names of organisms should be in “italics”.

Thank you for pointing this out, scientific organism names have been changed to italics.

5. The authors should provide an illustration of the summary of findings, limitations/challenges, and perspectives.

I believe this has been covered in the conclusion.

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript "Spontaneous hyperinflation of intragastric balloons: a systematic review" shows some interesting review of issues related with intragastric balloons. There some  parts that need to be addressed.

1. It would help for readers maybe in less clinical words how does integration of such balloons leading to weight loss. Are those obese person have it included feel less hungry? Please give more clear description of such in the introduction.
2. The Materials and method part is a bit short with also so many outsorted articles who do not match. What are the main criterions why those are not matching? Please comment such
3. Beside obesity which all patient share what other reasons might lead to lethal cases? Age, chronical diseases, immune response, etc? Are there not some research made to identify those and find prevention of such? The discussion provide some good solution how to address those such as MB detection system.
4. The result part needs some figures or images how such intragastric balloon integration looks like in patients and how changes appears in problematic cases. If possible include such.

Author Response

1. It would help for readers maybe in less clinical words how does integration of such balloons leading to weight loss. Are those obese person have it included feel less hungry? Please give more clear description of such in the introduction.

The introduction discusses how IGBs stimulate weight loss through dietary restriction, early satiety and reduced gastric emptying, leading to weight loss of between 10% and 20% of their total body weight.

2. The Materials and method part is a bit short with also so many outsorted articles who do not match. What are the main criterions why those are not matching? Please comment such

In the results section, we explain that 1689 studies were excluded because they did not meet the inclusion criteria. There are many studies which discuss any of the MeSH keywords including gastric balloons, complications, adverse effect, infection, hyperinflation etc which do not relate to the specific use-case of this paper; hence many were excluded.

3. Beside obesity which all patient share what other reasons might lead to lethal cases? Age, chronical diseases, immune response, etc? Are there not some research made to identify those and find prevention of such? The discussion provide some good solution how to address those such as MB detection system.

Unfortunately, given SIBH is a rare occurrence, and death extremely rare, there isn't enough literature to create a scientific hypothesis of the other confounding causes of death in the setting of SIBH.

4. The result part needs some figures or images how such intragastric balloon integration looks like in patients and how changes appears in problematic cases. If possible include such.

Thank you for highlighting this, I have included an endoscopic image of a hyperinflated balloon at the end of the introduction highlighting the air/fluid level seen in SIBH.

Reviewer 4 Report

Comments and Suggestions for Authors

Indeed, the problem of obesity is a global problem all over the world. Obesity is a trigger mechanism for other metabolic and cardiovascular pathologies. In this regard, the problem of combating obesity is very relevant. The technique of introducing intragastric balloons considered in the manuscript is one of the methods of treating obesity, so it is important to take into account all possible risks associated with this manipulation. The authors must indicate the depth of the literature search in years. It is preferable to use later manuscripts for analysis. Also, the authors should describe in more detail the existing techniques for installing intragastric balloons and alternative methods of combating obesity in the introduction section, indicating the advantages and disadvantages of each technique. Information on the percentage of complications from introducing intragastric balloons should be added. The authors gave recommendations for preventing complications associated with intragastric balloons; it is recommended to transform them into a diagram with step-by-step instructions for action.

Author Response

The authors must indicate the depth of the literature search in years. It is preferable to use later manuscripts for analysis.

- the last search was conducted on June 30, 2023. There was no lead date, allowing for all literature published since FDA approved use, in 1985.

Also, the authors should describe in more detail the existing techniques for installing intragastric balloons and alternative methods of combating obesity in the introduction section, indicating the advantages and disadvantages of each technique.

- thank you for highlighting this, I have briefly discussed the 2 methods of balloon placement in the introduction section, from lin. Given there are still variation in the techniques based on the manufacture guidelines, I have decided not to delve into too much detail in the introduction. I have also added a brief paragraph discussing other surgical and medical options for weight loss, although not in great detail.

Information on the percentage of complications from introducing intragastric balloons should be added.

- thank you for highlighting this error, I have added in percentages of complications which have been reported in the introduction on line 77 to 79.

The authors gave recommendations for preventing complications associated with intragastric balloons; it is recommended to transform them into a diagram with step-by-step instructions for action.

- given the likely aetiology is multifactorial, and there are a number of methods for balloon insertion, it is not feasible in this paper to create diagrams for each of the methods discussed.