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March 06, 2025, 10:40

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We greatly appreciate the authors and their team for their in-depth study on treatment strategies for rectal neuroendocrine neoplasms (R-NENs). This retrospective analysis compares the efficacy of endoscopic full-thickness resection (EFTR) and endoscopic submucosal dissection (ESD) in the treatment of R-NENs, demonstrating the superior R0 resection rate of EFTR while maintaining comparable short-term safety with ESD. This study provides critical clinical evidence supporting the use of EFTR in R-NENs and contributes to the refinement of function-preserving surgical approaches. However, we would like to offer some constructive suggestions to enhance the clinical applicability and long-term evaluation of this study. First, some terminology and definitions in the study are somewhat ambiguous, which may affect the interpretability of the results. For instance, the study mentions that some patients had "severe comorbidities" but does not specify the types of comorbidities or the inclusion/exclusion criteria applied. Certain comorbidities, such as diabetes or chronic kidney disease, may impact postoperative healing, and failing to differentiate them could introduce confounding among patients with varying risk profiles. Additionally, the description of lesion morphology is inherently subjective, and the study does not clarify whether standardized imaging assessments, such as endoscopic ultrasound (EUS), were used to measure lesion size and invasion depth. Inconsistencies in preoperative evaluation criteria could lead to bias in treatment selection. For example, was EFTR preferentially chosen for lesions with specific morphological characteristics? Future studies should adopt more detailed imaging assessment criteria and pathological grading methods to improve reproducibility and the interpretability of results. Second, the study does not assess the impact of the learning curve for EFTR and ESD on surgical outcomes. As a relatively novel technique, EFTR may require a longer period of experience accumulation to achieve stable performance. The study does not clarify whether operator experience was comparable between the EFTR and ESD groups or whether surgical success rates varied with increasing experience. If EFTR procedures were performed by highly experienced endoscopists while ESD procedures involved a broader range of operators, the results could be biased in favor of EFTR. Additionally, since EFTR has a steeper learning curve, factors such as procedure time and complication rates may decrease with increased experience, but the study does not conduct a dynamic analysis of these trends. Future studies should incorporate learning curve analyses to evaluate the influence of experience on surgical outcomes, ensuring a fair comparison between the two techniques. Furthermore, EFTR may cause greater bowel wall injury than ESD, potentially affecting postoperative bowel function, yet this study focuses primarily on R0 resection rates and short-term complications without assessing long-term functional outcomes. As a full-thickness resection technique, EFTR may alter rectal compliance, bowel movement frequency, and gut motility. However, the study does not provide data on postoperative bowel function changes, alterations in defecation patterns, bloating, or incontinence. If EFTR improves R0 resection rates but increases the risk of postoperative functional impairment, its clinical utility must be considered more cautiously. Future research should incorporate patient-reported outcomes (PROs) and quality of life (QoL) assessments and include long-term functional evaluations such as anorectal manometry and bowel dysfunction scoring to comprehensively assess the impact of EFTR on patient prognosis.

First, thank you very much for your professional comments on the article published in World Journal of Gastroenterology. Second, we read your comments with great interest. You are welcome to format your valuable comments into a Letter to the Editor and submit it online to World Journal of Gastroenterology at https://www.f6publishing.com. There are no restrictions on the number of words, figures (color, B/W) or authors for a Letter to the Editor. In addition, the article processing charge will be exempted for this Letter to the Editor. As with all articles published by the Baishideng Publishing Group, the Letter to the Editor will be published online after completing peer review. The guidelines for a Letter to the Editor can be found at: https://www.wjgnet.com/bpg/GerInfo/219. Finally, we look forward to receiving your high-quality Letter to the Editor, which will promote academic communication and lead the development of this discipline.