Review for 10.1186/s12876-024-03388-4 (2024)

Title: Benign hepaticojejunostomy strictures after pancreatoduodenectomy
Version: 2 Date: 21 Nov 2023
Reviewer's report:
I have read with great interest the manuscript you submitted to BMC Gastroenterology. Please,
allow me to make some comments.
Major points:
1. In the Methods/Figure 3: 58 patients who had follow up shorter than one year were excluded
from the analysis. How was this threshold established? Also, this seems a relevant number. The
authors are invited to update the follow up to increase the sample size.
2. In the Methods (most important point): How was BHS defined? Are there recognized,
established definitions of BHS? Did the authors employ some institutional definition? Were all
patients symptomatic/jaundiced? These points need more clarity.
3. In the Methods: How many open vs. minimally-invasive procedures were performed?
4. In the Methods: the authors state that a Cox proportional hazard model was built. However, no
such model appears in the results or tables. They are invited to request assistance of a dedicated
biostatistician for data analysis and interpretation.
5. Can the authors provide a time-to-event analysis to assess the (median) interval from surgery
to BHS onset? Are there predictors associated with earlier onset? This information is required to
enhance the clinical value of the work. Also, expressing interval from surgery to HPS diagnosis
in days might be confusing – months should be used.
6. The authors state that a modified Child reconstruction technique was employed in all cases.
They are encouraged to provide a picture/scheme of the post-surgical anatomy for clarity. Also,
since the anastomotic jejunal loop is supposed to be at least 40-50 cm in length, could they
provide some technical details of the ERC procedure? Were they successful in each case in
reaching the hepaticojejunostomy? I feel this might be unlikely.
7. In the results/Table 3: The multivariable model seems to be quite unstable since six predictors
were evaluated while only 13 events occurred. The authors are invited to look at the CIs of the
ORs – they are pretty large. How was the model built? Which criteria for entering the model
were employed?
8. In the Discussion: Could surgeons change their approach (alternatives to Child reconstruction?
Biliary stenting? Other tricks?) in scenarios presenting higher risk of HJ stenosis? What do the
authors suggest in this sense?
9. There are many occasions for writing improvement throughout the manuscript. The authors
are strongly encouraged to provide a thorough scientific English proofreading before submission
to a international journal.
Minor points:
1. In the Abstract: The sentence opening with ‘Of the patients who underwent anastomosis
of the common hepatic duct and jejunum’ is nonsense. All patients receiving Whipple have
hepaticojejunostomy.
2. In the Introduction: The authors state that ‘BHSs, (which) often occur after a certain period
of time after surgery’. What do they mean? Can they provide some time range or rather they are
implying that BHS is a late-onset complication?
3. In the Introduction: The authors state that BHS ‘requires invasive treatment’. Is this true for
every case? Can the author justify such a sentence?
4. In the Methods: The sentences ‘The bile duct diameter was measured using CT coronal
images. For the preoperative bile duct diameter, CT before ERC (before treatment in jaundice
cases) was used’ are confusing. Did the authors imply that bile duct diameter estimation at preop
imaging is unreliable after bile drainage?
5. In the Results: ‘The median incidence of BHS was 395 days (172-696) after PD’. Incidence
is a ratio and is inappropriate in this context. Use of expressions as ‘time-to-BHS-occurrence’
or ‘interval’ is encouraged.
6. Was there any (very) early onset anastomotic stricture? How was this treated?
7. Table 1: Percentages need to be reported for each examined variable.