Review for 10.1186/s12876-025-03896-x (2025)

Title: Association of Periampullary Diverticulum Types on Post-ERCP Hyperamylasemia: A
Retrospective Observational Study
Version: 3 Date: 22 Feb 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-While the introduction mentions that PAD prevalence in Turkey ranges from 4.6–19.8%, it
would be helpful to specify the prevalence rates from the hospital’s patient cohort for context.
This would allow readers to compare how the current study's findings relate to broader Turkish
data.
-Although the introduction introduces the He-Xian Shi classification, more details on its
advantages over previous systems (Lobo or Boix classifications) would help readers understand
why this new system is better suited for ERCP-related research.
-A brief mention of how PAD type might impact the anatomy or physiology of the papilla and
subsequent ERCP difficulties could provide further depth to the introduction and underscore the
significance of the classification.
-The study excludes patients with elevated amylase or lipase levels before ERCP. While this
makes sense for assessing post-ERCP outcomes, it could be clarified whether this exclusion
criteria might bias the results. For example, how common are elevated enzyme levels before
ERCP in this cohort, and does excluding these patients limit the generalizability of the findings?
-While the ERCP procedure protocol is clearly stated, the introduction would benefit from a brief
discussion on how the technique or operator experience might affect outcomes. For instance,
are there multiple endoscopists involved, and if so, could their experience level influence the
cannulation or complication rates in PAD patients? Including this consideration could help
interpret potential variability in the outcomes.
-The introduction provides a clear definition of hyperamylasemia, but it would be beneficial to
briefly discuss why hyperamylasemia (without associated symptoms) is a relevant outcome. This
could emphasize that even in the absence of clinical pancreatitis, elevated amylase levels might
indicate an underlying physiological change or procedural difficulty that has clinical relevance.
-While the discussion describes several key findings (e.g., the prevalence of PAD,
demographics, and the impact of PAD type on hyperamylasemia), the specific statistical
significance of these findings is not always mentioned in detail. For example, while the authors
note that the prevalence of CBD stones was higher in PAD patients, it would be helpful to include
the statistical results that support this conclusion (e.g., p-value or confidence interval).
-Similarly, while the statement that "the cannulation success rates and post-ERCP consequences
did not differ between PAD and non-PAD patients" is made, it would benefit from a more
detailed discussion of any statistical tests used and their outcomes.
-The discussion offers a reasonable hypothesis on why type 2b PAD may lead to reduced
hyperamylasemia, but it could benefit from further exploration of the physiological mechanisms
involved. For example, what specific aspects of sphincter dysfunction or bile duct alignment
make cannulation easier in type 2b PAD patients? Providing more detailed speculation or
referencing additional literature could further support the hypothesis.
-While the focus on hyperamylasemia and post-ERCP pancreatitis is appropriate, it would be
valuable to briefly discuss other potential complications or outcomes related to PAD and ERCP
procedures. For example, the authors could mention how PAD might influence the likelihood
of cholangitis, bleeding, or bile duct injury, even if these were not fully explored in the current
study.