Review for 10.1186/1471-230X-10-25 (2010)

Reviewer's report
Title:Budd-Chiari Syndrome: Long term success via hepatic decompression
using transjugular intrahepatic porto-systemic shunt
Version: 2Date:20 December 2009
Reviewer: Martin Rössle
Reviewer's report:
The manuscirpt does still need some revision.
Abstract
1. para, ll 8-9:
The aim of the study was not to compare different therapeutic strategies. What
you did was just to report your single centre experience in a retrospective study.
Therefore, the statement should be changed as follows:
“ The aim of this study was to report our single centre long term results of
patients with BCS receiving one of three treatment options i.e., medication only,
TIPS or OLT on an individually based decision of our local expert group”.
2. para 3, 2. sentence: Myeloproliferative disorders or plasmatic coagulapathy…
3. para 3, 3. sentence: …died from liver failure before any specific treatment
could be initiated.
4. para 3, 4. and last sentences:
My suggestion:
Eleven of 13 TIPS-patients required 2.5 +/- 2.4 revisions (range 0-8). One patient
died from his underlying haematological disease. The residual 12 patients still
have stable liver function not requiring OLT. All 4 patients who……
Survival in the TIPS group was 92.3% and in the OLT group 75% during a
median follow-up of 4 and xy years, respectively.
Conclusions:
5. You did not show any findings justifying the first statement. In addition, the
small number of patients with OLT do not justify a comparison with other OLT
indications. Please drop the para and insert instead:
Our results confirm the role of TIPS in the management of patients with acute,
subacute and chronic BCS. The limited number of patients with OLT does not
allow to draw a meaningful conlusion. However, the underlying disease my
generate major complications, a reason why OLT should be limited to patients
who can not be managed by TIPS.
Introduction
6. Please drop LL 4-10.
The study by Darwish Murad is a retrospective one.
7. 2. para:
“severity of liver disease” instead of condition of the liver.
8. 2. para, last sentence
Complete references for TIPS (12-14, 22-24, 36) and arrange accordingly.
9: Please drop “OLT seems …….in patients with chronic liver failure” and the last
sentence as well (“the aim…”). Insert instead: This may give rise to redefine the
role of OLT which may now be preserved for patients failing TIPS.
Please add:
“The present treatment recommendations of the BCS (27, 35) are not based on
randomized studies but on a small number of retrospective studies (Ref) and 1
prospective study (Ref). The aim of this single centre retrospective study was to
further enlarge the body of patients evaluated with the intention to allow steady
optimization of present treatment strategies”.
Patients an Methods
10. para 4:
Patients who underwent OLT… The statement is probably not true for patients 1
and 4 of the OLT group (1988 and 1992). The para should clearly mention case
by case the reasons why patients did not receive TIPS treatment. It should be
pointed out, that time of diagnosis influenced the treatment decision.
11. second page, first para:
“significant narrowing”… This is not defined, please delete.
Results
12. First para:
Lines 3-8 should be deleted because the information is also given in table 1.
Please mention in the text the number of patients with myeloproliferative
disorders and with plasmatic coagulation abnormalities instead.
13. Second para, table 1:
Pain is a typical sign of acute disease together with ascites. Ascites alone can
occur in chronic disease. Please check patients with pain alone. This seems to
me to be a rather uncommon situation.
14:
Please join first and second para. Subheading should be “patients
characteristics”
15. Third para:
Subheading should be “treatment and outcome”
Discussion
16. first and second para:
Please drop sentences 1-4. They are already part of the introduction. Begin with
“In this study, we assessed the clinical course and long term outcome of patients
with BCS referred to our University hospital analysing the data of ….” Drop the
following 2 sentences because your patients are not really comparable to those
of Murad et al. Go on mentioning the good results of your study confirming the
results of other studies using TIPS as a primary treatment option (ref). Mention
the advantages of TIPS in comparison to OLT as shown in this study. Mention
the results of ref 6 and go on with “surprisingly, in this study…..”. Please drop “or
transplantation” at the end of the second para.
17. third para:
Ref 14 does not report the Baveno Consensus. Please correct.
Please go on saying that you did not strictly follow the recommendations of the
Baveno Conference. Patients were initially treated according to their disease
severity without awaiting failure of a previous treatment step. The good results
and the fact that OLT was not required in any TIPS patient justifies primary TIPS
treatment in patients with severe disease. Both the high survival and the lack of
OLT in the patients treated initially with a TIPS demonstrate a clear advantage
over the stepwise strategy applied in the Plessier study (ref) and recommended
by Baveno.
18: Second page of the discussion, first line:
Ref 14 is not sufficient. Please cite also the other studies on TIPS supporting this
statement.
19: Second para
“As definitive methods to prevent….”
Please drop this and the following sentence. The paper does not present
sufficient data supporting this statement.
20.
Third para:
Drop “None of our patients” because already mentioned above. Insert the rest of
the paragraph after discussing the Plessier study.
21.
4. para:
Our patients were not eligible….”
This statement should be dropped. At least 2 patients could not receive a TIPS
because TIPS was not available as a recognized treatment for BCS at this time.
It should be discussed why the 2 remaining OLT patients did not receive a TIPS.
In general, the discussion should be rewritten.
22.
Figure 1:
The legend is missing. The graph does not start at 1.0, why? Why didn´t you also
present the survival curve of the TIPS-group?
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, and I have assessed the statistics in my report.