Review for 10.1186/s12876-024-03466-7 (2024)

Title: Effectiveness of Endoscopic Papillectomy with Stent Placement in Pancreatic and Bile
Ducts for Treating Duodenal Papillary Adenoma: A Retrospective Study
Version: 1 Date: 01 Sep 2024
Reviewer's report:
The document, entitled "Effectiveness of Endoscopic Papillectomy with Stent Placement in
Pancreatic and Bile Ducts for Treating Duodenal Papillary Adenoma: A Retrospective Study",
is a retrospective study which evaluates the efficacy of stent placement during endoscopic
papillectomy (EP) for the treatment of duodenal papillary adenoma, a potentially malignant
neoplasm. The study employed a comparative approach, analysing each stenting group in
conjunction with its corresponding non-stenting counterpart.
It is noteworthy that the recurrence of duodenal papillary adenoma was significantly lower
in the biliary stent group as well as a reduced incidence of common bile duct stenosis. No
statistically significant reduction in post-ERCP pancreatitis and post-ERCP cholangitis or other
early complications was observed between groups. The group that underwent stent placement
exhibited a diminished recurrence rate of duodenal papillary adenoma.
First of all, the English language is quite comprehensive and the accuracy of the used terms
is suitable; the text flows well, and the language is accessible considering the technical nature
of the paper. The cited references are up-to-date (the authors included last updated of ASGE
and ESGE guidelines on the management of ampullary lesions), I would add a very recent and
extensive meta-analysis on Prophylactic pancreatic duct stenting (39030415).
The study design is simple and clear, but the methodology lacks of some details which appears
quite important in this context. For instance, it would be beneficial to accurately describe how
the decision was made to place or not place the stents (biliary or pancreatic), whether the use
of a biliary stent with sphincterotomy was preferred due to an anticipated higher rate of post-
procedural bleeding. Additionally, the type and size of biliary (and also pancreatic) stents must
be specified, the influence of a plastic or metallic biliary stent may be not negligible in the
occurrence of CBD stenosis. If the number of the two stents differ, this should be added in a
sub-analysis.
Demographic data reported in Table 1 are very scarce, can you please add some more
characteristics? For example Paris classification of lesions, stent used, anticoagulant/
antiaggregant therapy, etc.
The follow-up period spanned a range of 8 to 36 months, with a median duration of 12 months,
which is not actually very long in this kind of disease.
The last sentence of the results (“Recurrent high-grade adenoma patients in the stenting group
underwent endoscopic submucosal resection, while the non-stenting group received varied
treatments, all resulting in favorable outcomes”) is quite surprising. Do you mean you performed
ESD of the recurrent adenoma of the ampulla? Or do you mean the performance of submucosal
injection before resection? In the first case, this is something not standardized, so please specify
it with more technical details; in the second case, justify its use because guidelines do not suggest
it with a high degree of confidence; there were lesions with a flat component?
The authors highlight a notable decline in adenoma recurrence with stent placement; however,
they acknowledge that this finding may be influenced by the larger lesion sizes observed in the
stenting groups. This raises the question of whether stenting truly reduces recurrence or whether
the result is confounded by lesion size, and this should be emphasized in the discussion.
The results are reported quite clearly, but the discussion around the clinical implications of their
results could be strengthened. For instance, the article could explore the potential mechanisms
by which stenting reduces recurrence rates or CBD stenosis, providing a deeper understanding
of the findings.
In conclusion, the study offers valuable insights into the potential benefits of stent placement
during endoscopic papillectomy for duodenal papillary adenomas, and there is nowadays a lack
of scientific literature specifically addressed in this practice, so it is good to add some evidence.
However, as acknowledged by the authors, the retrospective design, the small sample size and
the potential confounding factors reduce the statistical power and may limit the generalisability
and the strength of these findings. However, the study offers a good background for future further
prospective studies, which will be essential for establishing more clear indications.