Review for 10.1186/s12876-023-02901-5 (2023)

Title: External Application of Mirabilite before Surgery can Reduce the Inflammatory Response
and Accelerate Recovery in Mild Acute Biliary Pancreatitis
Version: 1 Date: 14 Jun 2023
Reviewer's report:
In this retrospective study, the authors investigated the effects of external application of
mirabilite on the inflammatory response and clinical outcomes in patients with mild acute biliary
pancreatitis (MABP). The study assessed several parameters including white blood cell count
(WBC), C-reactive protein (CRP), anal exhaust time, intraoperative modified American Fertility
Society (mAFS) adhesion score, waiting time for surgery, surgical duration, and length of stay
(LOC). The results showed that external application of mirabilite in MABP patients led to a
reduction in WBC and CRP levels, as well as a faster anal exhaust time. Additionally, the mAFS
adhesion score, waiting time for surgery, surgical duration, and LOS were also decreased in
MABP patients treated with topical alum.
However, there are some issues that need further clarification from the authors:
1. In the “Methods” section, the inclusion criteria mention "Consistent with the diagnosis of
MABP," but the diagnostic criteria for MABP, which is crucial to defining the study population,
are not thoroughly explained. Furthermore, the authors could provide more information on the
calculation process for sample size determination.
2. Previous studies have indicated the benefits of cholecystectomy in MABP patients, including
reduced recurrence rates of acute pancreatitis and decreased incidence of persistent stones.
However, there is still controversy regarding the timing and indications for early surgery.
It would be helpful if the authors could clarify how they defined the indications and
contraindications for surgery in the included MABP patients. Similarly, the assessment of
drainage placement as an outcome measure was determined by the operating surgeon based
on intraoperative conditions. The objectivity of such an approach should be further explained,
including the criteria used to determine drainage placement.
3. Difficult cholecystectomy is a common scenario, and strategies such as conversion to
open surgery or subtotal cholecystectomy are often employed to prevent bile duct injuries. A
systematic review comprising four randomized controlled trials and seven retrospective studies
on early cholecystectomy for MABP reported a conversion rate to open surgery of 7.27%
(59/812) in laparoscopic cholecystectomy (LC) [PMID: 30486807]. In this study, there were no
instances of conversion to open surgery or subtotal cholecystectomy even in the control group.
The authors should explain the reasons for this occurrence, such as whether it is related to case
selection. Additionally, the authors could further explain the choice of using the mAFS adhesion
score instead of other difficulty grading systems for cholecystectomy, such as Nassar, Miyazaki,
or Parkland scores.
4. In this study, baseline total bilirubin levels were mildly elevated in the patients, and those with
concomitant common bile duct stones were excluded from the study after undergoing abdominal
ultrasound or MRI within 24 hours. Therefore, the changes in bilirubin levels after treatment
could be a potentially meaningful outcome measure for BAP patients.
5. In this study, the number of patients with gallbladder wall thickness #3mm decreased in both
groups upon admission. The decrease was more significant in the mirabilite group. This is an
interesting finding as clinical experience suggests that gallbladder edema gradually increases
within the first week of illness, such as cholecystitis. The authors could further explore the
reasons for this phenomenon.
6. In Table 4, the authors used Pearson correlation analysis to demonstrate the relationship
between preoperative gallbladder wall thickness #3mm and mAFS score and surgical duration.
However, this presentation can be confusing to readers. It would be better to present this
information in a separate table.
7. On page 13, lines 277-281, "Although one patient had a positive preoperative common bile
duct stone, none of the remaining patients experienced biliary fistulas, bleeding, conversion
to laparotomy, surgical site infection, and the occurrence of biliary events at 3 months
postoperatively" needs clarification as it contradicts the exclusion of patients with common bile
duct stones from the study. The authors should verify the accuracy of this statement.