Review for 10.1186/s12876-021-01620-z (2021)

Reviewer’s report
Title: 
Percutaneous direct pancreatic duct intervention in management of
pancreatic fistulas: A primary treatment or temporizing therapy to prepare for
elective surgery.
Version: 
1 
Date: 
08 Oct 2020
Reviewer's report:
Dear authors,
first of all I want to thank you for the opportunity to review your interesting
work. The percutaneous pancreatic duct intervention is a technique seldom
reported. Increase the information available on it is a worth aim.
Unfortunately I have some major concerns in the conclusions you draw from you
experience.
Major concerns:
- Your population is extremely heterogeneous. Describe it is of paramount
interest but draw any clinical conclusion on the effectiveness of the technique
could be considered too speculative. You have in 10 cases 3 different type of
patients/settings (after PD, after distal pancreatectomy and after acute
pancreatitis) and at least 5 different types of approach you cannot considered
them as one population, it is more a collection of clinical cases.
- From the point of view of a surgeon a complex procedure as yours cannot be
considered a "bridge to surgery", it could be define effective if surgery is
avoided. You describe a chronic setting in which clinician and surgeons are try
to end or shorten the fistula presence without surgery, be a bridge to surgery
means that the technique had been not useful. Describe it as a success is at least
peculiar from my point of view.
- In one of your cases the fistula persists for 117 days after the procedure, you
cannot consider it as a success. In 4 month a fistula can close spontaneously.
Also you cannot use the only case in which the catheterization failed as a
comparison or an example in the discussion. It Is methodologically incorrect,
you can compare the results with other patients of your cohort and literature.
Many high volume centers that don't have experience in these percutaneous
techniques reported in the last 20 years their experience and one year of fistula
persistence is an almost unique case.
Minor concerns:
- You have to report the initial population from which you selected these 19
cases. 8 years practice in a high volume center should have produce an
enormous amount of cases and the 10 you reported could be extremely unique.
Draw from them absolute conclusion on effectiveness is in my opinion too
speculative.
- I think you should better explain what you mean by "for palliative intent in
terminally ill patients". It need some details. In the worst case scenario the reader
could think that you have made a complex procedure in a patient that needs only
supportive therapy (therapeutic futility).
Best regards
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