Review for 10.1186/s12876-021-01686-9 (2021)

Reviewer’s report
Title: 
Ectopic pancreas 
appearing as a giant gastric cyst mimicking gastric
lymphangioma: a case report and a brief review
Version: 
1 
Date: 
11 Jan 2021
Reviewer's report:
PEER REVIEWER ASSESSMENTS: 
RELEVANCE - Does this case report make a contribution to medical
knowledge, have educational value, or highlight the need for a change in clinical
practice or diagnostic/prognostic approaches? 
Yes, this report contributes to medical knowledge
CASE DESCRIPTION - Are the details of the case sufficiently well described to
understand the patient's symptoms and course of treatment? 
No - there are minor issues
DIAGNOSIS/INTERPRETATION - Based on the facts presented, are the
diagnosis, interpretation, and course of treatment medically sound?
Yes, the work described is medically sound
DISCUSSION OF THE CASE - Does the discussion appropriately analyse the
importance of the findings and their relevance to future understanding of disease
processes, diagnosis or treatment? Has an adequate literature review pertinent to
the case been included?
No - there are minor issues
OVERALL MANUSCRIPT POTENTIAL - Could an appropriately REVISED
version of this work represent a technically sound contribution?
Probably - with minor revisions
PEER REVIEWER COMMENTS: 
GENERAL COMMENTS: What is your overall impression of the report? 
This is an interesting and educational case report with a message. It needs sone
work and with major revision will add to the literature. One major point I want to
raise is that this patient 
did not need a gastrectomy and this lesion could(should)
have been respected locally; the assumption that malignant transformation is
possible is overstated- this lesion would have been resected because if was not
"just" an EP and was not characteristic of a gastric lymphangioma( which also
would have been respected locally.)
Are you confident in the authors' description and interpretation of the report? 
Yes this appears to be an EP with an associated serous oligocystic 
adenoma
Have the authors clearly outlined the need for publication by novelty of the case
or the specific adverse event? 
Yes I think so this case is quite educational and unique and will be of interest to
surgeons as well as gastroenterologists
REQUESTED REVISIONS: 
Suggested changes
Please note. This is the first time this reviewer has seen this case report and I
will evaluate it as a new case report- I did see the excellent prior reviews and the
detailed authors responses to these reviews
1. Page 2line 39 shouldn't the diagnosis be ectopic pancreas with associated
serous cystadenoma 
And not just "EP"? 
The uniqueness of this case report is the
presence of a serous cystadenoma in the EP
2. Page 4 line 9 delete the word "flocculent" and replace it with "intracystic fluid
with the question of particulate matter " 
3.page 4 line 14. The term "submucous membrane " is archaic and not an
accepted anatomic word anymore . 
Use " submucosa" but I would just delete this
sentence altogether because 
it adds nothing. Also page 8 line 47 delete
"submucous membrane"
4. page 4 line 17. What do you mean "lined by enhanced mucous membranes
and serous membrane" when discussing imaging? A CT cannot tell if the lining
of the cyst is mucinous or serous- all you can say is whether the stromal or lining
of the cystic cavity is enhancing-in this case I would interpret the thick wall of
the cyst as enhancing and not the lining. Look how thick the enhanced area is on
CT-- the lining is only one cell thick. You need to reword this description 
5. page 4 line 4 this mass arises clearly from the posterior wall not the "front
wall" moreover I see no evidence of "solid lesions" -"line 6. See also line 25. I
think the endoscopist should have seen this as a posterior lesion
6. Page 4 line 28 you cannot measure an endoscopic length to the hundredths of
a centimeter limit it to 5.5x3.8 cm
7. Page 4 line 44-45 I cannot condone a gastrectomy for what certainly 
looks like
a benign lesion and though I have not yet gotten to the discussion yet to see if
you address this point, this patient should have had a transgastric resection or a
wedge resection of the involved stomach- this lesion has no features of a
malignancy and did not require an antrectomy- sorry! Also why reconstruct with
a BII and not a BI?
8. Page 5 lines 43-51 I do not believe that you have any evidence or insight 
that
the pain was related to the causes you hypothesize- if that were true then other
with EP should have pain as well and as you say the vast majority are totally
asymptomatic. 
9. Page 6 lines 47-51. Are you suggesting that just because another paper found
the EXTREMELY RARE malignant transformation of a serous cystadenoma
into a serous cyst adenocarcinoma arising in the same area of the stomach as
yours that you had to treat this as a malignancy? If so I am sorry but I cannot
accept that assumption and maintain that the lesion could and should have been
resected locally . Moreover, your contention that even if you knew it was a
serous cystadenoma arising in an EP that it needs to be resected to prevent
malignant transformation, you have no data on this and it could have been
treated locally to do so
10. Page 6 lime 31 start a new paragraph
11. 
Page 8 lines 45 -51 delete these sentences you have already said this above
12 page 8 line 53- page 9 line4 I agree that lymphangioma should be included in
th4 d9fferential diagnosis, but these lesions 
have very thin walls and little
stromal or thickened enhanced wall .
Page 9 line 14 change "relatively" to " extremely. 
"
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