Reviewer ’s report  
 
Title: Liver Elasticity Measurement Before and After Biliary Drainage in Patients With  
Obstructive Jaundice -A Prospective Cohort Study  
 
Version: 0 Date: 25 Jan 2016  
 
Reviewer: Kidist Yimam  
 
Reviewer's report:  
This study further confirms previously reported increased liver stiffness in a setting of 
extrahepatic biliary obstruction. Additionally, it showed shortly after biliary drainage, liver 
elasticity as well serum markers of fibrosis (elevated in biliary obstruction) decrease.  
However, the reported correlations between T -Bil, TE, VTQ -L, and VTQ -R are not robust and 
not all clinically sound. T -Bil is shown to correlate better with VTQ -L values than VTQ -R or TE 
values. VTQ -L values tend to be higher than VTQ -R values due to moveme nt of body organs 
near left hepatic lobe and the value does not always reflect a true level of liver elasticity.  In 
addition, the small sample size of this study may limit the ability to define these correlations 
better statistically.  
The authors should also consider evaluating if changes in serum alkaline phosphates correlate 
better with VTQ -L, VTQ -R and TE than T -Bil in their current cohort. In addition to confirming 
the findings of this study in a larger cohort, a future study should aim at defining T -Bil and/or 
ALP cut -off valves that correlate with certain stages of liver elasticity measure by TE and/or 
VTQ in at least "acute" biliary obstruction. In a setting of chronic biliary obstruction, if liver 
elasticity measured by TE/VTQ is elevated more than  anticipated, this can give the clinician 
information on possible hepatic fibrosis as a result of the chronic biliary obstruction. We also 
need to learn if the location of the biliary obstruction has varying effect on the degree of hepatic 
elasticity.  
Addi tional comment: page 7, line 5 needs minor revision.  
Are the methods appropriate and well described?  
If not, pl ease specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the da ta shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what a spects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declar ation of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, eithe r now or in the future?  
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relatin g to the content of the manuscript?  
5. Do you have any other financial competing interests?  
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
I declare that I have no competing interests  
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the websi te along with the authors' 
responses. I agree for my report to be made available under an Open Acce ss Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my name d report can be included as confidential comments 
to the editors, which will not be published.  
I agree to the open peer review policy of the journal  
 
Reviewer ’s report  
 
Title: Liver Elasticity Measurement Before and After Biliary Drainage in Patients With  
Obstructive Jaundice -A Prospective Cohort Study  
 
Version: 0 Date: 25 Jan 2016  
 
Reviewer: Kidist Yimam  
 
Reviewer's report:  
This study further confirms previously reported increased liver stiffness in a setting of 
extrahepatic biliary obstruction. Additionally, it showed shortly after biliary drainage, liver 
elasticity as well serum markers of fibrosis (elevated in biliary obstruction) decrease.  
However, the reported correlations between T -Bil, TE, VTQ -L, and VTQ -R are not robust and 
not all clinically sound. T -Bil is shown to correlate better with VTQ -L values than VTQ -R or TE 
values. VTQ -L values tend to be higher than VTQ -R values due to moveme nt of body organs 
near left hepatic lobe and the value does not always reflect a true level of liver elasticity.  In 
addition, the small sample size of this study may limit the ability to define these correlations 
better statistically.  
The authors should also consider evaluating if changes in serum alkaline phosphates correlate 
better with VTQ -L, VTQ -R and TE than T -Bil in their current cohort. In addition to confirming 
the findings of this study in a larger cohort, a future study should aim at defining T -Bil and/or 
ALP cut -off valves that correlate with certain stages of liver elasticity measure by TE and/or 
VTQ in at least "acute" biliary obstruction. In a setting of chronic biliary obstruction, if liver 
elasticity measured by TE/VTQ is elevated more than  anticipated, this can give the clinician 
information on possible hepatic fibrosis as a result of the chronic biliary obstruction. We also 
need to learn if the location of the biliary obstruction has varying effect on the degree of hepatic 
elasticity.  
Addi tional comment: page 7, line 5 needs minor revision.  
Are the methods appropriate and well described?  
If not, pl ease specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the da ta shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what a spects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declar ation of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, eithe r now or in the future?  
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relatin g to the content of the manuscript?  
5. Do you have any other financial competing interests?  
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
I declare that I have no competing interests  
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the websi te along with the authors' 
responses. I agree for my report to be made available under an Open Acce ss Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my name d report can be included as confidential comments 
to the editors, which will not be published.  
I agree to the open peer review policy of the journal  
 
Please review this paper.
user
Reviewer ’s report  
 
Title: Liver Elasticity Measurement Before and After Biliary Drainage in Patients With  
Obstructive Jaundice -A Prospective Cohort Study  
 
Version: 0 Date: 25 Jan 2016  
 
Reviewer: Kidist Yimam  
 
Reviewer's report:  
This study further confirms previously reported increased liver stiffness in a setting of 
extrahepatic biliary obstruction. Additionally, it showed shortly after biliary drainage, liver 
elasticity as well serum markers of fibrosis (elevated in biliary obstruction) decrease.  
However, the reported correlations between T -Bil, TE, VTQ -L, and VTQ -R are not robust and 
not all clinically sound. T -Bil is shown to correlate better with VTQ -L values than VTQ -R or TE 
values. VTQ -L values tend to be higher than VTQ -R values due to moveme nt of body organs 
near left hepatic lobe and the value does not always reflect a true level of liver elasticity.  In 
addition, the small sample size of this study may limit the ability to define these correlations 
better statistically.  
The authors should also consider evaluating if changes in serum alkaline phosphates correlate 
better with VTQ -L, VTQ -R and TE than T -Bil in their current cohort. In addition to confirming 
the findings of this study in a larger cohort, a future study should aim at defining T -Bil and/or 
ALP cut -off valves that correlate with certain stages of liver elasticity measure by TE and/or 
VTQ in at least "acute" biliary obstruction. In a setting of chronic biliary obstruction, if liver 
elasticity measured by TE/VTQ is elevated more than  anticipated, this can give the clinician 
information on possible hepatic fibrosis as a result of the chronic biliary obstruction. We also 
need to learn if the location of the biliary obstruction has varying effect on the degree of hepatic 
elasticity.  
Addi tional comment: page 7, line 5 needs minor revision.  
Are the methods appropriate and well described?  
If not, pl ease specify what is required in your comments to the authors.  
 
Yes 
 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
No 
 
Are the conclusions drawn adequately supported by the da ta shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any statistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what a spects require further  
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declar ation of competing interests  
Please complete a declaration of competing interests, considering the following questions:  
1. Have you in the past five years received reimbursements, fees, funding, or salary from an 
organisation that may in any way gain or lose financially from the publication of this 
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose 
financially from the publication of this manuscript, eithe r now or in the future?  
3. Do you hold or are you currently applying for any patents relating to the content of the 
manuscript?  
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relatin g to the content of the manuscript?  
5. Do you have any other financial competing interests?  
6. Do you have any non -financial competing interests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below. If your reply is yes to any, please give details below.  
I declare that I have no competing interests  
I agree to the open peer review policy of the journal. I understand that my name will be included 
on my report to the authors and, if the manuscript is accepted for publication, my named report 
including any attachments I upload will be posted on the websi te along with the authors' 
responses. I agree for my report to be made available under an Open Acce ss Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my name d report can be included as confidential comments 
to the editors, which will not be published.  
I agree to the open peer review policy of the journal  
 
assistant