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. 
"
ADDITIONAL REQUESTS/SUGGESTIONS: 
see above
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Declaration 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
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gain or lose financially from the publication of this manuscript, either now
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3
. 
Do you hold or are you currently applying for any patents relating to the
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Have you received reimbursements, fees, funding, or salary from an
organization that holds or has applied for patents relating to the content of
the manuscript?
5
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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.
This reviewer has been recruited by a partner organization, Research Square.
Reviewers with declared or apparent competing interests are not utilized for
these reviews. This reviewer has agreed to publication of their comments online
under a Creative Commons Attribution License attributed to Research Square
and was paid a small honorarium for completing the review within a specified
timeframe. Honoraria for reviews such as this are paid regardless of the reviewer
recommendation.
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
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. 
"
ADDITIONAL REQUESTS/SUGGESTIONS: 
see above
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
No
Declaration 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, either 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 relating 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.
This reviewer has been recruited by a partner organization, Research Square.
Reviewers with declared or apparent competing interests are not utilized for
these reviews. This reviewer has agreed to publication of their comments online
under a Creative Commons Attribution License attributed to Research Square
and was paid a small honorarium for completing the review within a specified
timeframe. Honoraria for reviews such as this are paid regardless of the reviewer
recommendation.
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Please review this paper.
user
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. 
"
ADDITIONAL REQUESTS/SUGGESTIONS: 
see above
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
No
Declaration 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, either 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 relating 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.
This reviewer has been recruited by a partner organization, Research Square.
Reviewers with declared or apparent competing interests are not utilized for
these reviews. This reviewer has agreed to publication of their comments online
under a Creative Commons Attribution License attributed to Research Square
and was paid a small honorarium for completing the review within a specified
timeframe. Honoraria for reviews such as this are paid regardless of the reviewer
recommendation.
Reviewer Publication Consent.
 I agree for my report to be made available
under an Open Access Creative Commons CC-BY License (
http://creativecommons.org/licenses/by/4.0
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the editorial
office before completing the review.
If you wish, you can include your name in your published report. Please note
you must decide whether to include your name at the start of the process and
confirm this decision whenever prompted. If you change your decision later, we
will not be able to publish your name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
No
Are the methods sufficiently described to allow the study to be repeated?
No
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
assistant