Title: Comparison of the efficacy and safety between palliative biliary stent placement and duct
clearance among elderly patients with choledocholithiasis: A propensity score-matched analysis
Version: 1 Date: 05 Sep 2021
Reviewer's report:
The current study was a single center retrospective study to compare long-term outcomes after
endoscopic biliary stent placement and complete stone removal for elderly patients with common
bile duct stones. I suppose that this study contains an important information, but I have several
comments as follows.
1. The current study is single center retrospective study. Please clarify this point in the method
section.
2. The patients with surgically altered anatomy (SAA) were included in this study. Did all
patients with SAA undergo ERCP using balloon endoscope?
3. The sentence that “The EBS group had a significantly higher proportion of elderly individuals”
seems odd, because the inclusion criteria of this study is elderly patients as authors described
in the methods section.
4. Fourteen covariates were selected to calculate propensity score, but these variables were not
clarified in the main document.
5. Please show the rate of patient who underwent planned cholecystectomy after ERCP. The rate
of cholangitis in patients after complete stone removal seems to be low compared with previous
studies. I wonder you could not accumulate actual number of patients who developed cholangitis
after complete stone removal.
6. One cholecystitis was reported as late adverse event in Table 2. No patients after complete
stone removal did not develop cholecystitis after the long follow-up period?
7. Follow-up strategy after ERCP should be described. Were routine follow-up imaging studies
or blood test examined in outpatient basis with regular interval?
8. As you described in the discussion section, some patients were difficult to follow their long-
term outcomes. At least patients of their follow-up period within 30-days should be excluded
from the analyses.
9. Were patients with recurrent bile duct stone after complete stone removal were repeatedly
included in this study?
10. In the Table 1, the rate of patients of their performance score 3 is documented. Did you
exclude patients with their performance score 4? I assume that consecutive patients were
included in this study. EBS without stone removal was particularly important in patients PS 4.
11. The median duration of cholangitis-free periods in patients with palliative EBS was 596
days in this study. Usually, patients after plastic stent placement were recommend biliary stent
exchange in 3-6 months interval. Please describe the authors opinion about this long cholangitis-
free period after EBS.
12. The rate of patients who used dual or triplet antithromtobic agents should be documented.
13. The preferable long-term outcome after complete stone removal compared with EBS is
already known, and guidelines recommended stone removal. The authors intended to show
natural history of EBS without stone removal, but due to the small sample size, the study result
seemed to contain a lot of bias.
Title: Comparison of the efficacy and safety between palliative biliary stent placement and duct
clearance among elderly patients with choledocholithiasis: A propensity score-matched analysis
Version: 1 Date: 05 Sep 2021
Reviewer's report:
The current study was a single center retrospective study to compare long-term outcomes after
endoscopic biliary stent placement and complete stone removal for elderly patients with common
bile duct stones. I suppose that this study contains an important information, but I have several
comments as follows.
1. The current study is single center retrospective study. Please clarify this point in the method
section.
2. The patients with surgically altered anatomy (SAA) were included in this study. Did all
patients with SAA undergo ERCP using balloon endoscope?
3. The sentence that “The EBS group had a significantly higher proportion of elderly individuals”
seems odd, because the inclusion criteria of this study is elderly patients as authors described
in the methods section.
4. Fourteen covariates were selected to calculate propensity score, but these variables were not
clarified in the main document.
5. Please show the rate of patient who underwent planned cholecystectomy after ERCP. The rate
of cholangitis in patients after complete stone removal seems to be low compared with previous
studies. I wonder you could not accumulate actual number of patients who developed cholangitis
after complete stone removal.
6. One cholecystitis was reported as late adverse event in Table 2. No patients after complete
stone removal did not develop cholecystitis after the long follow-up period?
7. Follow-up strategy after ERCP should be described. Were routine follow-up imaging studies
or blood test examined in outpatient basis with regular interval?
8. As you described in the discussion section, some patients were difficult to follow their long-
term outcomes. At least patients of their follow-up period within 30-days should be excluded
from the analyses.
9. Were patients with recurrent bile duct stone after complete stone removal were repeatedly
included in this study?
10. In the Table 1, the rate of patients of their performance score 3 is documented. Did you
exclude patients with their performance score 4? I assume that consecutive patients were
included in this study. EBS without stone removal was particularly important in patients PS 4.
11. The median duration of cholangitis-free periods in patients with palliative EBS was 596
days in this study. Usually, patients after plastic stent placement were recommend biliary stent
exchange in 3-6 months interval. Please describe the authors opinion about this long cholangitis-
free period after EBS.
12. The rate of patients who used dual or triplet antithromtobic agents should be documented.
13. The preferable long-term outcome after complete stone removal compared with EBS is
already known, and guidelines recommended stone removal. The authors intended to show
natural history of EBS without stone removal, but due to the small sample size, the study result
seemed to contain a lot of bias.
Please review this paper.
user
Title: Comparison of the efficacy and safety between palliative biliary stent placement and duct
clearance among elderly patients with choledocholithiasis: A propensity score-matched analysis
Version: 1 Date: 05 Sep 2021
Reviewer's report:
The current study was a single center retrospective study to compare long-term outcomes after
endoscopic biliary stent placement and complete stone removal for elderly patients with common
bile duct stones. I suppose that this study contains an important information, but I have several
comments as follows.
1. The current study is single center retrospective study. Please clarify this point in the method
section.
2. The patients with surgically altered anatomy (SAA) were included in this study. Did all
patients with SAA undergo ERCP using balloon endoscope?
3. The sentence that “The EBS group had a significantly higher proportion of elderly individuals”
seems odd, because the inclusion criteria of this study is elderly patients as authors described
in the methods section.
4. Fourteen covariates were selected to calculate propensity score, but these variables were not
clarified in the main document.
5. Please show the rate of patient who underwent planned cholecystectomy after ERCP. The rate
of cholangitis in patients after complete stone removal seems to be low compared with previous
studies. I wonder you could not accumulate actual number of patients who developed cholangitis
after complete stone removal.
6. One cholecystitis was reported as late adverse event in Table 2. No patients after complete
stone removal did not develop cholecystitis after the long follow-up period?
7. Follow-up strategy after ERCP should be described. Were routine follow-up imaging studies
or blood test examined in outpatient basis with regular interval?
8. As you described in the discussion section, some patients were difficult to follow their long-
term outcomes. At least patients of their follow-up period within 30-days should be excluded
from the analyses.
9. Were patients with recurrent bile duct stone after complete stone removal were repeatedly
included in this study?
10. In the Table 1, the rate of patients of their performance score 3 is documented. Did you
exclude patients with their performance score 4? I assume that consecutive patients were
included in this study. EBS without stone removal was particularly important in patients PS 4.
11. The median duration of cholangitis-free periods in patients with palliative EBS was 596
days in this study. Usually, patients after plastic stent placement were recommend biliary stent
exchange in 3-6 months interval. Please describe the authors opinion about this long cholangitis-
free period after EBS.
12. The rate of patients who used dual or triplet antithromtobic agents should be documented.
13. The preferable long-term outcome after complete stone removal compared with EBS is
already known, and guidelines recommended stone removal. The authors intended to show
natural history of EBS without stone removal, but due to the small sample size, the study result
seemed to contain a lot of bias.
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