Reviewer’ s report
Title: Factors contributing to diagnostic delay of Caroli syndrome: a single-center, retrospective
study
Version: 1Date: 18 May 2020
Reviewer's report:
This study aims to quantify the delay in diagnosis to Caroli's disease. This disease is rare and thus
there would be an expected delay to diagnosis.
Caroli's disease diagnosis is established by imaging studies that demonstrate bile duct ectasia and
irregular cystic duct dilation of the large proximal intrahepatic bile ducts with a normal commonbile duct. A liver biopsy is rarely required to make a diagnosis.
Given this the questions to ask are:1)what percentage of studies show typical imaging characteristics of Caroli's . Is it that over time
the studies became more characteristic of Caroli's. Or is it that the diagnosis was missed on thefirst CT or imaging study performed. This is essential to characterizing the delay in diagnosis.2)It would be helpful to go back and review the old CTs or imaging studies to see if they weretypical of Caroli's disease. This would be helpful in characterizing the miss rate. It may be thatthese cases were not typical of caroli's and thus the diagnosis was difficult. This should ideally bedone by two experienced GI radiologists.3)What are the characteristics of the radiologists missing the diagnosis or not including it in thedifferential diagnosis of the impression. Is it younger radiologists with less experience or non-GI
radiologists. Years of experience of the radiologist would be helpful. Also years of experience of
the radiologist and correlation to time in delay of diagnosis would be helpful.4)It would be interesting to report what the differential was or impression of the scans that missedthe diagnosis. This will help future radiologists not miss the disease.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
YesDoes the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Unable to assess
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Unable to assessAre 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 aspects require furtherassessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
AcceptableDeclaration 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 thismanuscript, 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.
'I declare that I have no competing interests' below.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 reportincluding any attachments I upload will be posted on the website along with the authors'
responses. 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/). I understand that any comments
which I do not wish to be included in my named report can be included as confidential commentsto the editors, which will not be published.
I agree to the open peer review policy of the journal
Reviewer’ s report
Title: Factors contributing to diagnostic delay of Caroli syndrome: a single-center, retrospective
study
Version: 1Date: 18 May 2020
Reviewer's report:
This study aims to quantify the delay in diagnosis to Caroli's disease. This disease is rare and thus
there would be an expected delay to diagnosis.
Caroli's disease diagnosis is established by imaging studies that demonstrate bile duct ectasia and
irregular cystic duct dilation of the large proximal intrahepatic bile ducts with a normal commonbile duct. A liver biopsy is rarely required to make a diagnosis.
Given this the questions to ask are:1)what percentage of studies show typical imaging characteristics of Caroli's . Is it that over time
the studies became more characteristic of Caroli's. Or is it that the diagnosis was missed on thefirst CT or imaging study performed. This is essential to characterizing the delay in diagnosis.2)It would be helpful to go back and review the old CTs or imaging studies to see if they weretypical of Caroli's disease. This would be helpful in characterizing the miss rate. It may be thatthese cases were not typical of caroli's and thus the diagnosis was difficult. This should ideally bedone by two experienced GI radiologists.3)What are the characteristics of the radiologists missing the diagnosis or not including it in thedifferential diagnosis of the impression. Is it younger radiologists with less experience or non-GI
radiologists. Years of experience of the radiologist would be helpful. Also years of experience of
the radiologist and correlation to time in delay of diagnosis would be helpful.4)It would be interesting to report what the differential was or impression of the scans that missedthe diagnosis. This will help future radiologists not miss the disease.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
YesDoes the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Unable to assess
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Unable to assessAre 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 aspects require furtherassessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
AcceptableDeclaration 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 thismanuscript, 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.
'I declare that I have no competing interests' below.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 reportincluding any attachments I upload will be posted on the website along with the authors'
responses. 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/). I understand that any comments
which I do not wish to be included in my named report can be included as confidential commentsto 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: Factors contributing to diagnostic delay of Caroli syndrome: a single-center, retrospective
study
Version: 1Date: 18 May 2020
Reviewer's report:
This study aims to quantify the delay in diagnosis to Caroli's disease. This disease is rare and thus
there would be an expected delay to diagnosis.
Caroli's disease diagnosis is established by imaging studies that demonstrate bile duct ectasia and
irregular cystic duct dilation of the large proximal intrahepatic bile ducts with a normal commonbile duct. A liver biopsy is rarely required to make a diagnosis.
Given this the questions to ask are:1)what percentage of studies show typical imaging characteristics of Caroli's . Is it that over time
the studies became more characteristic of Caroli's. Or is it that the diagnosis was missed on thefirst CT or imaging study performed. This is essential to characterizing the delay in diagnosis.2)It would be helpful to go back and review the old CTs or imaging studies to see if they weretypical of Caroli's disease. This would be helpful in characterizing the miss rate. It may be thatthese cases were not typical of caroli's and thus the diagnosis was difficult. This should ideally bedone by two experienced GI radiologists.3)What are the characteristics of the radiologists missing the diagnosis or not including it in thedifferential diagnosis of the impression. Is it younger radiologists with less experience or non-GI
radiologists. Years of experience of the radiologist would be helpful. Also years of experience of
the radiologist and correlation to time in delay of diagnosis would be helpful.4)It would be interesting to report what the differential was or impression of the scans that missedthe diagnosis. This will help future radiologists not miss the disease.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
YesDoes the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
Unable to assess
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
Unable to assessAre 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 aspects require furtherassessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
AcceptableDeclaration 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 thismanuscript, 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.
'I declare that I have no competing interests' below.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 reportincluding any attachments I upload will be posted on the website along with the authors'
responses. 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/). I understand that any comments
which I do not wish to be included in my named report can be included as confidential commentsto the editors, which will not be published.
I agree to the open peer review policy of the journal
assistant