Title: Outcome of patients with perihilar cholangiocarcinoma and previous biliary
instrumentation: An observational study
Version: 2 Date: 20 Dec 2023
Reviewer:  Joris Erdmann
Reviewer's report:
Dr Brown and colleagues present relevant case series showing the results of  potentially
resectable patients with perihilar obstruction.  They show that patients who undergo drainage
procedures (mainly ERCP) in the referring center have less favourable outcomes than those who
undergo their first drainage in MSKCC. This is in line with previous literature and supports
the referral of these patients to expert centers directly without delay and especially untouched
bile ducts. Besides this very relevant observation and reason enough to publish this paper by
itself the authors add that PTCD is therefore superior to ERCP. The argumentation goes back
and forth and there is actually minimal evaluation of other literature. There is some unballanced
discussion about the results of the DRAINAGE trial. I think the DRAINAGE trial deserves
critical appraisal (as put forward in part in the long term follow up paper), but some comments
directed at the   investigators and clinicians involved in this study are unacceptable to my taste.
Please consult the surgeons involved how to put the strong words in a friendly form.  With
regard to surgical mortality: Referral to the SIR criteria is wrong. These are surgical patients
undergoing the most dangerous operation in general oncological surgery. Please refer to large
database data such as the ENCCA. I put a reference in the text.
Most importantly they did not study the choice of ERCP or PTCD, this series merely summarizes
the flow and outcomes of their daily practice. Any actual comparison is futile, most of the
patients were already drained, the dramatic early deaths due to post-ercp and post PTCD
pancreatitis or cholangitis disease progression etc etc are all filtered out. Two thirds of the
patients referred in this series were drained and thus already stood the test of time. In stark
contrast to the DRAINAGE trial from a highly centralised system (refer and not drain is the
motto) that included a very unselected group of patients.
I think this paper has serious merit when it is written toward changing daily practice in the
MSKCC referral area. Refer and not drain!  Add a balanced review of literature in support of
both techniques, elaborate a bit about innovations.
I added some recent publications to consider. Not to refer to but just to shape the thoughts.
Most of the above is in the text, and some additional remarks.
If the authors would consider to re-write the discussion toward a more balanced discussion aimed
at improving care in their region I would gladly revise and probably support publication.
Title: Outcome of patients with perihilar cholangiocarcinoma and previous biliary
instrumentation: An observational study
Version: 2 Date: 20 Dec 2023
Reviewer:  Joris Erdmann
Reviewer's report:
Dr Brown and colleagues present relevant case series showing the results of  potentially
resectable patients with perihilar obstruction.  They show that patients who undergo drainage
procedures (mainly ERCP) in the referring center have less favourable outcomes than those who
undergo their first drainage in MSKCC. This is in line with previous literature and supports
the referral of these patients to expert centers directly without delay and especially untouched
bile ducts. Besides this very relevant observation and reason enough to publish this paper by
itself the authors add that PTCD is therefore superior to ERCP. The argumentation goes back
and forth and there is actually minimal evaluation of other literature. There is some unballanced
discussion about the results of the DRAINAGE trial. I think the DRAINAGE trial deserves
critical appraisal (as put forward in part in the long term follow up paper), but some comments
directed at the   investigators and clinicians involved in this study are unacceptable to my taste.
Please consult the surgeons involved how to put the strong words in a friendly form.  With
regard to surgical mortality: Referral to the SIR criteria is wrong. These are surgical patients
undergoing the most dangerous operation in general oncological surgery. Please refer to large
database data such as the ENCCA. I put a reference in the text.
Most importantly they did not study the choice of ERCP or PTCD, this series merely summarizes
the flow and outcomes of their daily practice. Any actual comparison is futile, most of the
patients were already drained, the dramatic early deaths due to post-ercp and post PTCD
pancreatitis or cholangitis disease progression etc etc are all filtered out. Two thirds of the
patients referred in this series were drained and thus already stood the test of time. In stark
contrast to the DRAINAGE trial from a highly centralised system (refer and not drain is the
motto) that included a very unselected group of patients.
I think this paper has serious merit when it is written toward changing daily practice in the
MSKCC referral area. Refer and not drain!  Add a balanced review of literature in support of
both techniques, elaborate a bit about innovations.
I added some recent publications to consider. Not to refer to but just to shape the thoughts.
Most of the above is in the text, and some additional remarks.
If the authors would consider to re-write the discussion toward a more balanced discussion aimed
at improving care in their region I would gladly revise and probably support publication.
Please review this paper.
user
Title: Outcome of patients with perihilar cholangiocarcinoma and previous biliary
instrumentation: An observational study
Version: 2 Date: 20 Dec 2023
Reviewer:  Joris Erdmann
Reviewer's report:
Dr Brown and colleagues present relevant case series showing the results of  potentially
resectable patients with perihilar obstruction.  They show that patients who undergo drainage
procedures (mainly ERCP) in the referring center have less favourable outcomes than those who
undergo their first drainage in MSKCC. This is in line with previous literature and supports
the referral of these patients to expert centers directly without delay and especially untouched
bile ducts. Besides this very relevant observation and reason enough to publish this paper by
itself the authors add that PTCD is therefore superior to ERCP. The argumentation goes back
and forth and there is actually minimal evaluation of other literature. There is some unballanced
discussion about the results of the DRAINAGE trial. I think the DRAINAGE trial deserves
critical appraisal (as put forward in part in the long term follow up paper), but some comments
directed at the   investigators and clinicians involved in this study are unacceptable to my taste.
Please consult the surgeons involved how to put the strong words in a friendly form.  With
regard to surgical mortality: Referral to the SIR criteria is wrong. These are surgical patients
undergoing the most dangerous operation in general oncological surgery. Please refer to large
database data such as the ENCCA. I put a reference in the text.
Most importantly they did not study the choice of ERCP or PTCD, this series merely summarizes
the flow and outcomes of their daily practice. Any actual comparison is futile, most of the
patients were already drained, the dramatic early deaths due to post-ercp and post PTCD
pancreatitis or cholangitis disease progression etc etc are all filtered out. Two thirds of the
patients referred in this series were drained and thus already stood the test of time. In stark
contrast to the DRAINAGE trial from a highly centralised system (refer and not drain is the
motto) that included a very unselected group of patients.
I think this paper has serious merit when it is written toward changing daily practice in the
MSKCC referral area. Refer and not drain!  Add a balanced review of literature in support of
both techniques, elaborate a bit about innovations.
I added some recent publications to consider. Not to refer to but just to shape the thoughts.
Most of the above is in the text, and some additional remarks.
If the authors would consider to re-write the discussion toward a more balanced discussion aimed
at improving care in their region I would gladly revise and probably support publication.
assistant