Title: Association of Periampullary Diverticulum Types on Post-ERCP Hyperamylasemia: A
Retrospective Observational Study
Version: 3 Date: 18 Feb 2025
Reviewer's report:
Review Akca et al February 2025
This is a good study.  I have some suggestions..
General comments
(1) Data about the appropriate classification of PAD were derived from pictures which were
subsequently scrutinized by the investigators.  The authors seem to be quite certain about the
appropriate classification of each of the patients.  This seems a little surprising.  It would be hard
to be sure based on a single photograph.  Could the authors comment?
(2) A diagram/cartoon picture would be useful in which the classification system, which would
not be familiar to all readers of the journal, is explained pictorially.  If possible coloured
photographs of an example of each type of PAD type would be useful as well.
(3) The rate of PAD seems quite high.  Is the centre where the study was conducted a referral
centre for other ERCPists?  Could this have led to a higher than expected rate of PAD in the
cohort described?
(4) The discussion rambles on.  The first half could be reduced to a few sentences and the second
last paragraph of the second last page of text could be omitted.
(5) The explanation of the most important finding of the study (the association of PAD type
IIb periampullary diverticula with a reduced post ERCP hyperamylasaemia rate is reasonable
although one would have thought that the type III ampullae there would also have a “good
position of the ampulla entrance” and “better axial alignment of the common bile duct” compared
to those in the I and IIa groups.  Indeed some IIB cases depending on which part of the
diverticular rim the ampulla was, may not have had such a great position for cannulation.
Perhaps it is the sphincter dysfunction that is critical here in explaining why IIBs were easier/
less prone to complications than PAD III cases.  It might be better to use a different terminology
depending on what the authors are trying to say.  Perhaps the word “patulous” would be better
or it might be that the most distal few mms of the bile duct are straighter than is the case in the
standard non PAD/PAD III cases.  In this sense, III cases are probably more akin to standard
non PAD cases.    Certainly, the discussion about this should be more cogent and expansive.
(6) Maybe I missed it but what was the rate of post ERCP pancreatiits in each of the subgroups?
Minor comments
(1) Title page – it might be better to re phrase the title “Association of ….” The word impact
implies causation which is presumptuous in a retrospective study of this nature
(2) Introduction – I would omit “Therefore” – third last line
(3) Introduction – the last sentence does not make sense and should be revised (again without
the use of the word “impact”)
(4) Material and methods – why were outpatients excluded?  And how many were excluded for
this reason?
(5) Materials and methods – why was the use of PD stents avoided when it has been shown that
they reduce post ERCP pancreatitis?
Title: Association of Periampullary Diverticulum Types on Post-ERCP Hyperamylasemia: A
Retrospective Observational Study
Version: 3 Date: 18 Feb 2025
Reviewer's report:
Review Akca et al February 2025
This is a good study.  I have some suggestions..
General comments
(1) Data about the appropriate classification of PAD were derived from pictures which were
subsequently scrutinized by the investigators.  The authors seem to be quite certain about the
appropriate classification of each of the patients.  This seems a little surprising.  It would be hard
to be sure based on a single photograph.  Could the authors comment?
(2) A diagram/cartoon picture would be useful in which the classification system, which would
not be familiar to all readers of the journal, is explained pictorially.  If possible coloured
photographs of an example of each type of PAD type would be useful as well.
(3) The rate of PAD seems quite high.  Is the centre where the study was conducted a referral
centre for other ERCPists?  Could this have led to a higher than expected rate of PAD in the
cohort described?
(4) The discussion rambles on.  The first half could be reduced to a few sentences and the second
last paragraph of the second last page of text could be omitted.
(5) The explanation of the most important finding of the study (the association of PAD type
IIb periampullary diverticula with a reduced post ERCP hyperamylasaemia rate is reasonable
although one would have thought that the type III ampullae there would also have a “good
position of the ampulla entrance” and “better axial alignment of the common bile duct” compared
to those in the I and IIa groups.  Indeed some IIB cases depending on which part of the
diverticular rim the ampulla was, may not have had such a great position for cannulation.
Perhaps it is the sphincter dysfunction that is critical here in explaining why IIBs were easier/
less prone to complications than PAD III cases.  It might be better to use a different terminology
depending on what the authors are trying to say.  Perhaps the word “patulous” would be better
or it might be that the most distal few mms of the bile duct are straighter than is the case in the
standard non PAD/PAD III cases.  In this sense, III cases are probably more akin to standard
non PAD cases.    Certainly, the discussion about this should be more cogent and expansive.
(6) Maybe I missed it but what was the rate of post ERCP pancreatiits in each of the subgroups?
Minor comments
(1) Title page – it might be better to re phrase the title “Association of ….” The word impact
implies causation which is presumptuous in a retrospective study of this nature
(2) Introduction – I would omit “Therefore” – third last line
(3) Introduction – the last sentence does not make sense and should be revised (again without
the use of the word “impact”)
(4) Material and methods – why were outpatients excluded?  And how many were excluded for
this reason?
(5) Materials and methods – why was the use of PD stents avoided when it has been shown that
they reduce post ERCP pancreatitis?
Please review this paper.
user
Title: Association of Periampullary Diverticulum Types on Post-ERCP Hyperamylasemia: A
Retrospective Observational Study
Version: 3 Date: 18 Feb 2025
Reviewer's report:
Review Akca et al February 2025
This is a good study.  I have some suggestions..
General comments
(1) Data about the appropriate classification of PAD were derived from pictures which were
subsequently scrutinized by the investigators.  The authors seem to be quite certain about the
appropriate classification of each of the patients.  This seems a little surprising.  It would be hard
to be sure based on a single photograph.  Could the authors comment?
(2) A diagram/cartoon picture would be useful in which the classification system, which would
not be familiar to all readers of the journal, is explained pictorially.  If possible coloured
photographs of an example of each type of PAD type would be useful as well.
(3) The rate of PAD seems quite high.  Is the centre where the study was conducted a referral
centre for other ERCPists?  Could this have led to a higher than expected rate of PAD in the
cohort described?
(4) The discussion rambles on.  The first half could be reduced to a few sentences and the second
last paragraph of the second last page of text could be omitted.
(5) The explanation of the most important finding of the study (the association of PAD type
IIb periampullary diverticula with a reduced post ERCP hyperamylasaemia rate is reasonable
although one would have thought that the type III ampullae there would also have a “good
position of the ampulla entrance” and “better axial alignment of the common bile duct” compared
to those in the I and IIa groups.  Indeed some IIB cases depending on which part of the
diverticular rim the ampulla was, may not have had such a great position for cannulation.
Perhaps it is the sphincter dysfunction that is critical here in explaining why IIBs were easier/
less prone to complications than PAD III cases.  It might be better to use a different terminology
depending on what the authors are trying to say.  Perhaps the word “patulous” would be better
or it might be that the most distal few mms of the bile duct are straighter than is the case in the
standard non PAD/PAD III cases.  In this sense, III cases are probably more akin to standard
non PAD cases.    Certainly, the discussion about this should be more cogent and expansive.
(6) Maybe I missed it but what was the rate of post ERCP pancreatiits in each of the subgroups?
Minor comments
(1) Title page – it might be better to re phrase the title “Association of ….” The word impact
implies causation which is presumptuous in a retrospective study of this nature
(2) Introduction – I would omit “Therefore” – third last line
(3) Introduction – the last sentence does not make sense and should be revised (again without
the use of the word “impact”)
(4) Material and methods – why were outpatients excluded?  And how many were excluded for
this reason?
(5) Materials and methods – why was the use of PD stents avoided when it has been shown that
they reduce post ERCP pancreatitis?
assistant