Reviewer ’s report  
 
Title:  Uneven Acute Non -Alcoholic Fatty Change of the Liver after Percutaneous Transhepatic 
Portal Vein Embolization in a Patient with Hilar Cholangiocarcinoma - A case report  
 
Version: 0 Date: 20 May 2017 
 
Reviewer:  Joachim  Mertens  
 
Reviewer’s report:  
 
The manuscript BMGE -D-16-00293 is a case report of a segmental non -alcoholic transformation 
of the liver after portal vein embolization (PVE) in a patient with hilar cholangiocarcinoma 
(CCA).  
 
The authors report from a center with extensive exper ience in PVE for this indication. The 
manuscript is fairly well written and comprehensive in its description of the case and the case 
itself is of some general interest. Still the description feels somewhat diffuse while the key 
message of this case report  remains unclear. There is no discussion on the possible mechanisms 
of the observed segmental fatty changes.  
 
 
Major compulsory revisions  
  
1) In this case report, acute fatty change of the liver segments that had sufficient biliary 
drainage is described wh ile no such fatty alterations were seen in the segment that was 
incompletely drained. This is an interesting observation. Unfortunately, there is no 
mechanistic insight nor a discussion of possible underlying mechanisms. This affects the 
relevance of this case report.  
 
2) The different aspects of NAFLD, 'Two hit hypothesis', CCA and PVE described in the 
introduction appear loosely connected at best and the authors do not introduce a plausible 
link between these concepts.  
 
3) Large passages of the manuscript a re propaedeutic and provide little new insight.  
 
4) The sentence 'Although the mechanisms underlying these observations are unknown, they 
may have provided insight enabling further understanding of the mechanism of NAFLD' 
is a gross overstatement. The quest ion whether PVE induced fatty alterations of liver are 
similar in their pathomechanism as changes seen in NAFLD is completely unclear and 
not even discussed in the paper.  
 
5) What do the arrows in Fig 2A indicate?  
 
6) Why is there a visible difference in fat ty alterations between the Fig 2 B and C? There 
seems to be a loss of fat after 6 weeks, in contradiction to the authors statement that the 
fatty alterations were stationary.  
 
7) Is the visualization of changes in blood flow (Fig 4) based on any actual meas urements or 
merely speculative?  
 
 
Minor Essential Revisions  
 
1) There are some minor language and grammar issues that should be addressed.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Unable to assess  
 
Does 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.  
 
No 
 
Are 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 further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, cons idering 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.  
 
I declare that I have no competing interests  
 
I agree to the open pee r 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 report 
including any attachments I upload will be posted on the website along with the autho rs' 
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 comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title:  Uneven Acute Non -Alcoholic Fatty Change of the Liver after Percutaneous Transhepatic 
Portal Vein Embolization in a Patient with Hilar Cholangiocarcinoma - A case report  
 
Version: 0 Date: 20 May 2017 
 
Reviewer:  Joachim  Mertens  
 
Reviewer’s report:  
 
The manuscript BMGE -D-16-00293 is a case report of a segmental non -alcoholic transformation 
of the liver after portal vein embolization (PVE) in a patient with hilar cholangiocarcinoma 
(CCA).  
 
The authors report from a center with extensive exper ience in PVE for this indication. The 
manuscript is fairly well written and comprehensive in its description of the case and the case 
itself is of some general interest. Still the description feels somewhat diffuse while the key 
message of this case report  remains unclear. There is no discussion on the possible mechanisms 
of the observed segmental fatty changes.  
 
 
Major compulsory revisions  
  
1) In this case report, acute fatty change of the liver segments that had sufficient biliary 
drainage is described wh ile no such fatty alterations were seen in the segment that was 
incompletely drained. This is an interesting observation. Unfortunately, there is no 
mechanistic insight nor a discussion of possible underlying mechanisms. This affects the 
relevance of this case report.  
 
2) The different aspects of NAFLD, 'Two hit hypothesis', CCA and PVE described in the 
introduction appear loosely connected at best and the authors do not introduce a plausible 
link between these concepts.  
 
3) Large passages of the manuscript a re propaedeutic and provide little new insight.  
 
4) The sentence 'Although the mechanisms underlying these observations are unknown, they 
may have provided insight enabling further understanding of the mechanism of NAFLD' 
is a gross overstatement. The quest ion whether PVE induced fatty alterations of liver are 
similar in their pathomechanism as changes seen in NAFLD is completely unclear and 
not even discussed in the paper.  
 
5) What do the arrows in Fig 2A indicate?  
 
6) Why is there a visible difference in fat ty alterations between the Fig 2 B and C? There 
seems to be a loss of fat after 6 weeks, in contradiction to the authors statement that the 
fatty alterations were stationary.  
 
7) Is the visualization of changes in blood flow (Fig 4) based on any actual meas urements or 
merely speculative?  
 
 
Minor Essential Revisions  
 
1) There are some minor language and grammar issues that should be addressed.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Unable to assess  
 
Does 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.  
 
No 
 
Are 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 further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, cons idering 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.  
 
I declare that I have no competing interests  
 
I agree to the open pee r 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 report 
including any attachments I upload will be posted on the website along with the autho rs' 
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 comments 
to 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:  Uneven Acute Non -Alcoholic Fatty Change of the Liver after Percutaneous Transhepatic 
Portal Vein Embolization in a Patient with Hilar Cholangiocarcinoma - A case report  
 
Version: 0 Date: 20 May 2017 
 
Reviewer:  Joachim  Mertens  
 
Reviewer’s report:  
 
The manuscript BMGE -D-16-00293 is a case report of a segmental non -alcoholic transformation 
of the liver after portal vein embolization (PVE) in a patient with hilar cholangiocarcinoma 
(CCA).  
 
The authors report from a center with extensive exper ience in PVE for this indication. The 
manuscript is fairly well written and comprehensive in its description of the case and the case 
itself is of some general interest. Still the description feels somewhat diffuse while the key 
message of this case report  remains unclear. There is no discussion on the possible mechanisms 
of the observed segmental fatty changes.  
 
 
Major compulsory revisions  
  
1) In this case report, acute fatty change of the liver segments that had sufficient biliary 
drainage is described wh ile no such fatty alterations were seen in the segment that was 
incompletely drained. This is an interesting observation. Unfortunately, there is no 
mechanistic insight nor a discussion of possible underlying mechanisms. This affects the 
relevance of this case report.  
 
2) The different aspects of NAFLD, 'Two hit hypothesis', CCA and PVE described in the 
introduction appear loosely connected at best and the authors do not introduce a plausible 
link between these concepts.  
 
3) Large passages of the manuscript a re propaedeutic and provide little new insight.  
 
4) The sentence 'Although the mechanisms underlying these observations are unknown, they 
may have provided insight enabling further understanding of the mechanism of NAFLD' 
is a gross overstatement. The quest ion whether PVE induced fatty alterations of liver are 
similar in their pathomechanism as changes seen in NAFLD is completely unclear and 
not even discussed in the paper.  
 
5) What do the arrows in Fig 2A indicate?  
 
6) Why is there a visible difference in fat ty alterations between the Fig 2 B and C? There 
seems to be a loss of fat after 6 weeks, in contradiction to the authors statement that the 
fatty alterations were stationary.  
 
7) Is the visualization of changes in blood flow (Fig 4) based on any actual meas urements or 
merely speculative?  
 
 
Minor Essential Revisions  
 
1) There are some minor language and grammar issues that should be addressed.  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
Unable to assess  
 
Does 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.  
 
No 
 
Are 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 further 
assessment in your comments to the editors.  
 
Not relevant to this manuscript  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs some language corrections before being published  
 
Declaration of competing interests  
Please complete a declaration of competing interests, cons idering 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.  
 
I declare that I have no competing interests  
 
I agree to the open pee r 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 report 
including any attachments I upload will be posted on the website along with the autho rs' 
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 comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant