Reviewer ’s report  
Title: Proper Bile Duct Flow, Rather Than Radical Excisi on, is the Most Critical Factor 
Determining Treatment Outcomes of Bile Duct Cysts  
 
Version: 2 Date: 29 May 2018  
 
Reviewer: Georg Gyoeri  
 
Reviewer's report:  
I would like to thank the authors for resubmitting their improved manuscript.  
 
Nevertheless some points addressed in the last review still need clarification and should be 
adaequately adressed by the au thors:  
 
Major:  
 
1) As stated by the authors in their last reply the type of surgery differs significantly between the 
type of cysts. Thus, in the analysis the type of surgery performed should be added, especially as 
the authors suggest radical liver resection in one of th eir papers. Further the references shown in 
the response letter should be incorporated in the manuscript. Thus data might be biased and late 
complications might be caused by the surgery performed.  
 
2) The surgical complications reporting should be standard ized. Please incorporate the Clavien 
Dindo Classification in your manuscript. Of note: In the response letter you describe 27 cases of 
biliary leakage. How were these patients treated? If there was external or internal drainage as you 
describe in the follo wing paragraph  this is at least a Clavien Dindo Grade IIIa. Thus the 
reporting provided in the response letter might not be exact and should be carefully revised.  
 
Minor:  
3) Please incorporate the oncological follow up in your manuscript.  
 
4) Following st atements in the discussion should be properly referenced with literature providing 
evidence:  
 
--"First of all, there is no clear histological boundary between the lesion and normal bile duct; 
therefore, the so -called pathological radical resection may not be really radical."  
 
--"Second, the pathogenesis of carcinogenesis before and after resection of bile duct cysts is 
completely different. Preoperative carcinogenesis is the result of the abnormal confluent and 
pancreatic juice that erodes the bile duct, w hile postoperative carcinogenesis is caused by 
recurrent cholangitis due to obstructed bile flow."  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
Yes 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
Yes 
Are the conclusions drawn adequately supporte d by the data shown?  
If not, please explain in your comments to the authors.  
No 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please spe cify what aspects require further 
assessment in your comments to the editors.  
I am able to assess the statistics  
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, 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 financial ly from the publication of this 
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation t hat 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.  
 
no competing interests  
 
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 report 
including 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 comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
Title: Proper Bile Duct Flow, Rather Than Radical Excisi on, is the Most Critical Factor 
Determining Treatment Outcomes of Bile Duct Cysts  
 
Version: 2 Date: 29 May 2018  
 
Reviewer: Georg Gyoeri  
 
Reviewer's report:  
I would like to thank the authors for resubmitting their improved manuscript.  
 
Nevertheless some points addressed in the last review still need clarification and should be 
adaequately adressed by the au thors:  
 
Major:  
 
1) As stated by the authors in their last reply the type of surgery differs significantly between the 
type of cysts. Thus, in the analysis the type of surgery performed should be added, especially as 
the authors suggest radical liver resection in one of th eir papers. Further the references shown in 
the response letter should be incorporated in the manuscript. Thus data might be biased and late 
complications might be caused by the surgery performed.  
 
2) The surgical complications reporting should be standard ized. Please incorporate the Clavien 
Dindo Classification in your manuscript. Of note: In the response letter you describe 27 cases of 
biliary leakage. How were these patients treated? If there was external or internal drainage as you 
describe in the follo wing paragraph  this is at least a Clavien Dindo Grade IIIa. Thus the 
reporting provided in the response letter might not be exact and should be carefully revised.  
 
Minor:  
3) Please incorporate the oncological follow up in your manuscript.  
 
4) Following st atements in the discussion should be properly referenced with literature providing 
evidence:  
 
--"First of all, there is no clear histological boundary between the lesion and normal bile duct; 
therefore, the so -called pathological radical resection may not be really radical."  
 
--"Second, the pathogenesis of carcinogenesis before and after resection of bile duct cysts is 
completely different. Preoperative carcinogenesis is the result of the abnormal confluent and 
pancreatic juice that erodes the bile duct, w hile postoperative carcinogenesis is caused by 
recurrent cholangitis due to obstructed bile flow."  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
Yes 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
Yes 
Are the conclusions drawn adequately supporte d by the data shown?  
If not, please explain in your comments to the authors.  
No 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please spe cify what aspects require further 
assessment in your comments to the editors.  
I am able to assess the statistics  
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, 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 financial ly from the publication of this 
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation t hat 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.  
 
no competing interests  
 
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 report 
including 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 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: Proper Bile Duct Flow, Rather Than Radical Excisi on, is the Most Critical Factor 
Determining Treatment Outcomes of Bile Duct Cysts  
 
Version: 2 Date: 29 May 2018  
 
Reviewer: Georg Gyoeri  
 
Reviewer's report:  
I would like to thank the authors for resubmitting their improved manuscript.  
 
Nevertheless some points addressed in the last review still need clarification and should be 
adaequately adressed by the au thors:  
 
Major:  
 
1) As stated by the authors in their last reply the type of surgery differs significantly between the 
type of cysts. Thus, in the analysis the type of surgery performed should be added, especially as 
the authors suggest radical liver resection in one of th eir papers. Further the references shown in 
the response letter should be incorporated in the manuscript. Thus data might be biased and late 
complications might be caused by the surgery performed.  
 
2) The surgical complications reporting should be standard ized. Please incorporate the Clavien 
Dindo Classification in your manuscript. Of note: In the response letter you describe 27 cases of 
biliary leakage. How were these patients treated? If there was external or internal drainage as you 
describe in the follo wing paragraph  this is at least a Clavien Dindo Grade IIIa. Thus the 
reporting provided in the response letter might not be exact and should be carefully revised.  
 
Minor:  
3) Please incorporate the oncological follow up in your manuscript.  
 
4) Following st atements in the discussion should be properly referenced with literature providing 
evidence:  
 
--"First of all, there is no clear histological boundary between the lesion and normal bile duct; 
therefore, the so -called pathological radical resection may not be really radical."  
 
--"Second, the pathogenesis of carcinogenesis before and after resection of bile duct cysts is 
completely different. Preoperative carcinogenesis is the result of the abnormal confluent and 
pancreatic juice that erodes the bile duct, w hile postoperative carcinogenesis is caused by 
recurrent cholangitis due to obstructed bile flow."  
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
Yes 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
Yes 
Are the conclusions drawn adequately supporte d by the data shown?  
If not, please explain in your comments to the authors.  
No 
Are you able to assess any statistics in the manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please spe cify what aspects require further 
assessment in your comments to the editors.  
I am able to assess the statistics  
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, 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 financial ly from the publication of this 
manuscript, either now or in the future?  
2. Do you hold any stocks or shares in an organisation t hat 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.  
 
no competing interests  
 
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 report 
including 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 comments 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant