Reviewer ’s report  
 
Title:  A retrospective clinical and microbial analysis of 32 patients with bil omas  
 
Version: 0 Date: 04 Dec 2018 
 
Reviewer:  Evangelos  Kalaitzakis  
 
Reviewer’s report:  
 
Würstle et al have performed a case -series study aiming to investigate the etiology, clinical 
presentation, pathogen spectrum and treatment of patients with bilomas. They retrospectively 
enrolled 32 patients with bilomas (identified by means of a searc h in their endoscopy database 
amongst patients having undergone ERCP or PTC). Most patients (66%) developed bilomas 
following surgery. 34% of patients had multiple bilomas. Ten out of 32 patients had infected 
bilomas (31%) according to clinical criteria (f ever and CRP elevation and/or leukocytosis). Bile 
cultures were performed in 25/32 patients (78%) and 23/25 had a positive culture. Multiresistant 
bacteria were isolated from 8/32 (25% of patients) or 8/25 (32%) of those cultured. Most patients 
received in terventional treatment.  80% of patients receiving interventional treatment as well as 
80% of those treated in a conservative fashion achieved complete biloma resolution during 
follow -up. 
 
 
Major concerns  
 
1. Microbial pathogens were isolated from the bil e of patients without clinically infected 
bilomas. The authors, however, do not provide data on isolates from infected bilomas which 
would probably be very meaningful. Also, do the authors feel that isolates from non -clinically 
infected patients were clini cally relevant?  
 
2. A large proportion of patients in the study received antibiotics (p.10, l. 204; 11/32 
piperacillin/tazobactam and 18/32 ciprofloxacin). It is unclear why this is the case. Was this post 
operative/post -transplant rather than due to a dia gnosed infection/infected biloma? If yes, may 
this have prevented the diagnosis of further "clinically" infected bilomas?  
 
3. As the authors acknowledge, patients were identified through an endoscopy database; thus, 
they were more likely to require interve ntional therapy. Also, 37% of patients developed bilomas 
after liver transplantation or liver resection. This may have influenced the generalizability of the 
results of the study.  
 
 
Minor concerns  
 
1. Please provide tables at the end of the paper and do no t embed them in the text.  
 
2. Table 4, 3rd and 5th column: Please change "Number of patients (%)…" to "Proportion of 
patients (%)…)  
 
3. The paper would probably benefit from a grammar check.  
 
Are the methods appropriate a nd 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 supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
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.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs som e 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 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 m anuscript, 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 pat ents 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 peer review policy of the journal. I understand that my name will be included 
on my re port 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 Crea tive 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 comment s 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal   
Reviewer ’s report  
 
Title:  A retrospective clinical and microbial analysis of 32 patients with bil omas  
 
Version: 0 Date: 04 Dec 2018 
 
Reviewer:  Evangelos  Kalaitzakis  
 
Reviewer’s report:  
 
Würstle et al have performed a case -series study aiming to investigate the etiology, clinical 
presentation, pathogen spectrum and treatment of patients with bilomas. They retrospectively 
enrolled 32 patients with bilomas (identified by means of a searc h in their endoscopy database 
amongst patients having undergone ERCP or PTC). Most patients (66%) developed bilomas 
following surgery. 34% of patients had multiple bilomas. Ten out of 32 patients had infected 
bilomas (31%) according to clinical criteria (f ever and CRP elevation and/or leukocytosis). Bile 
cultures were performed in 25/32 patients (78%) and 23/25 had a positive culture. Multiresistant 
bacteria were isolated from 8/32 (25% of patients) or 8/25 (32%) of those cultured. Most patients 
received in terventional treatment.  80% of patients receiving interventional treatment as well as 
80% of those treated in a conservative fashion achieved complete biloma resolution during 
follow -up. 
 
 
Major concerns  
 
1. Microbial pathogens were isolated from the bil e of patients without clinically infected 
bilomas. The authors, however, do not provide data on isolates from infected bilomas which 
would probably be very meaningful. Also, do the authors feel that isolates from non -clinically 
infected patients were clini cally relevant?  
 
2. A large proportion of patients in the study received antibiotics (p.10, l. 204; 11/32 
piperacillin/tazobactam and 18/32 ciprofloxacin). It is unclear why this is the case. Was this post 
operative/post -transplant rather than due to a dia gnosed infection/infected biloma? If yes, may 
this have prevented the diagnosis of further "clinically" infected bilomas?  
 
3. As the authors acknowledge, patients were identified through an endoscopy database; thus, 
they were more likely to require interve ntional therapy. Also, 37% of patients developed bilomas 
after liver transplantation or liver resection. This may have influenced the generalizability of the 
results of the study.  
 
 
Minor concerns  
 
1. Please provide tables at the end of the paper and do no t embed them in the text.  
 
2. Table 4, 3rd and 5th column: Please change "Number of patients (%)…" to "Proportion of 
patients (%)…)  
 
3. The paper would probably benefit from a grammar check.  
 
Are the methods appropriate a nd 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 supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
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.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs som e 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 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 m anuscript, 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 pat ents 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 peer review policy of the journal. I understand that my name will be included 
on my re port 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 Crea tive 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 comment s 
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:  A retrospective clinical and microbial analysis of 32 patients with bil omas  
 
Version: 0 Date: 04 Dec 2018 
 
Reviewer:  Evangelos  Kalaitzakis  
 
Reviewer’s report:  
 
Würstle et al have performed a case -series study aiming to investigate the etiology, clinical 
presentation, pathogen spectrum and treatment of patients with bilomas. They retrospectively 
enrolled 32 patients with bilomas (identified by means of a searc h in their endoscopy database 
amongst patients having undergone ERCP or PTC). Most patients (66%) developed bilomas 
following surgery. 34% of patients had multiple bilomas. Ten out of 32 patients had infected 
bilomas (31%) according to clinical criteria (f ever and CRP elevation and/or leukocytosis). Bile 
cultures were performed in 25/32 patients (78%) and 23/25 had a positive culture. Multiresistant 
bacteria were isolated from 8/32 (25% of patients) or 8/25 (32%) of those cultured. Most patients 
received in terventional treatment.  80% of patients receiving interventional treatment as well as 
80% of those treated in a conservative fashion achieved complete biloma resolution during 
follow -up. 
 
 
Major concerns  
 
1. Microbial pathogens were isolated from the bil e of patients without clinically infected 
bilomas. The authors, however, do not provide data on isolates from infected bilomas which 
would probably be very meaningful. Also, do the authors feel that isolates from non -clinically 
infected patients were clini cally relevant?  
 
2. A large proportion of patients in the study received antibiotics (p.10, l. 204; 11/32 
piperacillin/tazobactam and 18/32 ciprofloxacin). It is unclear why this is the case. Was this post 
operative/post -transplant rather than due to a dia gnosed infection/infected biloma? If yes, may 
this have prevented the diagnosis of further "clinically" infected bilomas?  
 
3. As the authors acknowledge, patients were identified through an endoscopy database; thus, 
they were more likely to require interve ntional therapy. Also, 37% of patients developed bilomas 
after liver transplantation or liver resection. This may have influenced the generalizability of the 
results of the study.  
 
 
Minor concerns  
 
1. Please provide tables at the end of the paper and do no t embed them in the text.  
 
2. Table 4, 3rd and 5th column: Please change "Number of patients (%)…" to "Proportion of 
patients (%)…)  
 
3. The paper would probably benefit from a grammar check.  
 
Are the methods appropriate a nd 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 supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
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.  
 
I am able to assess the statistics  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Needs som e 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 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 m anuscript, 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 pat ents 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 peer review policy of the journal. I understand that my name will be included 
on my re port 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 Crea tive 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 comment s 
to the editors, which will not be published.  
 
I agree to the open peer review policy of the journal   
assistant