Reviewer’s report
Title: 
Transjugular intrahepatic portosystemic shunt for the treatment of portal
hypertensive biliopathy with cavernous transformation of the portal vein: a case
report
Version: 
0 
Date: 
06 Aug 2021
Reviewer: 
Ippei Matsumoto
Reviewer's report:
This manuscript presents a case report showing the usefulness of transjugular
intrahepatic portosystemic shunt (TIPS) combined transjugular/transsplenic
approach to the patient with portal hypertensive biliopathy (PHB) with
cavernous transformation of the portal vein. There are some reports of
transjugular/transsplenic approach to the case of unidentified portal vein such as
portal vein thrombosis 1-3, but few reports of transjugular/transsplenic approach
to PHB with cavernous transformation of the portal vein. In the case which trunk
and branch of portal vein was totally replaced by cavernous vessels, this
approach may be effective in identifying suitable collateral vessels for shunting
(thick and straight etc.) and as a puncture guide for stent placement. Therefore, 
this report is a rare and this approach could be an alternative treatment option for
PHB cases where conventional TIPS procedures are difficult.
However, there are several problems that need to be revised in the text.
The comments are summarized below.
Major comments
1 The content of the Discussion section as a whole is unclear and lacking in
depth. Authors should explain point by point what is novel, how useful and
potential alternative treatment option it is
2 The image of the figure.1 is rough as a whole. It is unreasonable to show that
the multiple tortuous hepatopetal collateral vessels was compressing the common
bile duct and proximal bile duct dilated in this MRCP image. If possible, we
recommend replacing or adding a more appropriate image, including the
portography image.
3 In the text, authors are described as there is no consensus regarding to the
optimal treatment for PHB (page3 line58-59). Addition, it is stated that the
jaundice did not improve after medical treatment (page4 line54-55). Although
previous systematic review has reported therapeutic approaches for PHB 4, the
treatment content and policy for this case should be described in a little more
detail in comparison with past reports. At least in the Discussion section, you
should explain how you came to this therapeutic approach.
Minor comments
1) Background section (page4 line10-11)
"At present, a few of studies have reported that transjugular intrahepatic
portosystemic shunt (TIPS) can treat the symptomatic PHB, but it is very
difficult to perform in the patients who have cavernous transformation of portal
vein."
Please list references.
2)Abstract; Case presentation (page3 line4-5)
"A 23-year-old man with liver cirrhosis caused by hepatolenticular degeneration
presented with jaundice."
Text; Case presentation (page4 line31-32)
"A 23-year-old man presented with 1 month of yellowed skin and sclera."
It may be better to include the disease name in the case presentation of the text.
3)Discussion and Conclusions (page5 line52-53)
"Indication of TIPS in PHB is given by the requirement to decompress the portal
system and to resolve the biliary obstruction following detension of portal
collateral vessels."
What does detension mean?
4) In the background section, "TIPS" is spelled out two times.
1. Kallini JR, Gabr A, Kulik L, et al. Noncirrhotic complete obliterative portal
vein thrombosis: Novel management using trans-splenic transjugular intrahepatic
portosystemic shunt with portal vein recanalization. Hepatology. Apr
2016;63(4):1387-1390.
2. Salsamendi JT, Gortes FJ, Shnayder M, Doshi MH, Fan J, Narayanan G.
Transsplenic portal vein reconstruction-transjugular intrahepatic portosystemic
shunt in a patient with portal and splenic vein thrombosis. Radiol Case Rep. Sep
2016;11(3):186-189.
3. Cheng Z, Wang F, Liu J. Transjugular intrahepatic portosystemic shunt
assisted with trans-splenic access. Clin Mol Hepatol. Dec 2019;25(4):417-419.
4. Franceschet I, Zanetto A, Ferrarese A, Burra P, Senzolo M. Therapeutic
approaches for portal biliopathy: A systematic review. World journal of
gastroenterology. Dec 7 2016;22(45):9909-9920.
Publons Reviewer Recognition
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Yes
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 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.
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Reviewer’s report
Title: 
Transjugular intrahepatic portosystemic shunt for the treatment of portal
hypertensive biliopathy with cavernous transformation of the portal vein: a case
report
Version: 
0 
Date: 
06 Aug 2021
Reviewer: 
Ippei Matsumoto
Reviewer's report:
This manuscript presents a case report showing the usefulness of transjugular
intrahepatic portosystemic shunt (TIPS) combined transjugular/transsplenic
approach to the patient with portal hypertensive biliopathy (PHB) with
cavernous transformation of the portal vein. There are some reports of
transjugular/transsplenic approach to the case of unidentified portal vein such as
portal vein thrombosis 1-3, but few reports of transjugular/transsplenic approach
to PHB with cavernous transformation of the portal vein. In the case which trunk
and branch of portal vein was totally replaced by cavernous vessels, this
approach may be effective in identifying suitable collateral vessels for shunting
(thick and straight etc.) and as a puncture guide for stent placement. Therefore, 
this report is a rare and this approach could be an alternative treatment option for
PHB cases where conventional TIPS procedures are difficult.
However, there are several problems that need to be revised in the text.
The comments are summarized below.
Major comments
1 The content of the Discussion section as a whole is unclear and lacking in
depth. Authors should explain point by point what is novel, how useful and
potential alternative treatment option it is
2 The image of the figure.1 is rough as a whole. It is unreasonable to show that
the multiple tortuous hepatopetal collateral vessels was compressing the common
bile duct and proximal bile duct dilated in this MRCP image. If possible, we
recommend replacing or adding a more appropriate image, including the
portography image.
3 In the text, authors are described as there is no consensus regarding to the
optimal treatment for PHB (page3 line58-59). Addition, it is stated that the
jaundice did not improve after medical treatment (page4 line54-55). Although
previous systematic review has reported therapeutic approaches for PHB 4, the
treatment content and policy for this case should be described in a little more
detail in comparison with past reports. At least in the Discussion section, you
should explain how you came to this therapeutic approach.
Minor comments
1) Background section (page4 line10-11)
"At present, a few of studies have reported that transjugular intrahepatic
portosystemic shunt (TIPS) can treat the symptomatic PHB, but it is very
difficult to perform in the patients who have cavernous transformation of portal
vein."
Please list references.
2)Abstract; Case presentation (page3 line4-5)
"A 23-year-old man with liver cirrhosis caused by hepatolenticular degeneration
presented with jaundice."
Text; Case presentation (page4 line31-32)
"A 23-year-old man presented with 1 month of yellowed skin and sclera."
It may be better to include the disease name in the case presentation of the text.
3)Discussion and Conclusions (page5 line52-53)
"Indication of TIPS in PHB is given by the requirement to decompress the portal
system and to resolve the biliary obstruction following detension of portal
collateral vessels."
What does detension mean?
4) In the background section, "TIPS" is spelled out two times.
1. Kallini JR, Gabr A, Kulik L, et al. Noncirrhotic complete obliterative portal
vein thrombosis: Novel management using trans-splenic transjugular intrahepatic
portosystemic shunt with portal vein recanalization. Hepatology. Apr
2016;63(4):1387-1390.
2. Salsamendi JT, Gortes FJ, Shnayder M, Doshi MH, Fan J, Narayanan G.
Transsplenic portal vein reconstruction-transjugular intrahepatic portosystemic
shunt in a patient with portal and splenic vein thrombosis. Radiol Case Rep. Sep
2016;11(3):186-189.
3. Cheng Z, Wang F, Liu J. Transjugular intrahepatic portosystemic shunt
assisted with trans-splenic access. Clin Mol Hepatol. Dec 2019;25(4):417-419.
4. Franceschet I, Zanetto A, Ferrarese A, Burra P, Senzolo M. Therapeutic
approaches for portal biliopathy: A systematic review. World journal of
gastroenterology. Dec 7 2016;22(45):9909-9920.
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
Yes
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 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.
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Please review this paper.
user
Reviewer’s report
Title: 
Transjugular intrahepatic portosystemic shunt for the treatment of portal
hypertensive biliopathy with cavernous transformation of the portal vein: a case
report
Version: 
0 
Date: 
06 Aug 2021
Reviewer: 
Ippei Matsumoto
Reviewer's report:
This manuscript presents a case report showing the usefulness of transjugular
intrahepatic portosystemic shunt (TIPS) combined transjugular/transsplenic
approach to the patient with portal hypertensive biliopathy (PHB) with
cavernous transformation of the portal vein. There are some reports of
transjugular/transsplenic approach to the case of unidentified portal vein such as
portal vein thrombosis 1-3, but few reports of transjugular/transsplenic approach
to PHB with cavernous transformation of the portal vein. In the case which trunk
and branch of portal vein was totally replaced by cavernous vessels, this
approach may be effective in identifying suitable collateral vessels for shunting
(thick and straight etc.) and as a puncture guide for stent placement. Therefore, 
this report is a rare and this approach could be an alternative treatment option for
PHB cases where conventional TIPS procedures are difficult.
However, there are several problems that need to be revised in the text.
The comments are summarized below.
Major comments
1 The content of the Discussion section as a whole is unclear and lacking in
depth. Authors should explain point by point what is novel, how useful and
potential alternative treatment option it is
2 The image of the figure.1 is rough as a whole. It is unreasonable to show that
the multiple tortuous hepatopetal collateral vessels was compressing the common
bile duct and proximal bile duct dilated in this MRCP image. If possible, we
recommend replacing or adding a more appropriate image, including the
portography image.
3 In the text, authors are described as there is no consensus regarding to the
optimal treatment for PHB (page3 line58-59). Addition, it is stated that the
jaundice did not improve after medical treatment (page4 line54-55). Although
previous systematic review has reported therapeutic approaches for PHB 4, the
treatment content and policy for this case should be described in a little more
detail in comparison with past reports. At least in the Discussion section, you
should explain how you came to this therapeutic approach.
Minor comments
1) Background section (page4 line10-11)
"At present, a few of studies have reported that transjugular intrahepatic
portosystemic shunt (TIPS) can treat the symptomatic PHB, but it is very
difficult to perform in the patients who have cavernous transformation of portal
vein."
Please list references.
2)Abstract; Case presentation (page3 line4-5)
"A 23-year-old man with liver cirrhosis caused by hepatolenticular degeneration
presented with jaundice."
Text; Case presentation (page4 line31-32)
"A 23-year-old man presented with 1 month of yellowed skin and sclera."
It may be better to include the disease name in the case presentation of the text.
3)Discussion and Conclusions (page5 line52-53)
"Indication of TIPS in PHB is given by the requirement to decompress the portal
system and to resolve the biliary obstruction following detension of portal
collateral vessels."
What does detension mean?
4) In the background section, "TIPS" is spelled out two times.
1. Kallini JR, Gabr A, Kulik L, et al. Noncirrhotic complete obliterative portal
vein thrombosis: Novel management using trans-splenic transjugular intrahepatic
portosystemic shunt with portal vein recanalization. Hepatology. Apr
2016;63(4):1387-1390.
2. Salsamendi JT, Gortes FJ, Shnayder M, Doshi MH, Fan J, Narayanan G.
Transsplenic portal vein reconstruction-transjugular intrahepatic portosystemic
shunt in a patient with portal and splenic vein thrombosis. Radiol Case Rep. Sep
2016;11(3):186-189.
3. Cheng Z, Wang F, Liu J. Transjugular intrahepatic portosystemic shunt
assisted with trans-splenic access. Clin Mol Hepatol. Dec 2019;25(4):417-419.
4. Franceschet I, Zanetto A, Ferrarese A, Burra P, Senzolo M. Therapeutic
approaches for portal biliopathy: A systematic review. World journal of
gastroenterology. Dec 7 2016;22(45):9909-9920.
Publons Reviewer Recognition
. Springer Nature can send verification of this
review directly to Publons (a subsidiary of Clarivate Analytics). If you would
like to take advantage of this service, please click on the “Yes” option below.
Your name, email address, title of the reviewed manuscript, name of the journal,
and date of your review submission (the “Review Data”) will then be transmitted
to Publons after the final decision on the manuscript has been made. If you have
already registered at Publons, they will notify you of the receipt of this review
and update your profile 
as per your settings and their policy. If you are not
registered with Publons, you will receive an email from them asking you to
register in order for them to be able to recognize your review on your new
profile page. Publons may use the Review Data to generate derivative metadata
for the benefit of Publons and you as a reviewer, carefully considering the
sensitivity of such information. For example, Publons may verify your record as
a reviewer by updating your profile published on its webservice if you have
registered for such service or help editors to identify candidate reviewers. Please
find the details of processing in Publons’ privacy policy
https://publons.com/about/terms
Yes
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 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.
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please publish my name with my
report.
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
assistant