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: 1 Date: 30 Apr 2018  
 
Reviewer: Georg Gyoeri  
 
Reviewer's report:  
The authors present a conclusive report on their experience with surgical procedures for simple 
and complex bile ducts cysts.  
 
In a retr ospective review of 382 patients from their center the authors propose that establishment 
rather than complete excision is important for long term outcomes.  
 
Comments:  
Todani IA, IC and IVA cysts differ very much in the surgical strategy, thus overall co nclusions 
should be drawn with caution.  
Could the authors comment on the surgical approach?  
 
As all the data are retrospective, the treatment regime was given. It seems to me that the very few 
cases without proper bile flow had postoperative complications ; Could the authors comment on 
surgical complications according to the CCI (comprehensive complication index) or if not 
available at least according to the classification by Clavien, Dindo et al.  
 
In addition failure to establish proper bile flow might als o reflect more complex cases in sick 
patients - could the authors correlate operating time, ASA risk scores, etc.  
 
It has been described that choledochal cysts and impaired bile flow have a negative effect on 
oncological outcomes - could the authors provide an oncological follow up of these patients - 
especially for those not completely resected.  
Minor remarks:  
Please have the manuscript checked by a native speaker for syntax and grammar one more time. 
eg: "For Type IVa cysts, proper bile flow vs. complete ex cision w as associated with good  long-
term outcomes with high (P < 0.00001) vs. no significance (P = 0.285), re spectively" does not 
make sense.  
 
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 compe ting interests to disclose  
 
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 w ill 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: 1 Date: 30 Apr 2018  
 
Reviewer: Georg Gyoeri  
 
Reviewer's report:  
The authors present a conclusive report on their experience with surgical procedures for simple 
and complex bile ducts cysts.  
 
In a retr ospective review of 382 patients from their center the authors propose that establishment 
rather than complete excision is important for long term outcomes.  
 
Comments:  
Todani IA, IC and IVA cysts differ very much in the surgical strategy, thus overall co nclusions 
should be drawn with caution.  
Could the authors comment on the surgical approach?  
 
As all the data are retrospective, the treatment regime was given. It seems to me that the very few 
cases without proper bile flow had postoperative complications ; Could the authors comment on 
surgical complications according to the CCI (comprehensive complication index) or if not 
available at least according to the classification by Clavien, Dindo et al.  
 
In addition failure to establish proper bile flow might als o reflect more complex cases in sick 
patients - could the authors correlate operating time, ASA risk scores, etc.  
 
It has been described that choledochal cysts and impaired bile flow have a negative effect on 
oncological outcomes - could the authors provide an oncological follow up of these patients - 
especially for those not completely resected.  
Minor remarks:  
Please have the manuscript checked by a native speaker for syntax and grammar one more time. 
eg: "For Type IVa cysts, proper bile flow vs. complete ex cision w as associated with good  long-
term outcomes with high (P < 0.00001) vs. no significance (P = 0.285), re spectively" does not 
make sense.  
 
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 compe ting interests to disclose  
 
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 w ill 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: 1 Date: 30 Apr 2018  
 
Reviewer: Georg Gyoeri  
 
Reviewer's report:  
The authors present a conclusive report on their experience with surgical procedures for simple 
and complex bile ducts cysts.  
 
In a retr ospective review of 382 patients from their center the authors propose that establishment 
rather than complete excision is important for long term outcomes.  
 
Comments:  
Todani IA, IC and IVA cysts differ very much in the surgical strategy, thus overall co nclusions 
should be drawn with caution.  
Could the authors comment on the surgical approach?  
 
As all the data are retrospective, the treatment regime was given. It seems to me that the very few 
cases without proper bile flow had postoperative complications ; Could the authors comment on 
surgical complications according to the CCI (comprehensive complication index) or if not 
available at least according to the classification by Clavien, Dindo et al.  
 
In addition failure to establish proper bile flow might als o reflect more complex cases in sick 
patients - could the authors correlate operating time, ASA risk scores, etc.  
 
It has been described that choledochal cysts and impaired bile flow have a negative effect on 
oncological outcomes - could the authors provide an oncological follow up of these patients - 
especially for those not completely resected.  
Minor remarks:  
Please have the manuscript checked by a native speaker for syntax and grammar one more time. 
eg: "For Type IVa cysts, proper bile flow vs. complete ex cision w as associated with good  long-
term outcomes with high (P < 0.00001) vs. no significance (P = 0.285), re spectively" does not 
make sense.  
 
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 compe ting interests to disclose  
 
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 w ill 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