Title: Management and outcomes of patients with obstructive jaundice from pancreatobiliary
diseases in Rwanda
Version: 1 Date: 14 May 2025
Reviewer:  Kenneth Tachi
Reviewer's report:
General Comments:
This is a potentially good contribution that highlights the burden and management outcomes of
obstructive jaundice in a resource-limited setting. The study addresses an important gap in the
literature by providing data from Rwanda, a region underrepresented in global pancreatobiliary
research. The topic is clinically relevant, and the manuscript demonstrates some effort from the
authors.
However, several areas require clarification and revision to enhance scientific rigour,
consistency, and clarity of presentation.
Overall
• Several grammatical errors that need correction
Abstract:
• Methods:
1. Please specify which biliary drainage procedures were used (e.g., ERCP, PTBD, surgery).
2. The abstract should state the technical and clinical success rates for ERCP.
• Conclusion:
1. Avoid introducing new information not previously presented in the results section.
Specifically, do not mention aetiologies if they were not reported in the results.
2. Consider rephrasing the conclusion for clarity and alignment with the presented data.
Background:
1. The flow of the introduction would benefit from revision. Consider beginning with a definition
of obstructive jaundice, followed by its burden and clinical implications. Currently, it oscillates
between burden and definition, making it harder to follow.
2. Consider revising the length by summarising some of the information presented
Methods:
1. Provide details on how patients were allocated to ERCP, PTBD, or surgical drainage. Was
this based on clinical judgment, availability, or failure of initial methods?
2. Describe the peri-procedural safety protocols, such as how coagulopathy (e.g., high INR or
thrombocytopenia) was managed.
3. Can you clarify whether procedures were elective or emergent, and who levels of expertise
of the persons who performed them?
Results:
1. Figures 2 and 3: These can be removed since all data is already clearly presented in the text.
2. Table 2 title: Revise for clarity. Consider: “Delay Between Presentation and Biliary Drainage
and Prior Drainage Procedures.”
3. Indicate whether patients underwent multiple imaging modalities and, if so, discuss the degree
of concordance between these modalities.
4. Table 4: Ensure consistency. If median values are presented, avoid using the term “averaging”
when referring to them in the text.
5. Clarify whether PT or INR is reported in Table 4. If INR, remember it has no unit.
6. Table 6:
a. Revise the structure: ‘Presence of stones’ and ‘strictures’ should not be categorised under
“Level of Obstruction.”
b. Report how stones identified in 27.54% of cases were managed.
c. “Biliary leaks” are stated in the text but not reflected in Table 6.
• “Biliary leaks were rare (0.7%), (Table 6).” Ensure consistency.
7. Table 10 and Table 4: Their content appears similar—clarify whether one replaces or
complements the other.
8. Table 10:
• Haemoglobin level: Minimum Hb of 0.8 g/dL appears biologically implausible. Please verify
this value.
• All laboratory and physiological parameters should have appropriate units.
9. Terms like “SO dysfunction” should be written out in full on first use (e.g., Sphincter of Oddi
dysfunction), and the diagnostic criteria must be explained.
• “Among procedural and disease-related factors, CBD stone (95% CI: 0.057-0.310, p<0.005),
pancreatic mass (95% CI: -0.378--0.078, p<0.003), and SO dysfunction (95% CI: -1.505--0.284,
p<0.004) were significantly associated with mortality”
10. Clearly define what constitutes “post-procedural complications” and “adverse events.”
• “Post-procedural complications (95% CI: -0.495--0.130, p<0.001), adverse events (95%
CI: -0.299--0.115, p<0.001),…  ”These terms should not be used interchangeably without
explanation.
11. What were the post-discharge events that did not affect mortality
Discussion:
The discussion heavily leans on comparison to other studies. It would be more valuable if the
authors offered interpretative insight; why were certain results similar or different?
1. Paragraph 2 (line 323): Refers to “icterus and pruritus,” but these symptoms were not
described in the results. If inferred, explain the assumption and justify the comparison to Khan
(2009).
2.  “Uncontrollable and intense itching correlated with elevated bilirubin more than 34 mmol/
L... we could utter the delay...” is awkwardly phrased and unclear. Reword to improve clarity
and scientific tone.
3. … Clarify what you are comparing to and drawing the conclusion of lower prevalence?
• “The lower prevalence of chronic pancreatitis and ampullary stenosis as causes may reflect
regional variations or differences in our study populations.”
4. Statements drawing comparisons should always include data from both studies being
compared. For example, the prevalence of biliary dilatation was not reported in the results. This
weakens comparisons to other studies.
5. The imaging findings should be discussed before procedure findings for a logical clinical
progression. Compare imaging and procedural diagnoses for agreement.
6. Avoid redundancy. For example:
“The findings of the current study align with those reported by Mangam et al. (2018)...”
and
“The ultrasound findings in the current study are almost the same as those reported by Chalya
et al. (2011)...” could be merged and streamlined for clarity.
• You did not indicate the prevalence of biliary dilatation in your results and so it is difficult
to accept this
• It is obvious that among patients with “obstructive jaundice” biliary dilatation on imaging
would be present in almost all patients selected for biliary drainage!
7. Report and discuss the ERCP success rate in comparison with relevant studies. Provide
possible explanations for any discrepancies. Please state the success rates for the comparator
studies
• “The overall success rate of 82.61% aligns with findings from a study in Germany Padersoli
et al. (2022),”
• “The 30-day survival rate of 92.41% is encouraging and comparable to findings from
Birmingham in UK, such as the study by Bramahall et al. (1995) which reported 45.2% survival
rates (32)”. This large difference needs to be discussed. Consider differences in patient profiles,
disease severity, and management settings.
8. “However, our post-procedure adverse event rate of 16.67% is slightly lower than the 20.2%
reported in most Sub-Saharan countries (33)” Avoid directly comparing adverse event rates
from ERCP and PTBD to surgical series. Instead, discuss the differing risk profiles of these
interventions and highlight the potential advantages of minimally invasive techniques like
ERCP.
Conclusion:
This section needs to be revised after incorporating the suggested corrections throughout
the manuscript. It should align with the presented data, avoid speculation, and refrain from
introducing new information.
Abbreviations:
Remove unused abbreviations like “AIDS” if not mentioned in the text.
Title: Management and outcomes of patients with obstructive jaundice from pancreatobiliary
diseases in Rwanda
Version: 1 Date: 14 May 2025
Reviewer:  Kenneth Tachi
Reviewer's report:
General Comments:
This is a potentially good contribution that highlights the burden and management outcomes of
obstructive jaundice in a resource-limited setting. The study addresses an important gap in the
literature by providing data from Rwanda, a region underrepresented in global pancreatobiliary
research. The topic is clinically relevant, and the manuscript demonstrates some effort from the
authors.
However, several areas require clarification and revision to enhance scientific rigour,
consistency, and clarity of presentation.
Overall
• Several grammatical errors that need correction
Abstract:
• Methods:
1. Please specify which biliary drainage procedures were used (e.g., ERCP, PTBD, surgery).
2. The abstract should state the technical and clinical success rates for ERCP.
• Conclusion:
1. Avoid introducing new information not previously presented in the results section.
Specifically, do not mention aetiologies if they were not reported in the results.
2. Consider rephrasing the conclusion for clarity and alignment with the presented data.
Background:
1. The flow of the introduction would benefit from revision. Consider beginning with a definition
of obstructive jaundice, followed by its burden and clinical implications. Currently, it oscillates
between burden and definition, making it harder to follow.
2. Consider revising the length by summarising some of the information presented
Methods:
1. Provide details on how patients were allocated to ERCP, PTBD, or surgical drainage. Was
this based on clinical judgment, availability, or failure of initial methods?
2. Describe the peri-procedural safety protocols, such as how coagulopathy (e.g., high INR or
thrombocytopenia) was managed.
3. Can you clarify whether procedures were elective or emergent, and who levels of expertise
of the persons who performed them?
Results:
1. Figures 2 and 3: These can be removed since all data is already clearly presented in the text.
2. Table 2 title: Revise for clarity. Consider: “Delay Between Presentation and Biliary Drainage
and Prior Drainage Procedures.”
3. Indicate whether patients underwent multiple imaging modalities and, if so, discuss the degree
of concordance between these modalities.
4. Table 4: Ensure consistency. If median values are presented, avoid using the term “averaging”
when referring to them in the text.
5. Clarify whether PT or INR is reported in Table 4. If INR, remember it has no unit.
6. Table 6:
a. Revise the structure: ‘Presence of stones’ and ‘strictures’ should not be categorised under
“Level of Obstruction.”
b. Report how stones identified in 27.54% of cases were managed.
c. “Biliary leaks” are stated in the text but not reflected in Table 6.
• “Biliary leaks were rare (0.7%), (Table 6).” Ensure consistency.
7. Table 10 and Table 4: Their content appears similar—clarify whether one replaces or
complements the other.
8. Table 10:
• Haemoglobin level: Minimum Hb of 0.8 g/dL appears biologically implausible. Please verify
this value.
• All laboratory and physiological parameters should have appropriate units.
9. Terms like “SO dysfunction” should be written out in full on first use (e.g., Sphincter of Oddi
dysfunction), and the diagnostic criteria must be explained.
• “Among procedural and disease-related factors, CBD stone (95% CI: 0.057-0.310, p<0.005),
pancreatic mass (95% CI: -0.378--0.078, p<0.003), and SO dysfunction (95% CI: -1.505--0.284,
p<0.004) were significantly associated with mortality”
10. Clearly define what constitutes “post-procedural complications” and “adverse events.”
• “Post-procedural complications (95% CI: -0.495--0.130, p<0.001), adverse events (95%
CI: -0.299--0.115, p<0.001),…  ”These terms should not be used interchangeably without
explanation.
11. What were the post-discharge events that did not affect mortality
Discussion:
The discussion heavily leans on comparison to other studies. It would be more valuable if the
authors offered interpretative insight; why were certain results similar or different?
1. Paragraph 2 (line 323): Refers to “icterus and pruritus,” but these symptoms were not
described in the results. If inferred, explain the assumption and justify the comparison to Khan
(2009).
2.  “Uncontrollable and intense itching correlated with elevated bilirubin more than 34 mmol/
L... we could utter the delay...” is awkwardly phrased and unclear. Reword to improve clarity
and scientific tone.
3. … Clarify what you are comparing to and drawing the conclusion of lower prevalence?
• “The lower prevalence of chronic pancreatitis and ampullary stenosis as causes may reflect
regional variations or differences in our study populations.”
4. Statements drawing comparisons should always include data from both studies being
compared. For example, the prevalence of biliary dilatation was not reported in the results. This
weakens comparisons to other studies.
5. The imaging findings should be discussed before procedure findings for a logical clinical
progression. Compare imaging and procedural diagnoses for agreement.
6. Avoid redundancy. For example:
“The findings of the current study align with those reported by Mangam et al. (2018)...”
and
“The ultrasound findings in the current study are almost the same as those reported by Chalya
et al. (2011)...” could be merged and streamlined for clarity.
• You did not indicate the prevalence of biliary dilatation in your results and so it is difficult
to accept this
• It is obvious that among patients with “obstructive jaundice” biliary dilatation on imaging
would be present in almost all patients selected for biliary drainage!
7. Report and discuss the ERCP success rate in comparison with relevant studies. Provide
possible explanations for any discrepancies. Please state the success rates for the comparator
studies
• “The overall success rate of 82.61% aligns with findings from a study in Germany Padersoli
et al. (2022),”
• “The 30-day survival rate of 92.41% is encouraging and comparable to findings from
Birmingham in UK, such as the study by Bramahall et al. (1995) which reported 45.2% survival
rates (32)”. This large difference needs to be discussed. Consider differences in patient profiles,
disease severity, and management settings.
8. “However, our post-procedure adverse event rate of 16.67% is slightly lower than the 20.2%
reported in most Sub-Saharan countries (33)” Avoid directly comparing adverse event rates
from ERCP and PTBD to surgical series. Instead, discuss the differing risk profiles of these
interventions and highlight the potential advantages of minimally invasive techniques like
ERCP.
Conclusion:
This section needs to be revised after incorporating the suggested corrections throughout
the manuscript. It should align with the presented data, avoid speculation, and refrain from
introducing new information.
Abbreviations:
Remove unused abbreviations like “AIDS” if not mentioned in the text.
Please review this paper.
user
Title: Management and outcomes of patients with obstructive jaundice from pancreatobiliary
diseases in Rwanda
Version: 1 Date: 14 May 2025
Reviewer:  Kenneth Tachi
Reviewer's report:
General Comments:
This is a potentially good contribution that highlights the burden and management outcomes of
obstructive jaundice in a resource-limited setting. The study addresses an important gap in the
literature by providing data from Rwanda, a region underrepresented in global pancreatobiliary
research. The topic is clinically relevant, and the manuscript demonstrates some effort from the
authors.
However, several areas require clarification and revision to enhance scientific rigour,
consistency, and clarity of presentation.
Overall
• Several grammatical errors that need correction
Abstract:
• Methods:
1. Please specify which biliary drainage procedures were used (e.g., ERCP, PTBD, surgery).
2. The abstract should state the technical and clinical success rates for ERCP.
• Conclusion:
1. Avoid introducing new information not previously presented in the results section.
Specifically, do not mention aetiologies if they were not reported in the results.
2. Consider rephrasing the conclusion for clarity and alignment with the presented data.
Background:
1. The flow of the introduction would benefit from revision. Consider beginning with a definition
of obstructive jaundice, followed by its burden and clinical implications. Currently, it oscillates
between burden and definition, making it harder to follow.
2. Consider revising the length by summarising some of the information presented
Methods:
1. Provide details on how patients were allocated to ERCP, PTBD, or surgical drainage. Was
this based on clinical judgment, availability, or failure of initial methods?
2. Describe the peri-procedural safety protocols, such as how coagulopathy (e.g., high INR or
thrombocytopenia) was managed.
3. Can you clarify whether procedures were elective or emergent, and who levels of expertise
of the persons who performed them?
Results:
1. Figures 2 and 3: These can be removed since all data is already clearly presented in the text.
2. Table 2 title: Revise for clarity. Consider: “Delay Between Presentation and Biliary Drainage
and Prior Drainage Procedures.”
3. Indicate whether patients underwent multiple imaging modalities and, if so, discuss the degree
of concordance between these modalities.
4. Table 4: Ensure consistency. If median values are presented, avoid using the term “averaging”
when referring to them in the text.
5. Clarify whether PT or INR is reported in Table 4. If INR, remember it has no unit.
6. Table 6:
a. Revise the structure: ‘Presence of stones’ and ‘strictures’ should not be categorised under
“Level of Obstruction.”
b. Report how stones identified in 27.54% of cases were managed.
c. “Biliary leaks” are stated in the text but not reflected in Table 6.
• “Biliary leaks were rare (0.7%), (Table 6).” Ensure consistency.
7. Table 10 and Table 4: Their content appears similar—clarify whether one replaces or
complements the other.
8. Table 10:
• Haemoglobin level: Minimum Hb of 0.8 g/dL appears biologically implausible. Please verify
this value.
• All laboratory and physiological parameters should have appropriate units.
9. Terms like “SO dysfunction” should be written out in full on first use (e.g., Sphincter of Oddi
dysfunction), and the diagnostic criteria must be explained.
• “Among procedural and disease-related factors, CBD stone (95% CI: 0.057-0.310, p<0.005),
pancreatic mass (95% CI: -0.378--0.078, p<0.003), and SO dysfunction (95% CI: -1.505--0.284,
p<0.004) were significantly associated with mortality”
10. Clearly define what constitutes “post-procedural complications” and “adverse events.”
• “Post-procedural complications (95% CI: -0.495--0.130, p<0.001), adverse events (95%
CI: -0.299--0.115, p<0.001),…  ”These terms should not be used interchangeably without
explanation.
11. What were the post-discharge events that did not affect mortality
Discussion:
The discussion heavily leans on comparison to other studies. It would be more valuable if the
authors offered interpretative insight; why were certain results similar or different?
1. Paragraph 2 (line 323): Refers to “icterus and pruritus,” but these symptoms were not
described in the results. If inferred, explain the assumption and justify the comparison to Khan
(2009).
2.  “Uncontrollable and intense itching correlated with elevated bilirubin more than 34 mmol/
L... we could utter the delay...” is awkwardly phrased and unclear. Reword to improve clarity
and scientific tone.
3. … Clarify what you are comparing to and drawing the conclusion of lower prevalence?
• “The lower prevalence of chronic pancreatitis and ampullary stenosis as causes may reflect
regional variations or differences in our study populations.”
4. Statements drawing comparisons should always include data from both studies being
compared. For example, the prevalence of biliary dilatation was not reported in the results. This
weakens comparisons to other studies.
5. The imaging findings should be discussed before procedure findings for a logical clinical
progression. Compare imaging and procedural diagnoses for agreement.
6. Avoid redundancy. For example:
“The findings of the current study align with those reported by Mangam et al. (2018)...”
and
“The ultrasound findings in the current study are almost the same as those reported by Chalya
et al. (2011)...” could be merged and streamlined for clarity.
• You did not indicate the prevalence of biliary dilatation in your results and so it is difficult
to accept this
• It is obvious that among patients with “obstructive jaundice” biliary dilatation on imaging
would be present in almost all patients selected for biliary drainage!
7. Report and discuss the ERCP success rate in comparison with relevant studies. Provide
possible explanations for any discrepancies. Please state the success rates for the comparator
studies
• “The overall success rate of 82.61% aligns with findings from a study in Germany Padersoli
et al. (2022),”
• “The 30-day survival rate of 92.41% is encouraging and comparable to findings from
Birmingham in UK, such as the study by Bramahall et al. (1995) which reported 45.2% survival
rates (32)”. This large difference needs to be discussed. Consider differences in patient profiles,
disease severity, and management settings.
8. “However, our post-procedure adverse event rate of 16.67% is slightly lower than the 20.2%
reported in most Sub-Saharan countries (33)” Avoid directly comparing adverse event rates
from ERCP and PTBD to surgical series. Instead, discuss the differing risk profiles of these
interventions and highlight the potential advantages of minimally invasive techniques like
ERCP.
Conclusion:
This section needs to be revised after incorporating the suggested corrections throughout
the manuscript. It should align with the presented data, avoid speculation, and refrain from
introducing new information.
Abbreviations:
Remove unused abbreviations like “AIDS” if not mentioned in the text.
assistant