Title: Large common bile duct stones in high-risk elderly patients: Immediate endoscopic stone
removal or elective stone removal? A single-center retrospective study
Version: 1 Date: 09 Sep 2023
Reviewer's report:
This is a retrospective study evaluating safety and effectiveness of temporary stent placement
and elective stone removal for elderly with serious comorbidities. The complete stone removal
rate was higher and the rate of post-procedural adverse events was lower in the elective group.
I enjoyed reading the paper, but I have several concerns as follows.
1. The authors concluded that temporary stent placement and elective endoscopic stone removal
is safer than immediate stone removal. Among post-procedural adverse events, cholangitis or
cholecystitis was significantly higher in group A (7.0% vs. 0.9%). I could not understand the
reason, because 65% of patient did not develop concomitant cholangitis. Why was the incidence
of cholangitis or cholecystitis lower among patients who underwent only biliary stent placement
in their first session? The authors recommend temporary stent placement even for patients
without concomitant cholangitis?
2. Medical costs must be higher for patients in group B, because they required admission twice.
Please add comments about this topic for the limitation.
3. The serum bilirubin level might be different between the groups. Please show the data, and if
there is between-group difference, please enter bilirubin level to calculate propensity score.
4. The patients in group B underwent ERCP at least twice. Did the patients in group A undergo
only a single session of ERCP? Why did the patients without complete stone removal undergo
second session of ERCP to achieve complete stone removal?
5. The rate of post-ERCP pancreatitis was 14% in group A although 70% of patients underwent
EST. This rate of PEP is much higher compared with previous studies which demonstrated the
safety of EST. Please explain the reason.
6. The rate of biliary stent placement should be added in the Table 2.
7. For patients in group B, the risk of biliary infection due to stent dysfunction before the second
session of ERCP could not be ignored. To access the safety of elective stone removal, the rate
of biliary events should be included in the post-procedural adverse events.
8. The authors described all patients received 100 mg of indomethacin to prevent PEP. I could
not believe because this study cohort included elderlies who had concomitant serious chronic
diseases. I assume that not a few percentages of patients had renal dysfunction who could not
receive NSAIDs.
9. The authors described that the risk mistakenly entering the pancreatic duct significantly
decreases in group B. However, the rate of accidental guidewire insertion to pancreatic duct or
pancreatic duct opacification were not shown in the results.
10. Were there any patients who underwent only biliary stent placement without subsequent
biliary stone removal (e.g., completely disabled patients) in this study cohort?
Title: Large common bile duct stones in high-risk elderly patients: Immediate endoscopic stone
removal or elective stone removal? A single-center retrospective study
Version: 1 Date: 09 Sep 2023
Reviewer's report:
This is a retrospective study evaluating safety and effectiveness of temporary stent placement
and elective stone removal for elderly with serious comorbidities. The complete stone removal
rate was higher and the rate of post-procedural adverse events was lower in the elective group.
I enjoyed reading the paper, but I have several concerns as follows.
1. The authors concluded that temporary stent placement and elective endoscopic stone removal
is safer than immediate stone removal. Among post-procedural adverse events, cholangitis or
cholecystitis was significantly higher in group A (7.0% vs. 0.9%). I could not understand the
reason, because 65% of patient did not develop concomitant cholangitis. Why was the incidence
of cholangitis or cholecystitis lower among patients who underwent only biliary stent placement
in their first session? The authors recommend temporary stent placement even for patients
without concomitant cholangitis?
2. Medical costs must be higher for patients in group B, because they required admission twice.
Please add comments about this topic for the limitation.
3. The serum bilirubin level might be different between the groups. Please show the data, and if
there is between-group difference, please enter bilirubin level to calculate propensity score.
4. The patients in group B underwent ERCP at least twice. Did the patients in group A undergo
only a single session of ERCP? Why did the patients without complete stone removal undergo
second session of ERCP to achieve complete stone removal?
5. The rate of post-ERCP pancreatitis was 14% in group A although 70% of patients underwent
EST. This rate of PEP is much higher compared with previous studies which demonstrated the
safety of EST. Please explain the reason.
6. The rate of biliary stent placement should be added in the Table 2.
7. For patients in group B, the risk of biliary infection due to stent dysfunction before the second
session of ERCP could not be ignored. To access the safety of elective stone removal, the rate
of biliary events should be included in the post-procedural adverse events.
8. The authors described all patients received 100 mg of indomethacin to prevent PEP. I could
not believe because this study cohort included elderlies who had concomitant serious chronic
diseases. I assume that not a few percentages of patients had renal dysfunction who could not
receive NSAIDs.
9. The authors described that the risk mistakenly entering the pancreatic duct significantly
decreases in group B. However, the rate of accidental guidewire insertion to pancreatic duct or
pancreatic duct opacification were not shown in the results.
10. Were there any patients who underwent only biliary stent placement without subsequent
biliary stone removal (e.g., completely disabled patients) in this study cohort?
Please review this paper.
user
Title: Large common bile duct stones in high-risk elderly patients: Immediate endoscopic stone
removal or elective stone removal? A single-center retrospective study
Version: 1 Date: 09 Sep 2023
Reviewer's report:
This is a retrospective study evaluating safety and effectiveness of temporary stent placement
and elective stone removal for elderly with serious comorbidities. The complete stone removal
rate was higher and the rate of post-procedural adverse events was lower in the elective group.
I enjoyed reading the paper, but I have several concerns as follows.
1. The authors concluded that temporary stent placement and elective endoscopic stone removal
is safer than immediate stone removal. Among post-procedural adverse events, cholangitis or
cholecystitis was significantly higher in group A (7.0% vs. 0.9%). I could not understand the
reason, because 65% of patient did not develop concomitant cholangitis. Why was the incidence
of cholangitis or cholecystitis lower among patients who underwent only biliary stent placement
in their first session? The authors recommend temporary stent placement even for patients
without concomitant cholangitis?
2. Medical costs must be higher for patients in group B, because they required admission twice.
Please add comments about this topic for the limitation.
3. The serum bilirubin level might be different between the groups. Please show the data, and if
there is between-group difference, please enter bilirubin level to calculate propensity score.
4. The patients in group B underwent ERCP at least twice. Did the patients in group A undergo
only a single session of ERCP? Why did the patients without complete stone removal undergo
second session of ERCP to achieve complete stone removal?
5. The rate of post-ERCP pancreatitis was 14% in group A although 70% of patients underwent
EST. This rate of PEP is much higher compared with previous studies which demonstrated the
safety of EST. Please explain the reason.
6. The rate of biliary stent placement should be added in the Table 2.
7. For patients in group B, the risk of biliary infection due to stent dysfunction before the second
session of ERCP could not be ignored. To access the safety of elective stone removal, the rate
of biliary events should be included in the post-procedural adverse events.
8. The authors described all patients received 100 mg of indomethacin to prevent PEP. I could
not believe because this study cohort included elderlies who had concomitant serious chronic
diseases. I assume that not a few percentages of patients had renal dysfunction who could not
receive NSAIDs.
9. The authors described that the risk mistakenly entering the pancreatic duct significantly
decreases in group B. However, the rate of accidental guidewire insertion to pancreatic duct or
pancreatic duct opacification were not shown in the results.
10. Were there any patients who underwent only biliary stent placement without subsequent
biliary stone removal (e.g., completely disabled patients) in this study cohort?
assistant