Title: Impact of cholangitis on survival of patients with malignant biliary obstruction treated
with percutaneous transhepatic biliary drainage
Version: 2 Date: 10 Aug 2022
Reviewer's report:
In this study the authors aimed to evaluate the impact of cholangitis on survival of patients with
gastrointestinal cancer and malignant biliary obstruction treated with percutaneous transhepatic
biliary drainage (PTBD).
The study included 588 patients, 258 (43.9%) patients with pancreatic cancer, 222 (37.7%) with
biliary tract cancer, and 108 (18.4%) with metastasis from gastrointestinal cancers. The 30-
day mortality rate was 30.8% for 156 patients with cholangitis before PTBD, 19.5% for 215
patients with cholangitis after PTBD and 25.8% for 217 patients without cholangitis (P=0.039).
The median survival was 1.8 months for patients with cholangitis before PTBD, 3.0 months for
patients with cholangitis after PTBD, and 3.2 months for patients without cholangitis (P=0.002).
After successful PTBD, 54 out of 291 patients received chemotherapy; the median survival was
5.2 months with cholangitis before PTBD, 9.4 months with cholangitis after PTBD and 15.3
months without cholangitis.
They concluded that  In gastrointestinal cancers with malignant biliary obstruction, survival is
poorer if cholangitis occurs before PTBD compared to cholangitis after PTBD.
The study addresses a critical clinical need and is of interest.
My only comment is related to recent literature data that should be discussed to improve the
clinical impact of the manuscript further.
-introduction: the authors should further discuss the Role of Cholangioscopy and EUS in the
evaluation of Indeterminate Biliary Strictures, as recently well addressed in a comprehensive
review (The Role of Cholangioscopy and EUS in the Evaluation of Indeterminate Biliary
Strictures. Gastroenterol. Insights 2022, 13, 192-205.), because differentiating between
malignant and benign biliary strictures remains a clinical challenge.
-also technical aspects of biliary procedures should be recalled as well summarized in a recent
review describing  the techniques, clinical efficacy, and potential pitfalls of advanced ERCP
techniques, percutaneous biliary drainage, and EUS-RV ERCP (Troubleshooting Difficult Bile
Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or
EUS-Guided Rendezvous Technique? Gastroenterol. Insights 2021, 12, 405-422.).
Title: Impact of cholangitis on survival of patients with malignant biliary obstruction treated
with percutaneous transhepatic biliary drainage
Version: 2 Date: 10 Aug 2022
Reviewer's report:
In this study the authors aimed to evaluate the impact of cholangitis on survival of patients with
gastrointestinal cancer and malignant biliary obstruction treated with percutaneous transhepatic
biliary drainage (PTBD).
The study included 588 patients, 258 (43.9%) patients with pancreatic cancer, 222 (37.7%) with
biliary tract cancer, and 108 (18.4%) with metastasis from gastrointestinal cancers. The 30-
day mortality rate was 30.8% for 156 patients with cholangitis before PTBD, 19.5% for 215
patients with cholangitis after PTBD and 25.8% for 217 patients without cholangitis (P=0.039).
The median survival was 1.8 months for patients with cholangitis before PTBD, 3.0 months for
patients with cholangitis after PTBD, and 3.2 months for patients without cholangitis (P=0.002).
After successful PTBD, 54 out of 291 patients received chemotherapy; the median survival was
5.2 months with cholangitis before PTBD, 9.4 months with cholangitis after PTBD and 15.3
months without cholangitis.
They concluded that  In gastrointestinal cancers with malignant biliary obstruction, survival is
poorer if cholangitis occurs before PTBD compared to cholangitis after PTBD.
The study addresses a critical clinical need and is of interest.
My only comment is related to recent literature data that should be discussed to improve the
clinical impact of the manuscript further.
-introduction: the authors should further discuss the Role of Cholangioscopy and EUS in the
evaluation of Indeterminate Biliary Strictures, as recently well addressed in a comprehensive
review (The Role of Cholangioscopy and EUS in the Evaluation of Indeterminate Biliary
Strictures. Gastroenterol. Insights 2022, 13, 192-205.), because differentiating between
malignant and benign biliary strictures remains a clinical challenge.
-also technical aspects of biliary procedures should be recalled as well summarized in a recent
review describing  the techniques, clinical efficacy, and potential pitfalls of advanced ERCP
techniques, percutaneous biliary drainage, and EUS-RV ERCP (Troubleshooting Difficult Bile
Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or
EUS-Guided Rendezvous Technique? Gastroenterol. Insights 2021, 12, 405-422.).
Please review this paper.
user
Title: Impact of cholangitis on survival of patients with malignant biliary obstruction treated
with percutaneous transhepatic biliary drainage
Version: 2 Date: 10 Aug 2022
Reviewer's report:
In this study the authors aimed to evaluate the impact of cholangitis on survival of patients with
gastrointestinal cancer and malignant biliary obstruction treated with percutaneous transhepatic
biliary drainage (PTBD).
The study included 588 patients, 258 (43.9%) patients with pancreatic cancer, 222 (37.7%) with
biliary tract cancer, and 108 (18.4%) with metastasis from gastrointestinal cancers. The 30-
day mortality rate was 30.8% for 156 patients with cholangitis before PTBD, 19.5% for 215
patients with cholangitis after PTBD and 25.8% for 217 patients without cholangitis (P=0.039).
The median survival was 1.8 months for patients with cholangitis before PTBD, 3.0 months for
patients with cholangitis after PTBD, and 3.2 months for patients without cholangitis (P=0.002).
After successful PTBD, 54 out of 291 patients received chemotherapy; the median survival was
5.2 months with cholangitis before PTBD, 9.4 months with cholangitis after PTBD and 15.3
months without cholangitis.
They concluded that  In gastrointestinal cancers with malignant biliary obstruction, survival is
poorer if cholangitis occurs before PTBD compared to cholangitis after PTBD.
The study addresses a critical clinical need and is of interest.
My only comment is related to recent literature data that should be discussed to improve the
clinical impact of the manuscript further.
-introduction: the authors should further discuss the Role of Cholangioscopy and EUS in the
evaluation of Indeterminate Biliary Strictures, as recently well addressed in a comprehensive
review (The Role of Cholangioscopy and EUS in the Evaluation of Indeterminate Biliary
Strictures. Gastroenterol. Insights 2022, 13, 192-205.), because differentiating between
malignant and benign biliary strictures remains a clinical challenge.
-also technical aspects of biliary procedures should be recalled as well summarized in a recent
review describing  the techniques, clinical efficacy, and potential pitfalls of advanced ERCP
techniques, percutaneous biliary drainage, and EUS-RV ERCP (Troubleshooting Difficult Bile
Duct Access: Advanced ERCP Cannulation Techniques, Percutaneous Biliary Drainage, or
EUS-Guided Rendezvous Technique? Gastroenterol. Insights 2021, 12, 405-422.).
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