Title: Clinical study on the necessity and feasibility of routine MRCP in patients with
cholecystolithiasis before LC
Version: 2 Date: 12 Nov 2023
Reviewer's report:
Thank you for the opportunity of reviewing this paper, very interesting study on a much debated
topic.
However, some issues need to be clarified.
In the introduction section:
- the sentence  at lines 56-57 should be referenced (studies confirming the MRCP as main method
for diagnosis of CBDS);
- among the factors of suspicion of CBD stones you should add the history of pancreatitis,
besides the dilated common bile duct on abdominal ultrasonography examination and a regular
appearance of the main extra-hepatic bile duct with abnormal levels of liver function tests;
- the interrogative sentences at lines  68-69 should be removed to my opinion, reporting  only
the main objective of the study;
In the method section I don't understand why patients with elevated direct bilirubin in non-
MRCP group did not perform MRCP pre-operatively? This is an important limitation of this
retrospective study;
The true problem to be solved is the management of patients with low-risk for CBD stones
(5-10%). We would do useless MRCPs in the remaining 90-95% of the population and with
higher costs.
Moreover, another factor should be considered, the spontaneous passage of small CBD stones.
In a recent study solitary and CBDSs sized < 6 mm may pass into duodenum before ERCP
(Unnecessary endoscopic retrograde cholangiopancreatography associated with the spontaneous
passage of common bile duct stones into the duodenum: a multicenter retrospective study. Surg
Endosc. 2023). This issue should be clarified in the discussion.
Regarding the sentence at line 270-273,  in 2019 Pesce A et al. analyzed the effectiveness
of NIRF-C in the detection of cystic duct-common hepatic duct anatomy intra-operatively in
comparison with pre-operative MRCP with high diagnostic accuracy values (Effectiveness of
near-infrared fluorescent cholangiography in the identification of cystic duct-common hepatic
duct anatomy in comparison to magnetic resonance cholangio-pancreatography: a preliminary
study. Surg Endosc. 2020). The multimodal imaging combining pre-operative MRCP to exclude
the presence of bile duct stones in high-risk patients and intra-operative navigation with
fluorescence
for better definition of biliary anatomy would be beneficial to replace IOC, which is time
consuming and burdened by morbidity (the authors should also consider this paper  titled Critical
View of Safety During Laparoscopic Cholecystectomy: From the Surgeon's Eye to Fluorescent
Vision. Surg Innov. 2018).
However, the cost-analysii is limited in China, so it needs multicenter studies from different
countries confirming the feasibility of pre-operative MRCP before all cholecystectomies in
terms of healthcare costs.
The manuscript needs careful editing by someone with expertise in technical English editing.
Title: Clinical study on the necessity and feasibility of routine MRCP in patients with
cholecystolithiasis before LC
Version: 2 Date: 12 Nov 2023
Reviewer's report:
Thank you for the opportunity of reviewing this paper, very interesting study on a much debated
topic.
However, some issues need to be clarified.
In the introduction section:
- the sentence  at lines 56-57 should be referenced (studies confirming the MRCP as main method
for diagnosis of CBDS);
- among the factors of suspicion of CBD stones you should add the history of pancreatitis,
besides the dilated common bile duct on abdominal ultrasonography examination and a regular
appearance of the main extra-hepatic bile duct with abnormal levels of liver function tests;
- the interrogative sentences at lines  68-69 should be removed to my opinion, reporting  only
the main objective of the study;
In the method section I don't understand why patients with elevated direct bilirubin in non-
MRCP group did not perform MRCP pre-operatively? This is an important limitation of this
retrospective study;
The true problem to be solved is the management of patients with low-risk for CBD stones
(5-10%). We would do useless MRCPs in the remaining 90-95% of the population and with
higher costs.
Moreover, another factor should be considered, the spontaneous passage of small CBD stones.
In a recent study solitary and CBDSs sized < 6 mm may pass into duodenum before ERCP
(Unnecessary endoscopic retrograde cholangiopancreatography associated with the spontaneous
passage of common bile duct stones into the duodenum: a multicenter retrospective study. Surg
Endosc. 2023). This issue should be clarified in the discussion.
Regarding the sentence at line 270-273,  in 2019 Pesce A et al. analyzed the effectiveness
of NIRF-C in the detection of cystic duct-common hepatic duct anatomy intra-operatively in
comparison with pre-operative MRCP with high diagnostic accuracy values (Effectiveness of
near-infrared fluorescent cholangiography in the identification of cystic duct-common hepatic
duct anatomy in comparison to magnetic resonance cholangio-pancreatography: a preliminary
study. Surg Endosc. 2020). The multimodal imaging combining pre-operative MRCP to exclude
the presence of bile duct stones in high-risk patients and intra-operative navigation with
fluorescence
for better definition of biliary anatomy would be beneficial to replace IOC, which is time
consuming and burdened by morbidity (the authors should also consider this paper  titled Critical
View of Safety During Laparoscopic Cholecystectomy: From the Surgeon's Eye to Fluorescent
Vision. Surg Innov. 2018).
However, the cost-analysii is limited in China, so it needs multicenter studies from different
countries confirming the feasibility of pre-operative MRCP before all cholecystectomies in
terms of healthcare costs.
The manuscript needs careful editing by someone with expertise in technical English editing.
Please review this paper.
user
Title: Clinical study on the necessity and feasibility of routine MRCP in patients with
cholecystolithiasis before LC
Version: 2 Date: 12 Nov 2023
Reviewer's report:
Thank you for the opportunity of reviewing this paper, very interesting study on a much debated
topic.
However, some issues need to be clarified.
In the introduction section:
- the sentence  at lines 56-57 should be referenced (studies confirming the MRCP as main method
for diagnosis of CBDS);
- among the factors of suspicion of CBD stones you should add the history of pancreatitis,
besides the dilated common bile duct on abdominal ultrasonography examination and a regular
appearance of the main extra-hepatic bile duct with abnormal levels of liver function tests;
- the interrogative sentences at lines  68-69 should be removed to my opinion, reporting  only
the main objective of the study;
In the method section I don't understand why patients with elevated direct bilirubin in non-
MRCP group did not perform MRCP pre-operatively? This is an important limitation of this
retrospective study;
The true problem to be solved is the management of patients with low-risk for CBD stones
(5-10%). We would do useless MRCPs in the remaining 90-95% of the population and with
higher costs.
Moreover, another factor should be considered, the spontaneous passage of small CBD stones.
In a recent study solitary and CBDSs sized < 6 mm may pass into duodenum before ERCP
(Unnecessary endoscopic retrograde cholangiopancreatography associated with the spontaneous
passage of common bile duct stones into the duodenum: a multicenter retrospective study. Surg
Endosc. 2023). This issue should be clarified in the discussion.
Regarding the sentence at line 270-273,  in 2019 Pesce A et al. analyzed the effectiveness
of NIRF-C in the detection of cystic duct-common hepatic duct anatomy intra-operatively in
comparison with pre-operative MRCP with high diagnostic accuracy values (Effectiveness of
near-infrared fluorescent cholangiography in the identification of cystic duct-common hepatic
duct anatomy in comparison to magnetic resonance cholangio-pancreatography: a preliminary
study. Surg Endosc. 2020). The multimodal imaging combining pre-operative MRCP to exclude
the presence of bile duct stones in high-risk patients and intra-operative navigation with
fluorescence
for better definition of biliary anatomy would be beneficial to replace IOC, which is time
consuming and burdened by morbidity (the authors should also consider this paper  titled Critical
View of Safety During Laparoscopic Cholecystectomy: From the Surgeon's Eye to Fluorescent
Vision. Surg Innov. 2018).
However, the cost-analysii is limited in China, so it needs multicenter studies from different
countries confirming the feasibility of pre-operative MRCP before all cholecystectomies in
terms of healthcare costs.
The manuscript needs careful editing by someone with expertise in technical English editing.
assistant