Reviewer's report 
 Management and Outcome of Bleeding Pseudoaneurysm Associated with Chronic Title: 
Pancreatitis 
 2  23 September 2005 Version: Date: 
 Peter Malfertheiner Reviewer: 
Reviewer's report: 
General 
Well written paper on an uncommon but serious complication of chronic pancreatitis. Although surgery is certainly a mainstay of therapy of this condition the authors need to comment more on criteria for selection for surgery and angiography. As they correctly note, there are no randomized 
trials and likely there will never be, but given the fact that this is such a serious complication it is 
worth that the authors discuss some more about the potential criteria to selct patients for one option 
or the other. They correctly say that choice of therapy should be tailored towards the individual 
patient. Therefore, it is important that they provide more data on their patients co-morbiditis and give 
is some idea on why surgery or angiography was performed first. 
------------------------------------------------------------------------------- Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
Abstract: were all tests performed in all patients. No. Please clarify (Methods). 
Methods section: follow up 38 months, range 10 to 87 months. Please clarify whether this data 
excluded the patient who died. 
Need to add to discussion that it is possible that the results of embolization were suboptimal due to 
lack of expertise of the interventional radiologist. This can be reworded, but it is important that 
authors mention in their discussion that expertise of interventionla radiologist may be an important 
factor determining success or failure of embolization (page 2 of discussion). ------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
Results: patient characteristics:....all patients had (acute) abdominla pain...I would think that all patients had acute abdomen. 
Two patients underwent exploratory laparotomy and wer efound to have bleeding pseudoaneurysms. 
Please discuss ways to improve pre-op diagnosis, and why this patients did not have a pre-op 
diagnosis of bleeding pseudoaneurysm (I assume that this patients had acute abdomen and signs of 
exsanguination). Did the surgeon consider the possibility of pseudoaneurysm pre-op, I am sure they 
did, but providing more data on this patients would help the clinician dealing with this potentially life 
threatening complication. Please describe what prompted to decide on angiographic treatment (embolization) versus surgery. Why was not embolization tried in all patients (expertise of radiographers, decision of surgeon to 
operate, etc). 
Page 10, Discussion: By contrast, (in this small series), angiographic....Although an experience with 9 patients is more than most clinicians ever will see, the reader needs to be made aware that only 3 embolizations were performed (with poor success as the authors correctly state. But based on this 
small numbers it is not possible to reach the strong conlcusion that surgery is better. certainly, 
surgery appears to be better, but this conlcusion cannot be reached from their study. Page 11, Discussion (paragraph 2, line 16): the sentence.....this observation underscores th importance of treating pseudocysts prophylactically to prevent life-threatening bleeding.... should be 
deleted or changed, so that the reader understands what types of pseudocysts are meant, as it is 
clear that there are many pseudocysts that resolve spontaneously. Please clarify what types of 
pseudocysts you mean. 
Table 2. patient 1....only A as initial treatment (no embolization). A is not treatment (just diagnosis, 
please clarify). ------------------------------------------------------------------------------- Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of importance in its field Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
Reviewer's report 
 Management and Outcome of Bleeding Pseudoaneurysm Associated with Chronic Title: 
Pancreatitis 
 2  23 September 2005 Version: Date: 
 Peter Malfertheiner Reviewer: 
Reviewer's report: 
General 
Well written paper on an uncommon but serious complication of chronic pancreatitis. Although surgery is certainly a mainstay of therapy of this condition the authors need to comment more on criteria for selection for surgery and angiography. As they correctly note, there are no randomized 
trials and likely there will never be, but given the fact that this is such a serious complication it is 
worth that the authors discuss some more about the potential criteria to selct patients for one option 
or the other. They correctly say that choice of therapy should be tailored towards the individual 
patient. Therefore, it is important that they provide more data on their patients co-morbiditis and give 
is some idea on why surgery or angiography was performed first. 
------------------------------------------------------------------------------- Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
Abstract: were all tests performed in all patients. No. Please clarify (Methods). 
Methods section: follow up 38 months, range 10 to 87 months. Please clarify whether this data 
excluded the patient who died. 
Need to add to discussion that it is possible that the results of embolization were suboptimal due to 
lack of expertise of the interventional radiologist. This can be reworded, but it is important that 
authors mention in their discussion that expertise of interventionla radiologist may be an important 
factor determining success or failure of embolization (page 2 of discussion). ------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
Results: patient characteristics:....all patients had (acute) abdominla pain...I would think that all patients had acute abdomen. 
Two patients underwent exploratory laparotomy and wer efound to have bleeding pseudoaneurysms. 
Please discuss ways to improve pre-op diagnosis, and why this patients did not have a pre-op 
diagnosis of bleeding pseudoaneurysm (I assume that this patients had acute abdomen and signs of 
exsanguination). Did the surgeon consider the possibility of pseudoaneurysm pre-op, I am sure they 
did, but providing more data on this patients would help the clinician dealing with this potentially life 
threatening complication. Please describe what prompted to decide on angiographic treatment (embolization) versus surgery. Why was not embolization tried in all patients (expertise of radiographers, decision of surgeon to 
operate, etc). 
Page 10, Discussion: By contrast, (in this small series), angiographic....Although an experience with 9 patients is more than most clinicians ever will see, the reader needs to be made aware that only 3 embolizations were performed (with poor success as the authors correctly state. But based on this 
small numbers it is not possible to reach the strong conlcusion that surgery is better. certainly, 
surgery appears to be better, but this conlcusion cannot be reached from their study. Page 11, Discussion (paragraph 2, line 16): the sentence.....this observation underscores th importance of treating pseudocysts prophylactically to prevent life-threatening bleeding.... should be 
deleted or changed, so that the reader understands what types of pseudocysts are meant, as it is 
clear that there are many pseudocysts that resolve spontaneously. Please clarify what types of 
pseudocysts you mean. 
Table 2. patient 1....only A as initial treatment (no embolization). A is not treatment (just diagnosis, 
please clarify). ------------------------------------------------------------------------------- Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of importance in its field Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
Please review this paper.
user
Reviewer's report 
 Management and Outcome of Bleeding Pseudoaneurysm Associated with Chronic Title: 
Pancreatitis 
 2  23 September 2005 Version: Date: 
 Peter Malfertheiner Reviewer: 
Reviewer's report: 
General 
Well written paper on an uncommon but serious complication of chronic pancreatitis. Although surgery is certainly a mainstay of therapy of this condition the authors need to comment more on criteria for selection for surgery and angiography. As they correctly note, there are no randomized 
trials and likely there will never be, but given the fact that this is such a serious complication it is 
worth that the authors discuss some more about the potential criteria to selct patients for one option 
or the other. They correctly say that choice of therapy should be tailored towards the individual 
patient. Therefore, it is important that they provide more data on their patients co-morbiditis and give 
is some idea on why surgery or angiography was performed first. 
------------------------------------------------------------------------------- Major Compulsory Revisions (that the author must respond to before a decision on publication can 
be reached) 
Abstract: were all tests performed in all patients. No. Please clarify (Methods). 
Methods section: follow up 38 months, range 10 to 87 months. Please clarify whether this data 
excluded the patient who died. 
Need to add to discussion that it is possible that the results of embolization were suboptimal due to 
lack of expertise of the interventional radiologist. This can be reworded, but it is important that 
authors mention in their discussion that expertise of interventionla radiologist may be an important 
factor determining success or failure of embolization (page 2 of discussion). ------------------------------------------------------------------------------- 
Minor Essential Revisions (such as missing labels on figures, or the wrong use of a term, which the 
author can be trusted to correct) 
Results: patient characteristics:....all patients had (acute) abdominla pain...I would think that all patients had acute abdomen. 
Two patients underwent exploratory laparotomy and wer efound to have bleeding pseudoaneurysms. 
Please discuss ways to improve pre-op diagnosis, and why this patients did not have a pre-op 
diagnosis of bleeding pseudoaneurysm (I assume that this patients had acute abdomen and signs of 
exsanguination). Did the surgeon consider the possibility of pseudoaneurysm pre-op, I am sure they 
did, but providing more data on this patients would help the clinician dealing with this potentially life 
threatening complication. Please describe what prompted to decide on angiographic treatment (embolization) versus surgery. Why was not embolization tried in all patients (expertise of radiographers, decision of surgeon to 
operate, etc). 
Page 10, Discussion: By contrast, (in this small series), angiographic....Although an experience with 9 patients is more than most clinicians ever will see, the reader needs to be made aware that only 3 embolizations were performed (with poor success as the authors correctly state. But based on this 
small numbers it is not possible to reach the strong conlcusion that surgery is better. certainly, 
surgery appears to be better, but this conlcusion cannot be reached from their study. Page 11, Discussion (paragraph 2, line 16): the sentence.....this observation underscores th importance of treating pseudocysts prophylactically to prevent life-threatening bleeding.... should be 
deleted or changed, so that the reader understands what types of pseudocysts are meant, as it is 
clear that there are many pseudocysts that resolve spontaneously. Please clarify what types of 
pseudocysts you mean. 
Table 2. patient 1....only A as initial treatment (no embolization). A is not treatment (just diagnosis, 
please clarify). ------------------------------------------------------------------------------- Discretionary Revisions (which the author can choose to ignore) 
 Unable to decide on acceptance or rejection until the authors have responded to the What next?: 
major compulsory revisions 
 An article of importance in its field Level of interest: 
 Acceptable Quality of written English: 
 No Statistical review: 
Declaration of competing interests: 
I declare that I have no competing interests. 
assistant