Reviewer ’s report  
 
Title: Expanding Laparoscopic Pancreaticoduodenectomy to Pancreatic -Head and Periampullary 
Malignancy: Major Findings Based on  Systematic Review and Meta -analysis  
 
Version: 0 Date: 30 Apr 2018  
 
Reviewer: GAYA SPOLVERATO  
 
Reviewer's report:  
 
- The authors compare OS of patients with different malignancies, without describing the 
primary diagnosis and the specific number and percentage of patients. Different outcome has 
been largely described between patients  with PDAC versus ampulloma. I don't think that this 
analysis is powered and structured to compare long term outcomes. Please better specify in 
the inclusion criteria which histologies have been included, only periampullary carcinoma 
and PDAC?  
 
- When compa ring patients undergoing a Whipple on regard to LN dissection, the authors 
should consider as a limitation the large institutional variability and the variability related 
different primaries. Pulling data from different institutions and comparing lap versu s open 
surgery does not take into account the enormous variability in the extension of dissection, 
often not related to the surgical approach but to the institution and the histology of the 
primary tumor  
 
- The methods and the analysis of the data should fo llow the PRISMA guidelines  
 
- The data extraction should be more clear and the outcomes should be stated in a separate 
paragraph  
 
- I would avoid to drive conclusions based on tendency and I would just consider significant P -
value to generate argument for di scussion  
 
- The data do not support the conclusion "It's time for considering changing the standard 
procedure of cancer treatment in the pancreatic head and ampulla from open to laparoscopic 
procedure in selected patients." Taking into account all the limi tations of the study I would 
conclude that MIS surgery is as adequate and safe as open surgery and that in selected 
patients it showed a better outcome, possibly biased by the selection criteria.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any st atistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statisti cs 
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the followi ng questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
No conflict of interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along wi th the authors'  
responses.  I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do  not wish to be included in my named report ca n be included as confidential comments 
to the  editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Reviewer ’s report  
 
Title: Expanding Laparoscopic Pancreaticoduodenectomy to Pancreatic -Head and Periampullary 
Malignancy: Major Findings Based on  Systematic Review and Meta -analysis  
 
Version: 0 Date: 30 Apr 2018  
 
Reviewer: GAYA SPOLVERATO  
 
Reviewer's report:  
 
- The authors compare OS of patients with different malignancies, without describing the 
primary diagnosis and the specific number and percentage of patients. Different outcome has 
been largely described between patients  with PDAC versus ampulloma. I don't think that this 
analysis is powered and structured to compare long term outcomes. Please better specify in 
the inclusion criteria which histologies have been included, only periampullary carcinoma 
and PDAC?  
 
- When compa ring patients undergoing a Whipple on regard to LN dissection, the authors 
should consider as a limitation the large institutional variability and the variability related 
different primaries. Pulling data from different institutions and comparing lap versu s open 
surgery does not take into account the enormous variability in the extension of dissection, 
often not related to the surgical approach but to the institution and the histology of the 
primary tumor  
 
- The methods and the analysis of the data should fo llow the PRISMA guidelines  
 
- The data extraction should be more clear and the outcomes should be stated in a separate 
paragraph  
 
- I would avoid to drive conclusions based on tendency and I would just consider significant P -
value to generate argument for di scussion  
 
- The data do not support the conclusion "It's time for considering changing the standard 
procedure of cancer treatment in the pancreatic head and ampulla from open to laparoscopic 
procedure in selected patients." Taking into account all the limi tations of the study I would 
conclude that MIS surgery is as adequate and safe as open surgery and that in selected 
patients it showed a better outcome, possibly biased by the selection criteria.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any st atistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statisti cs 
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the followi ng questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
No conflict of interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along wi th the authors'  
responses.  I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do  not wish to be included in my named report ca n be included as confidential comments 
to the  editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
Reviewer ’s report  
 
Title: Expanding Laparoscopic Pancreaticoduodenectomy to Pancreatic -Head and Periampullary 
Malignancy: Major Findings Based on  Systematic Review and Meta -analysis  
 
Version: 0 Date: 30 Apr 2018  
 
Reviewer: GAYA SPOLVERATO  
 
Reviewer's report:  
 
- The authors compare OS of patients with different malignancies, without describing the 
primary diagnosis and the specific number and percentage of patients. Different outcome has 
been largely described between patients  with PDAC versus ampulloma. I don't think that this 
analysis is powered and structured to compare long term outcomes. Please better specify in 
the inclusion criteria which histologies have been included, only periampullary carcinoma 
and PDAC?  
 
- When compa ring patients undergoing a Whipple on regard to LN dissection, the authors 
should consider as a limitation the large institutional variability and the variability related 
different primaries. Pulling data from different institutions and comparing lap versu s open 
surgery does not take into account the enormous variability in the extension of dissection, 
often not related to the surgical approach but to the institution and the histology of the 
primary tumor  
 
- The methods and the analysis of the data should fo llow the PRISMA guidelines  
 
- The data extraction should be more clear and the outcomes should be stated in a separate 
paragraph  
 
- I would avoid to drive conclusions based on tendency and I would just consider significant P -
value to generate argument for di scussion  
 
- The data do not support the conclusion "It's time for considering changing the standard 
procedure of cancer treatment in the pancreatic head and ampulla from open to laparoscopic 
procedure in selected patients." Taking into account all the limi tations of the study I would 
conclude that MIS surgery is as adequate and safe as open surgery and that in selected 
patients it showed a better outcome, possibly biased by the selection criteria.  
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
Does the work include the necessary controls?  
If not, please specify which controls are required in your comments to the authors.  
 
Unable to assess  
 
Are the conclusions drawn adequately supported by the data shown?  
If not, please explain in your comments to the authors.  
 
Yes 
 
Are you able to assess any st atistics in the manuscript or would you recommend an  
additional statistical review?  
If an additional statistical review is recommended, please specify what aspects require further  
assessment in your comments to the editors.  
 
I am able to assess the statisti cs 
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not suitable for publication unless extensively edited  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the followi ng questions:  
 
1. Have you in the past five years received reimbursements, fees, funding, or salary from an  
organisation that may in any way gain or lose financially from the publication of this  
manuscript, either now or in the future?  
 
2. Do you hold any stocks or shares in an organisation that may in any way gain or lose  
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents relating to the content o f the  
manuscript?  
 
4. Have you received reimbursements, fees, funding, or salary from an organization that 
holds  or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any  non-financial competing interests in relation to this paper?  
 
If you can answer no to all of the above, write 'I declare that I have no competing interests' 
below.  If your reply is yes to any, please give details below.  
 
No conflict of interests  
 
I agree to the open peer review policy of the journal. I understand that my name will be included  
on my report to the authors and, if the manuscript is accepted for publication, my named report  
including any attachments I upload will be posted on the website along wi th the authors'  
responses.  I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do  not wish to be included in my named report ca n be included as confidential comments 
to the  editors, which will not be published.  
 
I agree to the open peer review policy of the journal  
assistant