Title: Factors influencing failure to undergo interval cholecystectomy after percutaneous
cholecystostomy among patients with acute cholecystitis : A retrospective study
Version: 0 Date: 18 Jul 2021
Reviewer:  Gabriel Sandblom
Reviewer's report:
The manuscript describes an observational study on the decision process in patients having
undergone percutaneous cholecystostomy for acute cholecystitis. This is a patient group with
high co-morbidity and sometimes severe cholecystitis. The decision to insert a percutaneous
drain in the first place, whether this is intended the final therapy or as bridge to surgery, and
whether to carry out a planned cholecystectomy at a later stage requires careful consideration of
the expected natural course of the gallstone disease, the age and co-morbidity of the patient as
well as the patient’s own preference. The paper raises no doubt that the patients in this cohort
were managed in an optimal way and that the right decisions were taken in each individual
case, but the lack of data on the outcome after delayed cholecystectomy versus conservative
management makes the present cohort useless as a model for decision-making in similar
situations.
Major comments
1. Please provide data about treatment failure related to the percutaneous cholecystostomy. I
assume that there were cases of biliary leakage, dislocated drains and need for repeated insertion
of cholecystostomy, which may have affected the subsequent decision to perform surgery.
2. How were the patients followed after the initial treatment? The more active follow-up and
frequent visits, the greater the chance of being offered delayed cholecystectomy.
3. Mortality is a major confounding factor as it is related to age and co-morbidity, which has
a crucial impact on the decision to perform surgery.  The shorter the survival, the shorter the
time period when a delayed cholecystectomy could be carried out, notwithstanding the risk for
perioperative cardiovascular complications. This should be commented in the discussion.
4. How many patients were admitted with a recurrent episode of acute cholecystitis requiring
cholecystostomy? Did this have an impact on the chance of undergoing cholecystectomy as
bridge to surgery?
5. How many patients had liver cirrhosis?
Minor comments
1. What does concomitant AC (page 4, line 80) mean?
2. The manuscript needs language editing.
Title: Factors influencing failure to undergo interval cholecystectomy after percutaneous
cholecystostomy among patients with acute cholecystitis : A retrospective study
Version: 0 Date: 18 Jul 2021
Reviewer:  Gabriel Sandblom
Reviewer's report:
The manuscript describes an observational study on the decision process in patients having
undergone percutaneous cholecystostomy for acute cholecystitis. This is a patient group with
high co-morbidity and sometimes severe cholecystitis. The decision to insert a percutaneous
drain in the first place, whether this is intended the final therapy or as bridge to surgery, and
whether to carry out a planned cholecystectomy at a later stage requires careful consideration of
the expected natural course of the gallstone disease, the age and co-morbidity of the patient as
well as the patient’s own preference. The paper raises no doubt that the patients in this cohort
were managed in an optimal way and that the right decisions were taken in each individual
case, but the lack of data on the outcome after delayed cholecystectomy versus conservative
management makes the present cohort useless as a model for decision-making in similar
situations.
Major comments
1. Please provide data about treatment failure related to the percutaneous cholecystostomy. I
assume that there were cases of biliary leakage, dislocated drains and need for repeated insertion
of cholecystostomy, which may have affected the subsequent decision to perform surgery.
2. How were the patients followed after the initial treatment? The more active follow-up and
frequent visits, the greater the chance of being offered delayed cholecystectomy.
3. Mortality is a major confounding factor as it is related to age and co-morbidity, which has
a crucial impact on the decision to perform surgery.  The shorter the survival, the shorter the
time period when a delayed cholecystectomy could be carried out, notwithstanding the risk for
perioperative cardiovascular complications. This should be commented in the discussion.
4. How many patients were admitted with a recurrent episode of acute cholecystitis requiring
cholecystostomy? Did this have an impact on the chance of undergoing cholecystectomy as
bridge to surgery?
5. How many patients had liver cirrhosis?
Minor comments
1. What does concomitant AC (page 4, line 80) mean?
2. The manuscript needs language editing.
Please review this paper.
user
Title: Factors influencing failure to undergo interval cholecystectomy after percutaneous
cholecystostomy among patients with acute cholecystitis : A retrospective study
Version: 0 Date: 18 Jul 2021
Reviewer:  Gabriel Sandblom
Reviewer's report:
The manuscript describes an observational study on the decision process in patients having
undergone percutaneous cholecystostomy for acute cholecystitis. This is a patient group with
high co-morbidity and sometimes severe cholecystitis. The decision to insert a percutaneous
drain in the first place, whether this is intended the final therapy or as bridge to surgery, and
whether to carry out a planned cholecystectomy at a later stage requires careful consideration of
the expected natural course of the gallstone disease, the age and co-morbidity of the patient as
well as the patient’s own preference. The paper raises no doubt that the patients in this cohort
were managed in an optimal way and that the right decisions were taken in each individual
case, but the lack of data on the outcome after delayed cholecystectomy versus conservative
management makes the present cohort useless as a model for decision-making in similar
situations.
Major comments
1. Please provide data about treatment failure related to the percutaneous cholecystostomy. I
assume that there were cases of biliary leakage, dislocated drains and need for repeated insertion
of cholecystostomy, which may have affected the subsequent decision to perform surgery.
2. How were the patients followed after the initial treatment? The more active follow-up and
frequent visits, the greater the chance of being offered delayed cholecystectomy.
3. Mortality is a major confounding factor as it is related to age and co-morbidity, which has
a crucial impact on the decision to perform surgery.  The shorter the survival, the shorter the
time period when a delayed cholecystectomy could be carried out, notwithstanding the risk for
perioperative cardiovascular complications. This should be commented in the discussion.
4. How many patients were admitted with a recurrent episode of acute cholecystitis requiring
cholecystostomy? Did this have an impact on the chance of undergoing cholecystectomy as
bridge to surgery?
5. How many patients had liver cirrhosis?
Minor comments
1. What does concomitant AC (page 4, line 80) mean?
2. The manuscript needs language editing.
assistant