Percutaneous Biliary Rendez-Vous to Treat Complete Hepatic-Jejunal Anastomosis Dehiscence after Duodeno-Cephalo-Pancreasectomy
, Giuseppina Pacella 1,2, Eliodoro Faiella 3, Andrea Buoso 1,2, Carlo Altomare 1,2 and Rosario Francesco Grasso 1,2
Round 1
Reviewer 1 Report
In this paper the authors presented a case of a biliary percutaneous rendez-vous procedure performed to treat an HJA dehiscence which successfully ensured to avoid a new surgical approach.
The aim of the study was interesting but its implementation has some major shortcomings:
a) The literature presented is not recent. Only one references was published in the last ten year!
b) Following the point “a”, the discussion needs to be improve with up-to-date studies.
c) Reference n.16 is missed
Author Response
Response: We thank the reviewer for the comments, which definitely lead to a better quality manuscript. The bibliography was modified and several recent references were added and are now included into the discussion. Following the suggestion, the manuscript has now been modified.
Reviewer 2 Report
The article is a case report presenting a biliary percutaneous rendez-vous technique to treat complete hepatic-jejunal anastomosis dehiscence after duodeno-cephalo-pancreatectomy. The case is interesting and well documented and the presentation is very rich in good quality imagistic.
As minor issues:
English spelling should be checked for minor spelling errors.
The Discussions should be expanded, with references to other cases with postsurgical hepatic-jejunal anastomosis dehiscence treated by percutaneous stenting. As well, a paragraph regarding the material of the stents that should be used (plastic vs metal) could be interesting for the readers.
Author Response
Response: We thank the reviewer for the comments, which definitely lead to a better quality manuscript. We expanded the discussion; moreover, we did not positioned a stent to treat this patient due to the absence of residual stenosis at the 5 months percutaneous cholangiography and 12 months after the procedure the patient did not had dilatation of the biliary tree, with bilirubin levels in the normal range. Following the suggestion, the manuscript has now been modified.
Reviewer 3 Report
· Line 39 “Nonetheless, endoscopic treatment is impossible to perform following a Billroth II gastrectomy or Roux-en-Y billion-enteric reconstruction, due to the postoperative anatomy”. Not true, more than a study showed that is possible (i.e. Double balloon enteroscopy assisted ERCP)
· It would be nice to have more details of possible complications of the procedure, to balance and guide the pros/cons of conservative treatment versus surgical treatment. What are the indication and contraindications of this procedure? When do the authors suggest this procedure vs surgical repair?
· Was the peripheral intrahepatic bile duct dilatated? The radiologist had difficulty finding the biliary tree?
Author Response
Response: We thank the reviewer for the comments, which definitely lead to a better quality manuscript. The discussion has been improved with more references, including papers about the Double balloon enteroscopy assisted ERCP.
Potential risks of percutaneous biliary drainage include biloma, transitory haemobilia, or cutaneous hematomas; in addition, the main drawback of the rendezvous technique is the fact that if the biliary leak is secondary to a large defect, endoscopic or percutaneous techniques alone may fail in reestablishing the anatomic continuity due to the technical inability to traverse the large resection defect [21].
In these cases, the main options are the combined radiologic-endoscopic rendezvous technique [25] or a new a surgery. More recently, percutaneous cholangioscopy-assisted guidewire placement has been reported in post- liver transplant patients with severe biliary anastomotic strictures and failed endoscopic and conventional percutaneous ap-proaches [26,27]. We suggest to always try this procedure before a new surgical approach, as this could prevent major surgery in a minimally invasive way, without the need for the endoscopic approach.
In this case the puncture was easy to perform due to the mild dilatation of the biliary tree. Following the suggestion, the manuscript has now been modified.
Round 2
Reviewer 1 Report
the review is ok
Reviewer 3 Report
Ok for publication with the new changes.
