Evaluation of Open Surgical and Endovascular Treatment Options for Visceral Artery Erosions after Pancreatitis and Pancreatic Surgery

Round 1

Reviewer 1 Report

In this manuscript, the authors discussed their experience for the treatment of hemorrhagic complications of the visceral arteries by comparing two different treatments methods. By reviewing the treatment of 65 patients, they realized that the 30-days in-hospital mortality rates for endovascular treatment is lower than open surgery. While if the patients have other complications of the initial surgery, they need to do open surgery. This work is important since it can guide people the optimal method for treating hemorrhagic complications of the visceral arteries in the future.

1. They need to discuss more detail in the introduction such as the other works have contributed to this field and what kind of gap they are trying to fill. For example, there are indeed some works have compared the two treatment methods. E.g., Comparison of open surgery and endovascular procedures as a therapeutic choice for visceral artery aneurysms.
2. They should compare their results with others to guide the treating methods more accurately in the future occasions. For example, what are the same results they got and what are the different results they obtained any try to explain why from a variety of perspectives.
3. Explain more in how they obtain the data from lines 174-179 from Figure 4.

Author Response

Reviewer: 1

Comments and Suggestions for Authors

In this manuscript, the authors discussed their experience for the treatment of hemorrhagic complications of the visceral arteries by comparing two different treatments methods. By reviewing the treatment of 65 patients, they realized that the 30-days in-hospital mortality rates for endovascular treatment is lower than open surgery. While if the patients have other complications of the initial surgery, they need to do open surgery. This work is important since it can guide people the optimal method for treating hemorrhagic complications of the visceral arteries in the future.

Response: We thank the reviewer for pointing this out and appreciate the positive feedback.

1. They need to discuss more detail in the Introduction such as the other works have contributed to this field and what kind of gap they are trying to fill. For example, there are indeed some works have compared the two treatment methods. E.g., Comparison of open surgery and endovascular procedures as a therapeutic choice for visceral artery aneurysms.

Response: As suggested by the reviewer, we added more details about the gab in the literature and the aim of the study to compare the different treatment methods in the Introduction.

2. They should compare their results with others to guide the treating methods more accurately in the future occasions. For example, what are the same results they got and what are the different results they obtained any try to explain why from a variety of perspectives.

Response: As suggested, we added a comparison between the results of our study and other studies according to the best treatment options lines 317-321.

3. Explain more in how they obtain the data from lines 174-179 from Figure 4.

Response: As suggested, we added an explanation of the data in figure 4 in lines 211 -212.

 

Reviewer 2 Report

• General comment: Throughout the text of the manuscript, make sure to use a uniform number of decimal spots when listing values. Also, when reporting frequencies use a full-stop instead of a comma - 49.75% instead of 49,75%.
• Abstract: In the section Results, try to rephrase several sentences to improve readability by not always reporting both the number of the patients and the frequency. Most often, percentages are more informative.
• Lines 44-45: Rephrase this sentence by emphasizing which group had a statistically significantly higher in-hospital 30-day mortality - OS.
• Line 49: Add a sentence regarding suggestions for further and future research.
• Lines 54-74: Six out of ten references in the Introduction are older than 15 years. This section is well written, however the authors need to provide newer references, particularly when reporting the rates of certain events.
• Lines 59-61: Add a reference here.
• Line 70: When stating that descriptions of perioperative complications following pancreatic head resection can be found numerously in the literature - the authors need to cite at least one reference. This is particularly important here where authors are trying to explain the evidence gap which this study is trying to address.
• Lines 76-80: This section needs to be more detailed. Describe the database which was used. Explain the population from which the sample was chosen - which hospital is "our"? How many procedures are done per year or in the investigated period? Etc.
• Lines 96-97: Consider specifying the surgical approach was at the discretion of the surgeon. Did the same surgical team perform all procedures in this study? If not, was this taken into account in the analyses?
• Lines 105-106: Did you collect data on operative time, blood loss, transfusions etc.?
• Lines 107-108: Why does the paper not report on some of the endpoints which are listed here? Provide data for these and results for differences between the two approaches you have studied.
• Lines 110-113: Authors need to describe tests used to assess differences between the two approaches they were comparing.
• Throughout the manuscript, make sure to be precise when reporting percentages of the study sample and when of e.g. all procedures performed in the hospital - to improve comprehension.
• Lines 266-269: This is a very important paragraph in the Discussion. Authors need to expand it and provide possible explanations for the fact that the difference they noted in 30-day mortality was lost at 1-year. Also, explain "oncological situation"?

Author Response

Reviewer: 2

General comment: Throughout the text of the manuscript, make sure to use a uniform number of decimal spots when listing values. Also, when reporting frequencies use a full-stop instead of a comma - 49.75% instead of 49,75%.

Response: As suggested, we corrected the numbers.

Abstract: In the section Results, try to rephrase several sentences to improve readability by not always reporting both the number of the patients and the frequency. Most often, percentages are more informative.

Response: As suggested by the reviewer, we used only percentages in the abstract whenever it was possible.  

Lines 44-45: Rephrase this sentence by emphasizing which group had a statistically significantly higher in-hospital 30-day mortality - OS.

Response: As suggested by the reviewer, we rephrased the sentence. The in-hopital mortality was higher in the OS group.

Line 49: Add a sentence regarding suggestions for further and future research.

Response: As suggested by the reviewer, we added a suggestion for further studies to identify the optimal approach. 

Lines 54-74: Six out of ten references in the Introduction are older than 15 years. This section is well written, however the authors need to provide newer references, particularly when reporting the rates of certain events.

Response: As suggested by the reviewer, we added newer references to the Introduction. Due to the rarity of the disease and the lack of literature about hemorrhage of the visceral arteries, we had to provide older references. 

Lines 59-61: Add a reference here.

Response: As suggested by the reviewer, we added references.

Line 70: When stating that descriptions of perioperative complications following pancreatic head resection can be found numerously in the literature - the authors need to cite at least one reference. This is particularly important here where authors are trying to explain the evidence gap which this study is trying to address.

Response: As suggested by the reviewer, we added new references to show the gap in the literature about this complication.

Lines 76-80: This section needs to be more detailed. Describe the database which was used. Explain the population from which the sample was chosen - which hospital is "our"? How many procedures are done per year or in the investigated period? Etc.

Response: As suggested by the reviewer, we added more details about the study and our hospital in lines 83 - 88.

Lines 96-97: Consider specifying the surgical approach was at the discretion of the surgeon. Did the same surgical team perform all procedures in this study? If not, was this taken into account in the analyses?

Response: The treatment options were discussed in a multidisciplinary session, including surgeons and radiologists in lines 112 - 113. The same surgical radiological team performed all procedures in this study.

Lines 105-106: Did you collect data on operative time, blood loss, transfusions etc.?

Response: As suggested, we added the number of packed red blood cells units transferred to the patients. According to the operative time, the time of endovascular procedure was not documented, and a comparison between EVT and OS groups is therefore not possible. Additionally, the operative procedures ranged from simple ligation of the artery to vascular reconstruction of the visceral arteries with a reconstruction of the upper gastrointestinal tract in some cases. Therefore, the operating time was not relevant in this study.

Lines 107-108: Why does the paper not report on some of the endpoints which are listed here? Provide data for these and results for differences between the two approaches you have studied.

Response: As suggested, we added the results according to the endpoints in the manuscript in lines 205 -207.

Lines 110-113: Authors need to describe tests used to assess differences between the two approaches they were comparing.

Response: As suggested, we added a detailed description of the statistical tests used in the study.

Throughout the manuscript, make sure to be precise when reporting percentages of the study sample and when of e.g. all procedures performed in the hospital - to improve comprehension.

Response: As suggested, we added the number of all pancreatectomy procedures performed in the hospital to the manuscript and checked all percentages.

Lines 266-269: This is a very important paragraph in the Discussion. Authors need to expand it and provide possible explanations for the fact that the difference they noted in 30-day mortality was lost at 1-year. Also, explain "oncological situation"?

Response: As suggested, we added an explanation of this point in lines 374 - 376.

 

 

Round 2

Reviewer 2 Report

I would like to thank the Authors for making changes to their manuscript and acknowledging my comments. The manuscript has been improved significantly.

Minor comment: 

Line 293: I see you have not explained or rephrased the phrase "oncological situation" - it is not clear what the authors mean by this, therefore either revise or define the term.

Author Response

Review Report Form

Reviewer: 2

Comments and Suggestions for Authors

I would like to thank the Authors for making changes to their manuscript and acknowledging my comments. The manuscript has been improved significantly.

Response: We thank the reviewer and appreciate the positive feedback.

Minor comment:

Line 293: I see you have not explained or rephrased the phrase "oncological situation" - it is not clear what the authors mean by this, therefore either revise or define the term.

Response: As suggested by the reviewer we changed the wording as follows:  “However, at one-year follow-up, no statistical significance between the two groups was observed anymore, indicating that mid-term and long-term survivals are related to the staging and prognosis of the primary tumor.”