Computed Tomography Imaging Evaluation of Pancreatic Density and Muscular Mass as Predictive Risk Factors for Pancreatic Fistula Formation after Duodenocephalopancreasectomy

Round 1

Reviewer 1 Report

Dear Authors, I read with interest your paper. Pancreatic fistula is a frequent and potentially severe complication of pancreatic surgery. 

Paper is well written and in accordance with lilterature. A limitation is the samll number of patients included, but this can be accepted in a retrospective study, which can be intended as a proof of concept

A statistical evaluation of numerosity would be desirable in future studies.

Author Response

Dear Reviewer 1,

unfortunately we are aware of the limit regarding the small number of patients but, as specified in the conclusions, we had to exclude from the study patients who underwent other types of pancreasectomy (such as total pancreasectomy or left pancreaticosplenectomy).

However, as you said, we carried out a retrospective study, and this is why we rely on the fact that this can justify the small number of patients.

Otherwise, we propose to continue prospectively the enrollment of patients so as to obtain a larger sample size.

Thank you for your help.

Reviewer 2 Report

The authors aimed to evaluate the effectiveness of CT in measuring the density of the pancreatic parenchyma in patients who are subjected to DCP. In particular they tried to identify, prior to surgery, areas in the glandular tissue replaced by adipose tissue. These are more likely to develop post-operative complications, such as pancreatic fistulation.

In addition, using the same cohort of patients and same imaging technique, they investigated the correlation between sarcopenia and development of pancreatic fistulas.

The issue is important, moreover they conduct comprehensive results and discussion. Therefore, I have no further comments against the manuscript.

Author Response

Dear Reviewer 2,

thank you for your help.

Reviewer 3 Report

There are some comments.

It would be better to add whether tumor types affect the preoperative pancreatic density and muscular mass on CT images and the relationship between tumor types and pancreatic density and muscular mass.

It would be better to analyze any other factors affecting fistula formation.

Please check Table 4.

Please share the paragraph.

Please check English spelling.

  Muscolar -> muscular 

  Iit does -> It does

Please check English spelling and grammar.

Author Response

Dear Reviewer 3,

here are the answers to your suggestions:

• We added something about the existing relationship between tumor types and pancreatic density evaluated on the pre-operative CT images. You will find it in the discussion.
• As you suggested, in the discussion we examined futher factors affecting the fistula formation.
• We rearranged Table 4 (layout problems)
• The English spelling has been checked

Thank you for your help.