Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors present a case of a 46-year-old male patient diagnosed with chronic 18 alcohol pancreatitis with acute exacerbation, who developed a large pancreatic pseudocyst with 19 subcapsular location in the right hepatic lobe, successfully treated by laparoscopic surgical drain- 20 age. The topic is of clinical interest due to the rarity of the location of intrahepatic pseudocyst. However, several issues must be addressed before acceptance for publication.

Major Issues
1. Section heading formatting (Line 49): "2. case report" should be capitalized to "2. Case Report" per journal style.

2. Inconsistent pseudocyst dimensions: The CT dimensions are reported as "177x90x180 mm" (line 74) in the Case Report section but as "177x80x190 mm" (line 143) in the Discussion. The authors must clarify which measurements are correct and ensure consistency throughout.

3. Missing reference cross-check: Several references appear mismatched or mislabeled:
1) Reference [5] is cited as "Guesmi et al" in the text (lines 124, 202, 208, 212) but the reference list shows Patidar et al. (2018) as reference 5. The Guesmi et al. paper does not appear in the reference list at all.
2) Reference [6] is cited as "Patidar et al" in line 189 but the reference list shows Madani et al. (2023) as reference 6. The Patidar paper is listed as reference 5.
3) Reference [7] is cited as relating to Zhu et al (line 180) and as the first intrahepatic pseudocyst case from 1974 (line 44), but the reference list shows Tomar et al. (2019) as reference 7. The Zhu et al. paper is listed as reference 9.

The authors must carefully re-check and re-number ALL references against in-text citations. This is a critical issue.

4.  Missing informed consent details: While informed consent is stated (line 245), for a case report with intraoperative images, the authors should confirm that consent was specifically obtained for publication of identifiable clinical images, per ICMJE and journal guidelines.

5. No mention of MRCP findings in the case: The Discussion (lines 148-150) states that MRCP can demonstrate communication with the main pancreatic duct. The authors performed MR cholangiography postoperatively (line 101-102) but do not report whether communication with the pancreatic duct was present or absent. This is a missed opportunity for a complete case description and should be addressed.

Minor Issues
Typo in keywords 
line 28: "pseucyst" should be "pseudocyst."
Line 149: Typo: "cand be" should be "can be."
Line 160: "subhepatic" appears to be used where "subcapsular hepatic" or "intrahepatic" was intended. 
Line 225: "pseudocysts is" should be "pseudocysts are".
Line 243: "CommiOee" appears to be a typographical error for "Committee."

 

Comments on the Quality of English Language

The English requires improvement throughout. There are numerous grammatical issues, including subject-verb disagreement, inconsistent verb tenses, run-on sentences, and awkward phrasing. Examples include "pseudocysts is an extremely rare complication" (should be "are"), "the big volume" (should be "the large volume"), and "intraoperative images edifying for diagnosis" (unclear phrasing). A thorough language editing by a native English speaker or professional editing service is recommended before resubmission.

Author Response

Ansvew for reviewer 1

 

The team of authors would like to thank you for reviewing the manuscript, for your attention to detail, and for all your comments. Your observations have helped us improve this article.

Major issues:

1: done

2: It was a typo, it has been fixed. Thanks for the correction.

3: There was a writing error, the author Guesmi was not entered, and that is why the list of authors was shifted. Now I have rechecked and entered the missing author.

4: We have the patient's consent to publish the case, to use intraoperative images and personal data.

5: We omitted to mention that postoperatively, communication with the pancreatic duct was not evident. Probably due to the fact that this pseudocyst was drained. That is why this exploration is mandatory before surgery. Unfortunately, in our case it was not possible due to technical malfunctions, which were resolved after the surgical moment. That is why this exploration was done later.

 

Minor issues:  all done

Best regards,

Authors

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

Pseudocysts are a common complication of pancreatitis; however, they extend beyond the pancreas in only 20% of cases, and localization specifically in the right lobe of the liver is extremely rare. In this article, the authors describe a rare clinical case of a giant pancreatic pseudocyst located under the capsule of the right lobe of the liver in a 46-year-old patient with chronic alcoholic pancreatitis. In this case, the lesion had reached an impressive size (approximately 18 cm), causing severe pain and compression of the liver structures. The diagnosis was confirmed by computed tomography and biochemical analysis of the cyst contents, which revealed extremely high levels of amylase and lipase. Doctors successfully treated the pseudocyst with laparoscopic surgical drainage, resulting in a full recovery without complications or recurrence. In the discussion, the authors note the lack of uniform treatment protocols for such rare pathologies and emphasize the importance of a multidisciplinary approach and accurate imaging for differential diagnosis with liver tumors or abscesses. I believe that the article, overall, deserves publication in the journal Diseases and will be of interest to both practicing physicians and undergraduate and graduate students.
A very important conclusion and achievement of the authors of this article is the demonstration of the effectiveness of the laparoscopic method for treating even giant cysts. This is important, as traditionally, in such cases, either open surgery or less radical percutaneous drainage is often chosen.
Given that CT scanning is not always available in small clinics, do the authors have any recommendations for indirect diagnosis of this disease that should alert the treating physician? Is it possible to formulate this in the form of a questionnaire and algorithm? The same applies to the choice of criteria between conservative (laparoscopic) treatment and surgical intervention in this location. When choosing a treatment strategy, it is critical to know whether the cyst communicates with the main pancreatic duct. If so, the risk of recurrence after simple drainage is much higher. The authors should discuss why MRCP was not performed preoperatively to plan the intervention.
It is also worth more clearly emphasizing the choice of laparoscopy, as in many practices worldwide, the first step is less invasive percutaneous drainage under ultrasound/CT guidance. Severe pain and cholestasis, in my opinion, are not convincing arguments.

Author Response

Answer for reviewer 2

 

The team of authors would like to thank you for reviewing the manuscript, for your attention to detail, and for all your comments. Your observations have helped us improve this article.

Our experience is limited to be able to issue recommendations, but our results may be useful for centralization of data. We believe that for establishing the diagnosis, both the patient's history and imaging studies are important, which are mandatory: CT scan, MRCP and ERCP. For hospitals where imaging studies are limited or not performed, the diagnosis may be suspected following an abdominal ultrasound correlated with the patient's history. In this case, the diagnosis of certainty will be established after the dosage of amylases and lipases from the pseudocyst fluid. Regarding treatment, small pseudocysts can be treated conservatively. Medium and large pseudocysts, and symptomatic ones, require drainage, either endoscopically or percutaneously, and when the first two cannot be performed, or have not led to the pseudocyst's remission, surgical treatment, laparoscopic or classical, may be indicated.

 

To answer the other questions: we were unable to perform MRCP before surgery, as would have been necessary, due to technical issues. As soon as these were resolved, the patient underwent MRCP, but was postoperative, on the 7th postoperative day.

Regarding the choice of treatment and drainage type, we also agree that it is better for the patient to benefit from a minimally invasive treatment. However, at this time there are no clear specifications when one method or another should be chosen, or when surgical treatment is necessary. In our case, following discussions in the multidisciplinary team, it was concluded that percutaneous drainage for a subcapsular lesion of such dimensions would increase the risk of difficult-to-control hemorrhage. The hemorrhagic risk would have been lower for an intrahepatic pseudocyst, but in our case the location was subcapsular. There is no data in the published literature that differentiates between the drainage of an intrahepatic pseudocyst and a hepatic subcapsular one. It was considered to be a safer method for the patient.

Your indications were very useful in helping us understand several important aspects of this pathology. The problems and challenges regarding the treatment of these pseudocysts are much more profound than we initially realized when we wanted to publish this article.

Best regards,

Authors

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Case report

Uncommon location for a large hepatic subcapsular pancreatic pseudocyst: a rare case report and review

Authors present a case report outlining an adult patient with a rare Intrahepatic pancreatic pseudocyst located to the right hepatic lobe.  Patient was successfully treated by laparoscopic surgical drainage.  Due to the rarity of the condition this report should be of interest to those in the field, however some minor improvements are needed as outlined below. 

Comment/Questions:

Line 14: Intrahepatic pancreatic pseudocyst symptoms should be included

Line 20: "successfully treated"

Comment: please provide more detail as to patient outcome(s)

Line 26: Abstract conclusion(s)

Comment: abstract could better define the main "take-away" lesson(s) learned from this case

Line 27: Keywords should contain 'case report'

Line 34: "Pseudocysts occur most frequently as a complication of chronic pancreatitis and less commonly as a complication of acute pancreatitis"

Comment: please, if possible, provide hard numbers (e.g. occurring in 20% to 40% of patients with chronic pancreatitis)

Line 38: "This collection may resolve spontaneously in approximately 50% of cases, although spontaneous regression is less likely in the case of large pseudocysts exceeding 6 cm. "

Comment:  citation needed

Line 49:

Comment: please list any/all pharmacological interventions given (type, dosage, strength, duration etc)

Line 81: Figure 1

Comment: scales bars would be nice

Comment: Two yellow arrows identifying hepatic pancreatic pseudocyst and pancreatic body pseudocyst?  Should better differentiate between these two in figure and ligure legend

Line 93: Figure 2

Comment: scales bars would be nice

Comment: Arrows are hard to see (esp purple arrow), should make arrows thicker and with better contrast for improved visualization

Comment: would improve figure if each panel was labelled (e.g. A, B, C), then panel labels can be referenced in figure legend (e.g. Purple arrow in A = right hepatic lobe etc)

Line 95: "drainage tube was placed"

Comment: please outline surgical procedure used

Comment: please provide more information on drainage.  What type of drain was used, for how long, how was it monitored?

Line 102:

Comment: any further follow up or outcomes?

Comment: any adverse or unanticipated events?

Author Response

Answer for reviewer 3

 

The team of authors would like to thank you for reviewing the manuscript, for your attention to detail, and for all your comments. Your observations have helped us improve this article.

I took your recommendations into account and made the necessary changes.

Your comments were very helpful in revising this article.

 

Best regards,

Authors

 

 

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Thank you for the opportunity to review the revised manuscript. The clinical novelty of a subcapsular pancreatic pseudocyst in the right hepatic lobe is real and worth publishing. v2 contains meaningful improvements on the Round-1 review, but several central concerns remain unaddressed and the bibliography integrity has, in fact, worsened. Specific points are organized below by status.
Resolved in this revision (acknowledged): postoperative course detail (analgesics, PPI, anticoagulant prophylaxis, intraoperative antibiotic, drain-removal day); postoperative MRCP confirming absence of pancreatic-duct communication; 1-month follow-up imaging; subject–verb agreement in Conclusions; multiple typographic fixes (cand→can, subhepatic→subcapsular hepatic, Ethics CommiOee→Committee, pseucyst→pseudocyst, “2. case report”→“Case Report”, Figure 2 arrow color); CT dimensions corrected to 177×80×190 mm; new diagnostic/treatment-algorithm paragraph.
Major issues still outstanding — must be addressed before acceptance:
1.    Citation–reference numbering is broken. The authors inserted Guesmi as new ref [5] and Mofredj as new ref [14] without renumbering any in-text citations. As a result: (a) reference [14] (Mofredj) is uncited anywhere in the body text — fully orphan; (b) at least four “[7]” citations refer in context to Zhu et al.’s Budd–Chiari case and percutaneous-drainage recommendation, but [7] is Madani et al. on a kidney-abscess mimicker (Zhu is now [10]); (c) “The first case of intrahepatic pancreatic pseudocyst was published in 1974 [7]” — [7] is a 2023 paper; the original 1974 source must be cited; (d) reference [13] (Angsubhakorn et al.) still carries the placeholder “vol. XXX”, and the year is also incorrect — the complete citation is Angsubhakorn N, Laub L, Keenan JC. ERCP-associated infected intrahepatic pancreatic pseudocyst. IDCases 2019;15:e00507. Please rebuild the bibliography in a citation manager (EndNote / Zotero / Mendeley) and regenerate the manuscript so every [#] resolves to the correct entry.
2.    Decimal/thousand-separator notation. Cyst-fluid amylase “65.221 U/L” and lipase “>193.000 U/L” are ambiguous to English-language readers (would read as 65.221 U/L, which is clinically nonsensical). Convert all numeric values to the international convention (comma thousands, period decimal): amylase 65,221 U/L; lipase >193,000 U/L. Verify all other lab values throughout the abstract, Case Report, and Discussion.
3.    2012 Revised Atlanta classification / IAP-APA 2013 framing. The collection formed in ~2 weeks, which is shorter than the classical pseudocyst-maturation window. Please cite Banks PA et al. (Gut 2013) and the 2013 IAP/APA evidence-based guidelines (Pancreatology 13(4 Suppl 2):e1–15) and explain why this is a true pseudocyst rather than acute peripancreatic fluid collection (APFC), acute necrotic collection (ANC), or walled-off necrosis (WON), citing the intraoperative finding of granulation-tissue/fibrosis wall and markedly elevated cyst-fluid amylase/lipase.
4.    Cyst-fluid characterization is incomplete. Standard practice (Brugge WR et al., Gastroenterology 2004; ACG cystic-lesion guideline 2018) recommends cyst-fluid CEA and cytology to formally exclude a mucinous cystic neoplasm in any unifocal cyst. If CEA and cytology were not measured, please state this as a limitation. The manuscript states samples were collected for microbiological analysis but does not report the result — please disclose (or confirm negative).
5.    Anemia (Hb 10.5 g/dL) is unexplained. In a giant subcapsular collection in a chronic-alcohol patient with chronic pancreatitis, intracystic hemorrhage and pseudoaneurysm should be excluded explicitly. Please add a sentence on whether the cyst fluid was sanguinous and whether arterial-phase CT was reviewed.
6.    Add a formal Limitations subsection. Currently absent. Acknowledge: single-patient experience; 1-month follow-up too short to claim definitive non-recurrence (recommend 6- and 12-month imaging); no cyst-fluid CEA/cytology; preoperative ductal anatomy not delineated by MRCP.
7.    CARE-checklist statement. Per MDPI policy for case reports, please state adherence to the CARE Checklist (Gagnier JJ et al., 2013; updated 2017) and submit the completed checklist as supplementary material.
Newly introduced issues in v2:
8.    “…and patient were discharged on postoperative day 11.” → “…and the patient was discharged…”
9.    “No antibiotic therapy (a prophylactic dose of antibiotic was administered intraoperatively)” — internally contradictory. Rewrite, e.g., “Postoperative antibiotic therapy was not administered; only one prophylactic intraoperative dose of [agent, dose] was given.”
10.    The new diagnostic-algorithm paragraph frames CT, MRCP, and ERCP as “mandatory.” ERCP is not mandatory and carries the very risks the manuscript itself cites (Angsubhakorn et al., IDCases — see correction below regarding the actual publication year). Soften.
Other editorial issues:
11.    Reference-list typos preserved verbatim from v1: “sistematic” → “systematic”; “topno” → “Topno”; “trated” → “treated”; “psuedocyst” → “pseudocyst”; “wayward cyst0:a” → “(wayward cyst): a”; “l Clin gastroenterol” → “J Clin Gastroenterol”. Capitalize all author surnames consistently. Also: reference [13] currently lists year 2018 — the correct year for Angsubhakorn et al. (IDCases) is 2019, volume 15, e00507.
12.    Author Contributions, Funding, and Conflicts of Interest still contain unmatched quotation marks and stray punctuation — close all quotes and use CRediT terms with consistent colon/semicolon punctuation.
13.    Citation order within clusters is non-sequential (e.g., [11, 7]; [12, 4, 3, 13, 7]) — MDPI requires sequential ordering.
14.    Inconsistent compound spelling (“extra pancreatic” vs “extrapancreatic”); inconsistent en-dash use (“3–4 weeks” vs “2-3 weeks”); literal phrasing (“From the data we know” → “To our knowledge”); “Take-away lesson learned” → pick one phrase.
15.    Title is grammatically awkward — consider tightening to: “Subcapsular pancreatic pseudocyst of the right hepatic lobe: a rare case and literature review.”
16.    Optional but high-value: a small timeline table (Day 0 / Day 7 / Day 30) of ALP, GGT, amylase, and lipase trends would resolve the “results clearly presented” issue.
The case is salvageable in one focused revision. None of the required corrections require new experiments or new clinical follow-up.

Comments on the Quality of English Language

The English requires moderate copy-editing before acceptance. Notable issues include a newly introduced subject–verb error (“patient were discharged”), inconsistent compound spelling (“extra pancreatic” vs “extrapancreatic”), inconsistent number/range punctuation (“3-4” vs “3–4 weeks”), several literal Romance-language constructions (“From the data we know”), unmatched quotation marks in the Author Contributions, Funding, and Conflicts-of-Interest sections, and a contradictory antibiotic-treatment phrasing in the Case Report. A professional English language edit is recommended at the next round.

Author Response

Answer to reviewer 1-  round 2

 

Thank you for your additions. We have tried to improve the article according to your suggestions.  Your suggestions have clarified certain aspects in supporting the diagnosis. We hope we have managed to answer all the issues.

1. done: the bibliography and the correlation between the citation in the text and the index in the bibliography were reviewed.
2. done: the numerical values ​​have been converted according to the indications
3. done: the article was supplemented with the differential diagnosis between WON, ANC and AFNC- line 213-227
4. The CEA value was normal. The microbiological analysis of intracystic fluid was negative. I have completed this information in the text.
5. I mentioned the anemia that the patient had as a comorbidity. It was not related to the intracystic fluid. This pseudocyst was not hemorrhagic, the fluid was clear, without signs of intracystic hemorrhage. There was no connection between these two diagnoses.
6. done: line 15-18 with the limitation subsection
7. done (Please find the attached file)
8. done: typos have been corrected
9. done: the indicated information has been completed - lines 99-113
10. done: We completely agree with the observation made. The text has been corrected.
11. done: typos have been corrected
12. done: typos have been corrected
13. done: the bibliographic index citation was ordered
14. done: typos have been corrected

15.done:  The title has been changed, as indicated.

 

Given that a large part of the changes were technical details, we considered it sufficient to mention that we made those changes - "done". For the other situations, where the changes were more substantial, we mentioned the lines where the changes are found. Thank you for your attention to this article.

 

Respectfully,

The authors

Author Response File: Author Response.pdf