Biliary Leak after Pediatric Liver Transplantation Treated by Percutaneous Transhepatic Biliary Drainage—A Case Series

Round 1

Reviewer 1 Report

Bile leakage after liver transplantation is a complex complication to manage. Percutaneous Transhepatic Cholangiodrainage (PTCD) is a common practice for addressing this issue. However, the unique aspect of this article is the application of this procedure in children. Although the number of cases is small, the data is invaluable given the rarity of children undergoing liver transplantation.

Author Response

Thank you very much.

Reviewer 2 Report

Dear Authors,

I would like to thank you for the opportunity to review this interesting paper focused on a very remarkable and challenging topic that is a lively argument in daily clinical practice. 

First of all, although the title is correct, due to the small population enrolled, I suggest adding: “a case series” to it.

Secondly, Keywords from the MeSH Browser are missing. This is important, in my opinion, in order to increase the traceability of this paper (and consequently the possibility of the Journal being cited by Readers and Stakeholders).

Although the introduction fits the context of the study, it should be rewritten and the topic of “bile leakage” be better presented. Lines 58-91: please drastically reduce this part since the study is focused on biliary complications rather than vascular complications. Moreover, the Authors should better present the pediatric complications described in lines 92-97, briefly analyzing their incidence and main therapies. 

Lines 122-126: The authors should simply state that the aim of their study is to evaluate the long-term prognosis of liver transplants in the pediatric population, specifying that the factors associated with an increased risk of bile leaks have been analyzed. Moreover, since biliary strictures have been also reported in the results of the study, the title should probably be more generalized (for example: “Biliary complications” and not “Biliary leak”).

“Procedure techniques”: it is important to explicate the inclusion and exclusion criteria for the study, possibly by providing a Flow Chart of the study population. For example, how bile leakage was diagnosed? their observation is based on clinical or radiological evidence or both? By reading the discussion, it seems that the diagnosis of bile leakage was achieved through PTC, however, it is not clear if these complications were observed simply during periodic PTC follow-ups or due to clinical and/or radiological suspicion.

In the Results section, the Authors stated that 76 PTBDs were performed but the population included 10 patients and “a total of 12 PTBDs were placed” (line 192). Please clarify this concept, possibly through a flow chart of the study.

Lines 194-196, the Authors should analyze and discuss these considerations more deeply, underlining the importance of performing a correct pre-operative evaluation of the biliary anatomy. In particular, MRCP has proved to be an excellent noninvasive technique for the evaluation of the anatomy and pathology of the pancreato-biliary system, relying on the high signal intensity of fluid-containing structures in T2-weighted images. An understanding of the anatomy of the biliary tree and its main variations is essential for many reasons, such as providing precise pre-operative information for surgeons in order to reduce the rate of procedure-related complications. [J Anat. 2023 Apr;242(4):683-694. doi: 10.1111/joa.13808][ AJR Am J Roentgenol. 2001 Aug;177(2):389-94. doi: 10.2214/ajr.177.2.1770389] Please discuss this topic in the discussion and cite the aforementioned references.

Line 215 “Demographic data are shown in Table 1” should be moved in the “Study cohort” paragraph. Moreover, please add “and clinical” to Table 1 description.

The paragraph “Laboratory data” should be reduced and shortened in order to make it more engaging. Consider reporting only statistically significant data and leaving the other ones in the Tables. In Table 2, the last column (measure unit) should be incorporated in the parameter column.

The conclusion should be improved, underlining the results obtained (for example, the significance of the laboratory values) and trying to hypothesize possible correlation with clinical and practical conclusions. Furthermore, the Authors should write a few sentences on what could be the factors that, according to their experience, more probably lead to bile leakage.

In addition, despite on adults, some previous reports have analyzed the impact of the type of intervention on the resolution and the time of resolution of the bile leakage based on the type of intervention, demonstrating that increased clinical success was associated with patients who underwent hepatic resection or cholecystectomy while low success rate was associated to liver-transplantation [HPB (Oxford). 2021 Oct;23(10):1518-1524. doi: 10.1016/j.hpb.2021.02.014]. Have the Authors found similar results? If not, please briefly cite this evidence in the discussion and add this limitation at the end of the paragraph.

Please briefly discuss limitations of the study before conclusion.

Finally, I think references should be reformatted as suggested by the Author’s guidelines (Author 1, A.B.; Author 2, C.D. Title of the article. Abbreviated Journal Name Year, Volume, page range).

Author Response

Please see the attachment.

Author Response File: Author Response.pdf

Reviewer 3 Report

It is an article about percutaneous transhepatic biliary drainage (PTBD) to treat Biliary leak after pediatric liver transplantation (pLT). In this article, the authors introduced all kinds of complications after pLT in detail. The authors collected 10 PTBD cases and proved PTBD is an extraordinarily successful strategy for bile leak therapy by a lot of lab parameters and X-ray pictures. It is an interesting article to help readers understand PTBD is an effective choice besides ERCP to treat Biliary leak after pLT.     

Author Response

Thank you very much.

Round 2

Reviewer 2 Report

The Authors have correctly addressed all raised points.