PONE-D-22-32458Development of clinical prediction rule for the requirement of endoscopic large papillary balloon dilation (EPLBD) on endoscopic CBD stone clearance.PLOS ONE

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Additional Editor Comments:

Reviewer 1

In the present study, the authors explore a very interesting idea about developing a predictive score for EPLBD needs during ERCP. The paper is well written. This is an exciting topic for all advanced endoscopists. They found that the size of CBD stones, stone shape, and distal CBD arm length <36 mm could be used to calculate the score that in case of being ≥ 5, the PPV was high. This is an interesting result; however, I have some concerns:

1. The author did not mention if they included only adult patients

2. Were the procedures (ERCPs) done under MAC or general IV anesthesia?

3. Which was the number and experience of the endoscopists?

4. One-third of the patients who required EPLBD have scores <5….this seems to be a very high proportion.

5. Maybe my most important question is the following: this new score that the authors are proposing needs information obtained through/during the ERCP procedure. After you get it you calculate the score (ex. To calculate the CBD angle, you need to measure the angle formed by the CBD between 1 cm below the bifurcation and 1 cm above the papilla, the distance between the ampullary orifice to the distal CBD angulation point, the longitudinal diameter and transverse diameter of the stone at the point of maximum diameter, etc)….so which is the advantage in doing all this (with the time that takes to do it) vs to do a swept with the extraction balloon (and if you see is not possible, go directly to EPLBD or refer the patient).

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

Reviewer 2

This paper developed a simplified scoring system for clinical prediction of difficulty in CBD stone removal to assist endoscopists working in resource-limited settings in deciding whether to proceed with an intervention or refer patients to a center capable of performing additional procedures and interventions.The paper is very well written, and contributes a scoring system which has acceptable prediction performance in assisting endoscopists in their choice of stone removal procedure.

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Reviewers' comments:

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Comments to the Author

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Reviewer #1: Partly

Reviewer #2: Yes

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2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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Reviewer #1: Yes

Reviewer #2: Yes

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5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: In the present study, the authors explore a very interesting idea about developing a predictive score for EPLBD needs during ERCP. The paper is well written. This is an exciting topic for all advanced endoscopists. They found that the size of CBD stones, stone shape, and distal CBD arm length <36 mm could be used to calculate the score that in case of being ≥ 5, the PPV was high. This is an interesting result; however, I have some concerns:

1. The author did not mention if they included only adult patients

2. Were the procedures (ERCPs) done under MAC or general IV anesthesia?

3. Which was the number and experience of the endoscopists?

4. One-third of the patients who required EPLBD have scores <5….this seems to be a very high proportion.

5. Maybe my most important question is the following: this new score that the authors are proposing needs information obtained through/during the ERCP procedure. After you get it you calculate the score (ex. To calculate the CBD angle, you need to measure the angle formed by the CBD between 1 cm below the bifurcation and 1 cm above the papilla, the distance between the ampullary orifice to the distal CBD angulation point, the longitudinal diameter and transverse diameter of the stone at the point of maximum diameter, etc)….so which is the advantage in doing all this (with the time that takes to do it) vs to do a swept with the extraction balloon (and if you see is not possible, go directly to EPLBD or refer the patient).

Reviewer #2: This paper developed a simplified scoring system for clinical prediction of difficulty in CBD stone removal to assist endoscopists working in resource-limited settings in deciding whether to proceed with an intervention or refer patients to a center capable of performing additional procedures and interventions.The paper is very well written, and contributes a scoring system which has acceptable prediction performance in assisting endoscopists in their choice of stone removal procedure.

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Reviewer #1: No

Reviewer #2: No

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Development of clinical prediction rule for the requirement of endoscopic papillary large balloon dilation (EPLBD) on endoscopic CBD stone clearance.

PONE-D-22-32458R1

Dear Dr. Tantraworasin,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

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Kind regards,

Roberto Coppola, MD, FACS

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

The authors thoroughly answered the Reviewer's requests. I have decided to accept the paper for publication.

Reviewers' comments: