Review for 10.1186/1471-230X-10-130 (2010)

Reviewer's report
Title:The role of endoscopy in the management of intestinal obstruction: a
20-year retrospective study
Version: 3Date:15 September 2010
Reviewer: David Watson
Reviewer's report:
This paper is getting better, but still requires some modifications
1) All procedures in this study are colonoscopies. Endoscopy implies upper GI
endoscopy in many parts of the world. To avoid ongoing confusion, the word
endoscopy should be replaced with colonoscopy throughout. As far as I can
determine colonoscopy is the only intervention considered in this paper.
2) The background should focus better on the problem – large bowle obstruction.
The references to small bowel obstruction are now unnecessary and should be
deleted. This will shorten the background by 1/3.
3) I still think the stats are unnecessary. They provide a veneer of authority that
the data from this study cannot validly provide. It would be better for this study to
be descriptive only.
4) There is a mismatch in the data in the first and second paragraphs on page 9.
The second paragraph implies 16/67 avoided an operation following successful
endoscopy intervention, yet the paper now acknowledges that on 17 patients
actually had a therapeutic endoscopic intervention. No data is provided to
support the statement – “…operated with a better pre-op schedule”. Without data
these claims should be removed.
5) I disagree with the statement in paragraph 2, page 11 that “the study clearly
demonstrates the advancing role….”. (also see Table 3) The study shows an
increased use of non-therapeutic colonoscopy over the last 5 years. However,
the proportion of therapeutic procedures was very low. An alternative explanation
is that a lot of patients who were managed conservatively before 2005, now
undergo colonoscopy. An increased use of colonoscopy does not prove that this
approach is helpful. It just shows the authors use colonoscopy more often.
Others might argue that they have undertaken a lot of unnecessary
colonoscopies! Or that they have replaced contrast radiology with colonoscopy.
The only way to address this is to review the conservatively managed patients as
well, but the authors acknowledge that they can’t do this. This is a serious
limitation which means that the conclusions drawn are not supported by good
evidence. The discussion and conclusions should reflect this uncertainty. The
data shows colonoscopy use has increased, but not that this has led to improved
management. More careful conclusions whould make the paper more
acceptable.
6) Colonoscopy is done by colonoscopists – these can be gastroenterologists or
surgeons. The discussion on page 13 (2nd para) to page 14 (1st para) should
reflect this. The conclusions should be limited to the role of colonoscopy, noit
who does it, as who does it reflects the way medical services are delivered in
various countries. This discussion, as it is written, is quite strange, except in a
continental European setting where gastroenterologists do all colonoscopies.
Elsewhere in the world it is different, so please limit the message to the
procedure, not who does it.
Level of interest: An article of limited interest
Quality of written English: Acceptable
Statistical review: No, the manuscript does not need to be seen by a
statistician.