Review for 10.1186/s12876-024-03500-8 (2024)

Title: Advantages Comparison of Peritoneal Drainage versus No Drainage after Laparoscopic
Appendectomy for Complicated Appendicitis: A Meta-analysis
Version: 3 Date: 14 Sep 2024
Reviewer:  Claudia Rudroff
Reviewer's report:
Review Report on the manuscript:
Advantages Comparison of Peritoneal Drainage versus No Drainage after Laparoscopic
Appendectomy for Appendicitis: A Meta-analysis
General Overview:
Comparing the peritoneal drainage (PD) and no peritoneal drainage (NPD) following
laparoscopic appendectomy (LA) for appendicitis this meta-analysis explores a highly relevant
clinical question, especially in light of evolving surgical practices and the debate over the
necessity of drainage in the management of appendicitis.
Strengths:
1.   Timeliness and Relevance: The manuscript tackles a clinically significant and timely
question, and the findings could contribute to the ongoing debate about PD in appendicitis
management and GI surgery in general.
2.   Methodological Rigor: The authors have adhered to well-established guidelines for meta-
analyses, including PRISMA, MOOSE, and AMSTRA. The study's inclusion and exclusion
criteria, data synthesis, and quality assessments were conducted appropriately.
3.   Comprehensive Search Strategy: The manuscript details a broad search of databases
(PubMed, Cochrane, etc.) over a significant timeframe (2000–2022), ensuring a comprehensive
meta-analysis of available literature.
4.   Clear Conclusions: The results are mostly clear in that PD offers no significant benefits
and might even increase certain postoperative complications, aligning with the evolving
understanding in surgical fields.
Limitations:
1.   Patient-Centric Limitations: The focus of the limitations should be centered on patient needs.
Statistical outcomes and heterogeneity like operative time and duration of hospital stay within
the studies analyzed are important, greater emphasis on the clinical impact, such as patient
comfort, safety, and postoperative recovery experience, would enhance the relevance of the
findings to patient-centered care.
2.   Language and Spelling: The manuscript suffers from spelling and grammatical issues that
detract from its overall readability. The text would benefit from thorough proofreading and
revision for language consistency.
3.   Heterogeneity and Bias: Although heterogeneity was explored through subgroup analyses,
it remains an issue for the secondary outcomes, particularly operative time and hospital stay.
Publication bias was already evident in some funnel plots. These limitations should be addressed
including further possible reasons for heterogeneity (e.g., differences in surgical expertise,
hospital settings, and appendicitis severity).
4.   Overemphasis on Secondary Outcomes: The manuscript devotes significant attention to
secondary outcomes (e.g., operative time and hospital stay duration). While these findings are
important, the primary outcomes (complications such as wound infection and abscesses) should
take precedence in the discussion, as they more directly affect patient outcomes.
Methodological Considerations:
-   Statistical Analyses: The manuscript employs both fixed- and random-effects models based
on heterogeneity (I² values). Further random-effects models, particularly in areas of high
heterogeneity, could strengthen the argument.
-   Data Sources and Inclusion Criteria: The inclusion of both randomized controlled trials
(RCTs) and retrospective studies is appropriate given the limited number of RCTs on this topic.
However, the authors should explicitly address the limitations of retrospective data, and the
potential biases introduced by non-randomized studies.
Specific Comments on Presentation:
-   Abstract: The abstract accurately reflects the contents of the manuscript. However, it might
profit focusing on the key findings and their clinical implications.
-   References: The references are up to date and relevant. However, the authors might want
to include some recent studies on the evolving role of drainage in minimally invasive surgery
beyond appendicitis to further contextualize their findings.
Conclusion:
This manuscript offers valuable insights into the ongoing debate about the necessity of peritoneal
drainage after laparoscopic appendectomy. However, it has limitations in the presentation -
particularly in relation to patient-centered outcomes.
With revisions to improve language quality and clarity, patient-centered focus, and further
exploration of heterogeneity, the manuscript would be a strong candidate for publication.