Review for 10.1186/s12876-025-03865-4 (2025)

Title: Unfavorable outcomes and their predictors in patients treated for perforated peptic ulcer
disease in Ethiopia: systematic review and meta-analysis
Version: 1 Date: 11 Mar 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-The exclusion of non-English studies may introduce language bias, particularly since there
could be valuable data from studies published in local Ethiopian languages or other regional
languages that might offer insights into PPUD outcomes in the context of Ethiopia.
-While the review mentions subgroup analysis by region, it could benefit from a deeper
exploration of how healthcare infrastructure, access to medical care, and socio-economic factors
across different regions of Ethiopia may influence outcomes.
-While the Newcastle-Ottawa tool is used for quality assessment, the review does not provide
enough detailed information about the study quality scores or the specific strengths and
weaknesses identified in the individual studies. Including this would enhance the transparency
and trustworthiness of the conclusions.
-The review emphasizes identifying predictors of poor outcomes, but the inclusion criteria for
predictors seem a bit broad. It would be beneficial to clarify whether the extracted predictors
were consistently reported across studies and if any key predictors (e.g., age, comorbidities)
were consistently found to influence outcomes.
-While the review mentions the I² statistic for assessing heterogeneity, further elaboration on the
findings of heterogeneity would be useful. For example, were there specific studies or regions
that exhibited particularly high heterogeneity? How did this affect the robustness of the pooled
results?
-Lifestyle factors (e.g., smoking, underweight) were identified as predictors of poor outcomes,
but the review could explore more potential confounders (e.g., socioeconomic status, healthcare
access, preoperative care) and whether these were adequately controlled in the included studies.
-Although the authors used a systematic and structured approach to study inclusion, there may
still be potential for selection bias if the studies included in the meta-analysis were not entirely
representative of the full range of Ethiopian healthcare settings (e.g., including only studies from
hospitals with better facilities or larger patient populations).
-One of the main limitations highlighted in the review is the insufficient number of studies
examining predictors of mortality. While delayed presentation, advanced age, and complications
were identified as significant, the inability to perform a meta-analysis on mortality predictors
weakens the ability to generalize these findings. A more extensive dataset would have
strengthened the validity of these conclusions.
-The discrepancy between in-hospital mortality and 30-day mortality rates in the studies
compared to global reviews introduces potential challenges in comparing outcomes. Although
the authors appropriately note this difference, it remains a limitation in terms of generalizing
their results to broader, global contexts. The lack of a clear understanding of these variations
makes cross-country comparisons difficult.
-Although the review identifies several clinical predictors (e.g., low SBP, delayed presentation),
there is limited discussion of the role of socioeconomic and healthcare system factors in patient
outcomes. In countries like Ethiopia, where healthcare infrastructure can vary significantly,
factors such as access to healthcare, socioeconomic status, and the quality of preoperative care
could play a critical role in the outcomes of PPUD patients. These factors were not thoroughly
explored in the current review.
-Given the small number of studies included, there is a possibility of publication bias, where
studies with significant or positive results are more likely to be published than those with null
or negative findings. The review mentions the use of statistical methods to address publication
bias, but given the small sample size of studies, this might not fully mitigate the issue.