Review for 10.1186/s12876-019-1154-2 (2020)

Reviewer’s report
Title: The challenging diagnosis and treatment of duodenal diverticulum perforation. A report of two
cases.
Version: 1 Date: 28 Oct 2019
Reviewer: Deeksha Kapoor
Reviewer's report:
The authors have made an effort in the correct direction to address the absence of consensus in the
management of duodenal diverticular perforation. 
However, i would like to make a few comments and raise a few questions 
Case 1 - 
- There is no mention of any oral contrast being given during CT abdomen, which helped in identifying
the site of perforation. 
- Is it a routine protocol at the author's institute to perform a oral contrast study after perforation repair
before initiating oral feeds? And if not, why was it done for this case? 
Case 2 - 
- What was the indication of performing a MR abdomen for this patient ?
- Patient was started on oral diet from day 10 on wards, so what was the indication of performing a CT
scan on day 18 and then a MR abdomen the next day ? 
Would like to respond to the authors reply, and am open to further interaction over this article.
On page 6, lines 30/31 - What does 'limited perforation' mean ? and how will it be identified/ defined ? 
Endoscopic management is just mentioned, without describing where it would be indicated and what
would be the success rate for the same 
Comments - 
A patient presenting with free intra abdominal duodenal leak is  expected to have peritonitis and
requires surgery. However, conservative management can be attempted in a patient with contained
retroperitoneal leak, no signs of generalized peritonitis and maybe a patient with known duodenal
diverticulum. 
It is by extension of logic that a properly performed CT abdomen with on table oral contrast is
important in treatment  planning and maybe considered  imperative for diagnosis  of a  diverticular
perforation. Surgical versus conservative measures can be described depending on peritoneal features,
patient's hemodynamic status, CT findings and availability of interventional radiology team. 
These parameters have not been adequately highlighted in the article and should be emphasized.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
Does the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
No
Are the conclusions drawn adequately supported by the data shown?
If not, please explain in your comments to the authors.
No
Are you able to assess any statistics in the manuscript or would you recommend an additional
statistical review?
If  an  additional  statistical  review  is  recommended,  please  specify  what  aspects  require  further
assessment in your comments to the editors.
Not relevant to this manuscript
Quality of written English
Please indicate the quality of language in the manuscript:
Needs some language corrections before being published
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