Review for 10.1186/s12876-025-03810-5 (2025)

Title: Analysis of the incidence of post-cholecystectomy diarrhea and its influencing factors in
Hainan Province
Version: 0 Date: 16 Feb 2025
Reviewer:  Anwar Ashraf Abouelnasr
Reviewer's report:
Dear Authors, please address the following points below
-While the introduction provides background on the topic, it could be slightly more concise and
structured. For example, the mention of the wide variation in PCD incidence (2.1%-57.2%) could
be expanded with more detail on why such variation exists (e.g., methodological differences
across studies, population differences).
-Additionally, the reference to bile acid diarrhea (BAD) as a potential cause of PCD is valuable,
but the pathophysiology of bile acid metabolism and how it links to PCD could be explained a
bit more clearly to enhance the reader's understanding of the rationale behind the study.
-Although the inclusion and exclusion criteria are clear, it would be helpful to elaborate on how
data was collected during the face-to-face interviews and how follow-up was conducted via
telephone. Were the same standardized questionnaires used in both settings? Were there any
challenges related to follow-up (e.g., patient non-response)?
-It might also be useful to clarify whether there were any regional variations in risk factors (e.g.,
different dietary patterns in different areas of Hainan) or any adjustments made in the analysis
to account for such regional differences.
-The results suggest that certain factors like age, BMI, dietary patterns, alcohol consumption,
history of diabetes, and fatty liver disease are linked to PCD, but the exact nature of these
associations could be described in more detail. For example, were the effects of BMI and age
linear, or did they follow a specific threshold pattern (e.g., an increased risk above a certain
BMI or age)?
-The study notes that no significant differences were found for gender, ethnicity, use of
antimicrobial drugs, smoking, and history of hypertension. It would be useful to explain why
these factors were not found to influence PCD incidence, especially since they are commonly
considered risk factors in other gastrointestinal conditions.
-Some parts of the discussion are dense and could benefit from clearer organization. For instance,
the discussion of pathogenesis and risk factors can be more succinctly structured, perhaps with
distinct subsections for pathogenesis, risk factors, and study limitations. This would enhance the
readability and make the section more accessible.
-The statement about the "physical and mental illness" influencing PCD could be expanded
to clarify the potential mechanisms by which anxiety or depression might contribute to
gastrointestinal symptoms in PCD patients.
-While the study compares its findings with other literature, the discussion could further delve
into why the study's PCD incidence rate (14.2%) is lower than that reported in some other studies.
Are there regional, methodological, or patient population differences that might explain this
discrepancy?
-More context could be provided on studies that found no influencing factors (like Kim et
al.), explaining potential reasons for these null results. This could help readers understand why
different studies yield different outcomes, particularly concerning risk factors like age, BMI,
and comorbidities.