Review for 10.1186/s12876-015-0257-7 (2015)

Reviewer's report
Title:A retrospective cohort study of Laparoscopic Subtotal Colectomy with
Antiperistaltic Cecorectal Anastomosis in Treating Adult Slow Transit
Constipation : 81 cases
Version:2Date:7 January 2014
Reviewer: Renato Costi
Reviewer's report:
Major compulsory revisions
The paper is definitely about outcome of surgery, and surgery is not described in
detail.
Rationale and ethics of the paper are debatable: as, according to authors, in the
literature a 5-7cm-long cecal reservoir has better outcome of 10-15cm-long cecal
reservoir, they decide to perform a 2-3-cm-long cecal reservoir. This latter means
just to let the ileocecal valve. In the literature, although the rationale of cecorectal
anastomosis is to avoid the postoperative diarrhoea typical of ileorectal
anastomosis, still, diarrhoea is definitely a severe and intractable complication.
Has any preclinical trial been performed? Has any consent been signed by
patients before undergoing such an innovative procedure?
The paper is not well written and should be extensively re-edited. English needs
revision.
Minor essential revisions
Title
Actually the main purpose of the study is not explained by the title which should
be revised: “A retrospective comparison of short term results and functional
recovery after subtotal colectomy and cecorectal anastomosis with short colonic
reservoir vs. long colonic reservoir” should sound more appropriated.
Abstract
There are several typing errors.
In the Results section the sentence “at each time point, the outcomes...” should
be replaced with real results (numbers).
Introduction
The first sentence needs references.
The reported background of present surgical management of constipation is
poor.
Total colectomy followed by ileorectal anastomosis is the most performed
operaton worldwide for constipation, thus it may be deduced that has some
success, whereas it is described by the authors only with its main drawbacks.
Subtotal colectomy followed by cecorectal anastomosis is described only with its
theoretical advantages, whereas some complications have been described.
Moreover, several other technical options have been described, as side-to-end
cecorectal anastomosis, or isoperistaltic anastomosis by cecum translational
rotation in the left iliac fossa, thus avoiding any vascular torsion. Finally, the
laparoscopic approach is not reported.
Methods
Methods section is poor.
The sentences relative to patients lost at follow up should follow patients'
selection description.
Patient selection section is poorly described: what is “sure” diagnosis (is there
any unsure diagnosis?)? What is “repeated” GTT? Why repeated? How many
times? Which are symptoms of outlet obstruction? What is conservative
treatment? Inclusion and exclusion criteria are mixed in a confused way. Is there
any minimum age for surgery? Preoperative work up should be clearly reported
before a clear list of inclusion and exclusion criteria.
The “Surgical procedure” is poorly described. Considering that the authors are
comparing the outcomes of two surgical procedures, five lines is not enough,
especially if we consider that a laparoscopic subtotal colectomy is definitely a
technically demanding procedure. Trocar position deserves to be described as
well as the main operating phases of the procedure. The figures 1 to 4 propose
drawings of poor quality. Some of operative data are reported intable 1, but there
is not any link in the text. Hospital stay is 13 days after both procedures, which is
a lot, and deserve a commentary from the authors. Postoperative complications
are poorly reported.
In the Patient data acquisition section, the sentence beginning with “We
designated..” needs references unless it is an arbitrarious action of the authors.
In any case it is unclear what is the APFS/ABS score: is it the sum? If it is not,
what happens if a patient have APFS=0 and ABS=3?
Reference no. 25 refers to a paper from Todd and coworkers.
In the Comparative Method paragraph, the “improved value” is the preop value
less the observed value. This way to mesure improvement needs references. If it
is not validated by other papers, it should be stated and discussed, since it is
debatable that a fraction preop value/observed postop value is not more
appropriated.
Stats need review by a statistician. In tables some other stats are reported than
those listed in the dedicated text section.
Results
Surgical outcome description is poor.
It is unclear what “transferred to open operation” means. Conversion to
laparotomy? Revision? Second procedure? Re-do?
Morbidity description is poor. The meaning of “incomplete ileus” and “pulmonary
infection” is unclear and should be better explained in a scientific journal.
In tables 2 and 3 the absence of the preoperative values make the whole tables
difficult to read.
The Wexner Incontinence Score (WIS) at 6 months is virtually higher for control
group than observation group (p=0.05). This datum deserve some discussion
since the control group have much longer cecal stump (10-15 cm. in lenght vs.
2-3), thus bigger reservoir capacity and theoretically higher water absorption
activity.
Four decimals after the comma are too many (one is sufficient).
Discussion is not focused.
The authors compare their laparoscopic cases vs. those operated on with open
access by the Italian group, and it is not clear why. Moreover, they maintain to
have a lower morbidity, which is not, as, in small series, 11% may be considered
consistent with 13% reported by Marchesi and co.
The authors refer to six patients in control group with poor results of surgery, but
they do not present them in the results and refer to those results not in details
(when they did have pain? It seems perioperatively, since they apparently had
long treatment in hospital, etc.). If it is, it is unclear why the hospital stay of the
two groups is the same (13 days) if the results in control group where poorer.
The period (7 lines) beginning with “We observed considerable excrements..” is
not scientifically acceptable, not proved by results, without any reference, and is
therefore a personal opinion.
How the authors may observe anything in the research of Jiang?....
Level of interest: An article whose findings are important to those with closely
related research interests
Quality of written English: Needs some language corrections before being
published
Statistical review: Yes, but I do not feel adequately qualified to assess the
statistics.
Declaration of competing interests:
I have not competing interests