Review for 10.1186/s12876-025-04089-2 (2025)

Title: Comparison of Efficacy and Safety Between Surgical and Conservative Treatments for
Hemorrhoids: A Meta-Analysis
Version: 0 Date: 12 Apr 2025
Reviewer's report:
I read the manuscript with great interest and appreciate the authors’ efforts in synthesizing the
current evidence on this clinically relevant topic. The study addresses an important question and
is, overall, well-conducted. However, a few points should be addressed to improve the clarity
and methodological transparency of the work.
1 -There are minor punctuation errors and inconsistencies in the use of capital letters, particularly
in the second paragraph of the Introduction. A careful language revision is recommended.
2- The authors should cite the PRISMA 2020 guidelines.
3- The full search strategy for each database  should be included, either in the main text
or as supplementary material. Listing keywords alone is insufficient for transparency and
reproducibility.
4- In the “Inclusion and Exclusion Criteria,” “Data Extraction,” and “Quality Assessment”
sections, the initials of the authors responsible for each task should be stated.
5- Regarding the sentence: “Publication bias was assessed using a funnel plot due to the small
number of included studies,” it is advisable not to perform a funnel plot when fewer than 10
studies are included, due to low power for detecting asymmetry. A reference such as Lau et al.
(2006) may support this recommendation.
Lau J, Ioannidis JP, Terrin N, Schmid CH, Olkin I. The case of the misleading funnel plot. BMJ.
2006 Sep 16;333(7568):597-600. doi: 10.1136/bmj.333.7568.597. PMID: 16974018; PMCID:
PMC1570006.
6- The interpretation of heterogeneity (e.g., I² > 50%) is already defined in the Methods section
and need not be repeated in the Results for each outcome. For example, the sentence:
“Surgical treatments were significantly more effective in achieving asymptomatic status
compared to conservative treatments, with a pooled OR of 2.96 (95% CI: 1.66 to 5.28, p<0.001)
(Figure 2A). Heterogeneity was moderate (I2=50%, p=0.11), reflecting some variability among
studies but not enough to compromise the reliability of the results.”
could be simplified as:
“Surgical treatments were significantly more effective in achieving asymptomatic status
compared to conservative treatments, with a pooled OR of 2.96 (95% CI: 1.66 to 5.28, p<0.001;
I² = 50%) (Figure 2A).”
This suggestion applies to all outcomes. The impact of heterogeneity on interpretation should
be reserved for the Discussion section.
7- The term “overall pain reduction” is vague. I recommend adding a supplementary table
detailing how this outcome was measured in each study.
8- In the analysis of post-treatment pain, it would be helpful to clarify what is meant—e.g., pain
persisting longer than 10 days or measured at a specific follow-up point.
9- The statistical analysis section should describe the planned subgroup analyses.
10- In the section on post-treatment complications, the use of the word “incidence” appears to be
incorrect. Since incidence refers to the number of new cases over a defined time in a population
at risk, “occurrence” or “frequency” would be more appropriate in this context.