Review for 10.1186/s12876-023-03063-0 (2024)

Title: High-Resolution Anorectal Manometry for Diagnosing Obstructed Defecation Syndrome
Associated with Moderate Rectocele Compared to Healthy Individuals
Version: 6 Date: 13 Sep 2023
Reviewer's report:
"PEER REVIEWER ASSESSMENTS:
OBJECTIVE - Full research articles: is there a clear objective that addresses one or several
testable research questions? (Brief or other article types: is there a clear objective?)
Yes - there is a clear objective
DESIGN - Is the current approach (including controls and analysis protocols) appropriate for
the objective?
No - there are minor issues
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
No - there are major issues
STATISTICS - Is the use of statistics in the manuscript appropriate?
Yes - appropriate statistical analyses have been used in the study
INTERPRETATION - Is the current interpretation/discussion of the results reasonable and not
overstated?
No - there are major issues
OVERALL MANUSCRIPT POTENTIAL - Has the author addressed your concerns sufficiently
for you to now recommend the work as a technically sound contribution? If not, can further
revisions be made to make the work technically sound?
Maybe - with major revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: The authors have investigated an important and interesting area in
pelvic floor dysfunction. The main strength of the article is their sample size.
The biggest fundamental flaw I see is that they have not commented about dyssynergic
defaecation in the results. ODS is characterized by manometry, which they have performed for
all patients. Their analysis is confined to resting and squeeze pressure values, without looking
for subtypes of dyssynergic defaecation.
The authors have addressed all issues raised by reviewer 2.
Reviewer 1 has provided extensive feedback, and I feel the authors have not addressed some
of them satisfactorily.
REQUESTED REVISIONS:
Word selection and writing style needs to improve - E.g. ""healthy"" subjects, not ""health""
subjects, ""anal relaxation"" not ""anal laxity""
Abstract
""maximum squeezing pressure of the disease "" - what does this mean?
Materials and methods
""moderate rectocele"" - how was this defined?
Inclusion
""Subject with anorectal trauma (grade 3 - 4 lacerations) during delivery or prior anorectal
surgery, including hemorrhoid surgery. "" - were they included or excluded - its unclear
""diameter of the rectocele "" - how was this measured
""mild to moderate rectal mucosal prolapse "" how was this defined?
Exclusion
""Patients with DD"" - what is this?
HRAM study
This description looks like its been directly retrieved from a laboratory manual. It's written in
present tense.
Additionally, the methods described in taking measurements is not clear (e.g. ""After that, the
volume was increased every 20 ml, until the maximum volume was 300 ml, a total of 3 times"").
Statistics
""Linear regression of 3D HRAM data with age as a dependent variable "" - This doesn't make
sense.
""HSW and MRSW had a better degree of adjustment (Figure 3)."" - what does this mean?
""and rectoanal inhibitory reflex (P = 0.001) "" - what was the operationalzed variable? The
presence of RAIR?
""The age # 50 years subgroup "" - Why 50?
Why no analysis on bearing down / dyssynergic defaecation?
How is age going to be 0.31? The Youden index gives the value of best sensitivity/specificity
for each parameter assessed.
Discussion
""diagnostic value for the age > urge to defecate > rectoanal pressure differential in the MRW
group, "" - Idea not clear
""Our study was a retrospective cohort study "" - how did you recruit a retrospective cohort of
controls?
ADDITIONAL REQUESTS/SUGGESTIONS:
The omission of data on defaecation patter is a major omission."