Review for 10.1186/s12876-019-1070-5 (2019)

Reviewer ’s report  
 
Title: Indications and complications of intestinal stomas at a tertiary care hospital in a resource -
limited setting: A Tanzan ian experience  
 
Version: 2 Date: 29 Nov 2018  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER:  
 
Has the author addressed your concerns sufficiently for you to now recommend the work as a 
technically sound contribution? No  
 
 
Reviewer comments: The author has not yet adequately addressed two points  
 
1. The group of patients need to be separated into Chil dren ( ages <18 years old) and adults (> 18 
years old)  
 
 
2. An honest description of the actual supervision of junior doctors operating on these patients in  
response to my question, the authors say that the junior doctors had " direct supervision" in the 
majority of cases - yet throughout the paper they talk about inadequate technique, lack of 
supervision, and a greater rate of complications when the operation was done by junior surgeons. 
If they had direct supervision, the  technique would not have been imp roper.  
 
 
What was well done?/ is there anything else needed  
 
Well done - they have improved the manuscript by clarifying several points in response to my 
questions and addressing the differences I populations studies and used as comparisons to their 
data 
 
Wha t else is needed? See below. I encourage the authors to revise the manuscript according to 
my following suggestions. This paper has the potential for being a very important paper !  
 
1. Page 2 line 19 delete the word "it"  
 
2. Page 2 line 24 Add the word "are"  after "factors"  
 
3. Page 2 line 41. You need to separate the population into children (< 18 yo) and adults >18yo 
throughout the entire paper. The mean age can then be calculated for each group. Reporting an 
overall mean age in this study is meaningless bec ause the two groups have totally different 
etiologies requiring a stoma.  
 
4. Add "in children and adults" to the title.   This will tell the story better and more completely  
 
5. There are multiple problems with verb tense etc that will require editing by pr ofessional 
editors. I will not provide any more suggestions from now on but these can be corrected by an 
editor.  
 
6. Page 6 line 27. Define SOPD  
 
7. Page 6 lines 4 and 46 "stomy" needs to be changed to stoma and "stomal" respectably  
 
8. Page 7 line 19 this s entence is absolutely critical BUT the way it is written means that there 
was direct supervision (what the readership will interpret as the consultant surgeon being in the 
operating room and overlooking or assisting the "surgeon" in the operating room. I a m very sorry 
but this reviewer does not believe that the consultant surgeon was actually in the OR all the time 
and especially if it was done "after hours"  i.e. nights and weekends. You need to be able to 
define this accurately whether the operating surge on was alone in the operating room or whether 
the. Consultant surgeon was actually in the OR at the time of creation of the stoma. This may be 
the *most important variable* to quantitate accurately.   
 
9. Page 8 line 4. Change " status of the operating surg eon" level of training of the operating 
surgeon"  
 
10. Page 8 line 37 add the phrase "12 month" after the word "the"  
 
11. Page 8 lines42 here is also where you can separate the adults from the children. To report a 
median age of 8 with a range of one day to 8 6 years is meaningless.  
 
12 . Page 8 lines 47 through 49 which group does this refer to? all patients or only  the children. 
You also need to report these variables separately for the males and the females  
 
13. Page 8 line 56 - page 9 line 17  and. Page 9 lines 43 -47.   the indications need to be reported 
separately for the children and the adults - again these represent two totally different age groups 
with different indications for stomal creation. Also there may end up being a difference in 
complication r ate as well as complication rate according to the experience and level of training 
of the operating surgeons as well as the actual presence of a consultant surgeon in the Operating 
room? Stomas are much more difficult to make in children  
 
14. Page 9 line 12  delete the attempt to describe a mean and SD for the congenital anomalies just 
give the range and maybe also those requiring a stoma in the first 2 weeks of life - a much more 
risky procedure with greater morbidity  
 
15. Page 9 line 14 change the mean to 5.8  years and round off the SD to 2.6  
16. Page 9 line 16 the difference  in age is unimportant and the statistical difference is fully 
expected. Delete this sentence - it is meaningless and you appear naive In even reporting it.  
 
17. Page 9 lines 33 and 34. A gain the need for an emergency operation will vary because of age. 
These data should be reported separately for the two age groups.  
 
18. Page 10 line 4 again the complication rate should be reported separately for children and for 
adults in each anatomic lo cation  
 
19. Page 10 line 31 round off the numbers; you cannot measure a one hundredths of a day!  
 
20. Page 10 Definitive (curative) surgery and Line 57 - page 11 line 33 again the 2 groups of 
adults and children need to be reported separately  
 
21. Page 11 line 34. Do you mean "intraperitoneally " rather than intraoperatively"?  
 
22. Page 12 line 14 -19. Is this section really necessary. The populations are totally different? 
Aren't there other published papers from Africa on this same topic that y ou could compare your 
practice to that of others? This would be more meaningful than comparing your experience with 
that of  the experience of surgeons in the developed world or elsewhere who  primarily deal with 
adults ?  
 
23. Page 12 line 32 did Ahmed and colleagues treat only adults ? Or only children? Or both. In 
each case you need to compare apples with apples (adults with adults) and  oranges with oranges 
( children with children) -see why separating the population into adults and children is crucial. 
This will convert your study into a very well written and analyzed one that then will be quoted - 
Grouping all ages into one category confuses the issues of etiology as well as complications  
 
24. Page 12 line 57 did Hussein et al treat only adults?  
 
25 page 1 3 lines 4 -7. Here is where you need to be fully transparent and exact. When you say 
"despite adequate supervision by senior doctors" what does this mean?   "adequate supervision" 
to most readers means " direct advice and oversight  IN THE OPERATING ROOM - not prior 
training  and not over the phone. I will admit, my guess is that there was minimal or no direct 
supervision at night or on weekends - and here is your problem - you can determine this by 
looking at the day of the week and the hour of the day when these emergency procedures were 
performed - I really doubt ( though maybe you can determine this) that you will be able to 
document  if a consultant surgeon was actually on the OR or not by looking at the operative 
report - too many potential problems of poo r or inaccurate documentation.  
 
My guess is that there was rarely a consultant surgeon in the OR for the emergency cases and 
this is why the complication rates were so much greater when performed by a junior doctor (and 
you have never described what you me an by a junior doctor) vs a consultant doctor. I really do 
not believe the sentence on page 13 line 7. If the consultant surgeon was there, then under his/her 
direct supervision, the should be NO difference when they were directly there as you imply on 
page 13 line 22 and then describe on page 14 lines 57 - 60 this does not agree with your 
statement that the operating surgeons had direct supervision.  
 
26. Page 13 lines 51 -56. You need to report the incidence according to transverse loop vs 
sigmoid end colost omies here as well as in the table  
 
27. Page 14 line 34. Other cause of bowel retraction is obesity, bowel wall edema, ischemia in a 
devascularized segment that was exteriorized.  
 
28. Page 15 line 22 again were the stomas closed by junior doctors without a ny direct 
supervision? My guess is that many were! You need to look into this or at the least describe your 
impression of whether the consultant surgeons were really there IN THE OR or not.  
 
29. Page 15 lines 43 -58. When you say extraperitoneal closure, wha t do you mean? Was the 
Anastomosis left exteriorized for several days and then interiorized ? If so when was it placed 
back into the peritoneum?  
 
30. Page 16 lines 11 -14. Here is where the truth comes out. You say "improper technique" are 
you really saying "lack of supervision"? Because if the junior doctors had direct supervision the 
technique would not be "improper"  
 
31. Page lines 21 - 24 shouldn't you say that transverse loop colostomies should rarely be done? 
Be more definitive. In our 1200 bed hospital ,  I have not seen a transverse loop colostomy 
performance in over 20 years.  
 
32. Concerning the tables - See table 1 you have essentially already separated the total into two 
groups because congenital diseases rarely have the stoma created after age 18, and a cquired 
diseases that you report rarely occur in children  
 
Tables 2, 3,4, and 6   again separate into children and adults  
 
 33. You have the chance to turn this into a very good comprehensive paper AND one that 
challenges the government and your hospital to provide better care for the patients -meaning 
much more training and supervision of emergency operations performed by inadequately trained 
and inadequately supervised junior doctors.  
 
This really is the message of your paper and no matter how you try to ca mouflage it, the message 
is obvious whether your hospital or consultant surgical staff wants to hear it  
 
 
 
 
 
 
 
 
Are the methods appropriate and well described?  
If not, please specify what is required in your comments to the authors.  
 
No 
 
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 manus cript or would you recommend an 
additional statistical review?  
If an additional statistical review is recommended, please speci fy 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:  
 
Acceptable  
 
Declaration of competing interests  
Please complete a declaration of competing interests, considering the following ques tions:  
 
1. Have you in the past five years received reimbursements, f ees, funding, or salary from an 
organisation that may in any way gain or lose financial ly from the publication of this 
manuscript, either now or in the future?  
 
2. Do you hold any stocks or  shares in an organisation t hat may in any way gain or lose 
financially from the publication of this manuscript, either now or in the future?  
 
3. Do you hold or are you currently applying for any patents  relating to the content of the 
manuscript?  
 
4. Have yo u received reimbursements, fees, funding, or salary from an organization that 
holds or has applied for patents relating to the content of the manuscript?  
 
5. Do you have any other financial competing interests?  
 
6. Do you have any non -financial competing int erests in relation to this paper?  
If you can answer no to all of the above, write 'I declare that I have  no competing interests' 
below. If your reply is yes to any, please give details below.  
 
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recommendation.  
 
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