Title: The Efficacy of Retrograde and Antegrade Enemas in the Management of Low Anterior
Resection Syndrome in Patients Undergoing Rectal Resection: A Systematic Review and Meta-
analysis
Version: 0 Date: 24 Mar 2025
Reviewer's report:
This is a systematic review and meta-analysis comparing the use of antegrade and retrograde
enema with no intervention for LARS after low anterior resection of rectum. The study has
been conducted in accordance with PRISMA statement and includes a thorough literature search
and adequate quality assessment using Cochrane’s ROB2 tool. The authors have concluded
maximum effectiveness of enema at three months of follow up when compared with no
intervention for LARS. However, I have some comments.
1. As the authors have stated in the discussion section, the limitations of this meta-analysis is
small number of patients. Out of these, some patients discontinued and some were dropped from
the follow up, further reducing the numbers. Administration of enema after low anterior resection
is not a normal practice by the colorectal surgeons. How the results of this meta-analysis would
bring a change in clinical practice?
2. The study by Meurette et al and Rosen et al had a follow up of three months, which is the
basis of author’s conclusion. The forest plots at 1 week, 1 month, 6 months and 12 months (Fig
2) are based on the results of only one study each, which is unnecessary and therefore, could
be excluded. In my opinion, it would be better to report on the overall scores and scores at 3
months as the main findings of the analysis. The results of individual studies at different follow
ups can be included in the discussion section.
3. The inconsistency index (I2). is not a measure of heterogeneity. Instead, Cochrane’s Q
test with a cut off P-value of < 0.1 is indicative of heterogeneity and may be reported in the
manuscript.
Title: The Efficacy of Retrograde and Antegrade Enemas in the Management of Low Anterior
Resection Syndrome in Patients Undergoing Rectal Resection: A Systematic Review and Meta-
analysis
Version: 0 Date: 24 Mar 2025
Reviewer's report:
This is a systematic review and meta-analysis comparing the use of antegrade and retrograde
enema with no intervention for LARS after low anterior resection of rectum. The study has
been conducted in accordance with PRISMA statement and includes a thorough literature search
and adequate quality assessment using Cochrane’s ROB2 tool. The authors have concluded
maximum effectiveness of enema at three months of follow up when compared with no
intervention for LARS. However, I have some comments.
1. As the authors have stated in the discussion section, the limitations of this meta-analysis is
small number of patients. Out of these, some patients discontinued and some were dropped from
the follow up, further reducing the numbers. Administration of enema after low anterior resection
is not a normal practice by the colorectal surgeons. How the results of this meta-analysis would
bring a change in clinical practice?
2. The study by Meurette et al and Rosen et al had a follow up of three months, which is the
basis of author’s conclusion. The forest plots at 1 week, 1 month, 6 months and 12 months (Fig
2) are based on the results of only one study each, which is unnecessary and therefore, could
be excluded. In my opinion, it would be better to report on the overall scores and scores at 3
months as the main findings of the analysis. The results of individual studies at different follow
ups can be included in the discussion section.
3. The inconsistency index (I2). is not a measure of heterogeneity. Instead, Cochrane’s Q
test with a cut off P-value of < 0.1 is indicative of heterogeneity and may be reported in the
manuscript.
Please review this paper.
user
Title: The Efficacy of Retrograde and Antegrade Enemas in the Management of Low Anterior
Resection Syndrome in Patients Undergoing Rectal Resection: A Systematic Review and Meta-
analysis
Version: 0 Date: 24 Mar 2025
Reviewer's report:
This is a systematic review and meta-analysis comparing the use of antegrade and retrograde
enema with no intervention for LARS after low anterior resection of rectum. The study has
been conducted in accordance with PRISMA statement and includes a thorough literature search
and adequate quality assessment using Cochrane’s ROB2 tool. The authors have concluded
maximum effectiveness of enema at three months of follow up when compared with no
intervention for LARS. However, I have some comments.
1. As the authors have stated in the discussion section, the limitations of this meta-analysis is
small number of patients. Out of these, some patients discontinued and some were dropped from
the follow up, further reducing the numbers. Administration of enema after low anterior resection
is not a normal practice by the colorectal surgeons. How the results of this meta-analysis would
bring a change in clinical practice?
2. The study by Meurette et al and Rosen et al had a follow up of three months, which is the
basis of author’s conclusion. The forest plots at 1 week, 1 month, 6 months and 12 months (Fig
2) are based on the results of only one study each, which is unnecessary and therefore, could
be excluded. In my opinion, it would be better to report on the overall scores and scores at 3
months as the main findings of the analysis. The results of individual studies at different follow
ups can be included in the discussion section.
3. The inconsistency index (I2). is not a measure of heterogeneity. Instead, Cochrane’s Q
test with a cut off P-value of < 0.1 is indicative of heterogeneity and may be reported in the
manuscript.
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