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: 1 Date: 27 Jul 2018  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
PEER REVIEWER COMMENTS: To view the full report from the academic peer review er, 
please see the attached file.  
 
REVIEWER COMMENTS FROM REPORT: This study is really a quality improvement study 
for their hospital and cannot be taken as indicative of the practice of surgery throughout 
Tanzania or Africa as a whole. The group has done a complete, well carried out analysis of their 
results in their hospital, but what this report lacks is a good contrast of the practice at their 
hospital in their population versus what has been reported before in the literature. There is not an 
attempt to  contrast the population of differences in practice of previous reports from non -
Tanzanian or African groups who see a different patient population, especially the lack of 
children with such problems, who would be referred to a primary pediatric surgeon, n ot a general 
hospital that treats all comers like this one.  A major potential problem is the very blatant 
description of the markedly increased complication rate of these operations done by junior 
doctors, who they clearly state are not adequately trained , yet they are still the ones doing the 
majority of these cases without supervision. In fact, there is only one brief statement saying that 
these junior doctors "should" have more supervision, and they don't describe that in their hospital 
such increased s upervision has been established or how it was done. Indeed, there is no outcry to 
FIX THIS PROBLEM! This will need to be addressed before the submission can be considered 
for publication.  
 
REQUESTED REVISIONS:  
 
The first sentence of the introduction is dir ected at non -physicians and certainly not surgeons. 
Which audience are you addressing, because for surgeons, this paragraph is not appropriate.  
You need to work on verb tense, singular and plural words. You need the help of an English 
Editor.  
Page 4 line 48: include diverticulitis.  
Page 5 Line 4+5 begs the question of what are the complications - you should define them and 
move this sentence down to the next paragraph. Also, it would be better to add "colonies and 
small bowel obstruction" to the list.  
Page 7 Lines 4 -31: were there any patients who had a stoma done during a colectomy or other 
intra abdominal procedure that was part of a definitive  operation. All the stomas you describe 
sound like they were done as bypasses or for decompression!  
Page 7 Line  47: the mean value is not appropriate. Delete it or describe the median and 
interquartile range; the mean is not statistically accurate with this range.  
Page 8 Lines 19 -25: too many significant figures are shown in the months. Also, be certain to 
define that Lines 17 -25 relate only to children!  
Page 8 Line 51: please define junior doctors and if they were supervised. This is a potentially big 
problem! Be careful! You are going to need to discuss this in the discussion, especially with the 
incidence of com plications related to their formation and not the underlying diseases for which 
they were constructed. Also, most surgeons try to avoid transverse loop colostomies because of 
the known problems with them.  They have gone out of favor in the last 25 years a nd are 
constructed only very rarely in most practices.  
Page 10 Line 58: these practices are very different from yours and really cannot be compared 
unless you define the differences. Also, the sentence on Page 11 Lines 7 -8 is naive. Of course 
there are dif ferences in the patient populations - the situation is markedly different!  
Page 11 Lines 22 -25: of course the differences are obvious, as there are different patient 
populations.  Did refs 11 and 13 involve pediatric patients or only adults? Are those stud ies done 
in Africa? You need to be more definitive with your explanations of these differences. Moreover, 
why is this important to you in your goals of this study?  
Page 12 Lines 14 and 15: Then why were they allowed to do it without supervision?  
Page 12 Li nes 35 -50: did skin problems vary with colon vs ideal stomas? They should have!  
Page 13 Line 7: Then why were they done?  
Page 14 Lines 4 -40: What have you done to address this very obvious problem?  
 
 
ADDITIONAL REQUESTS/SUGGESTIONS:  
This manuscript really  is a quality improvement study for their hospital and cannot be used as a 
general manuscript representing this surgical practice across  Tanzania or for that matter across 
the different countries in sub -Saharan Africa.  Moreover, the study clearly defines  action items 
that need to be taken - most blatantly the lack of supervision of junior doctors in even doing 
these operations without direct supervision, or better education and training in how to do these 
colostomy formations, or even the use of a loop tr ansverse colostomy, which should almost 
never be done because of the very well known complication rate of this procedure!  
 
 
 
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:  
 
Needs some language corrections before being published  
 
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.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declar ed or apparent competing interests are not utilized for these reviews. This reviewer has 
agreed to publication of their comments online under a Creative Commons Attribution License 
attributed to Research Square and was paid a small honorarium for completin g the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open  peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the a uthors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which wi ll not be published.   
 
I agree to the open peer review policy of the journal  
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: 1 Date: 27 Jul 2018  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
PEER REVIEWER COMMENTS: To view the full report from the academic peer review er, 
please see the attached file.  
 
REVIEWER COMMENTS FROM REPORT: This study is really a quality improvement study 
for their hospital and cannot be taken as indicative of the practice of surgery throughout 
Tanzania or Africa as a whole. The group has done a complete, well carried out analysis of their 
results in their hospital, but what this report lacks is a good contrast of the practice at their 
hospital in their population versus what has been reported before in the literature. There is not an 
attempt to  contrast the population of differences in practice of previous reports from non -
Tanzanian or African groups who see a different patient population, especially the lack of 
children with such problems, who would be referred to a primary pediatric surgeon, n ot a general 
hospital that treats all comers like this one.  A major potential problem is the very blatant 
description of the markedly increased complication rate of these operations done by junior 
doctors, who they clearly state are not adequately trained , yet they are still the ones doing the 
majority of these cases without supervision. In fact, there is only one brief statement saying that 
these junior doctors "should" have more supervision, and they don't describe that in their hospital 
such increased s upervision has been established or how it was done. Indeed, there is no outcry to 
FIX THIS PROBLEM! This will need to be addressed before the submission can be considered 
for publication.  
 
REQUESTED REVISIONS:  
 
The first sentence of the introduction is dir ected at non -physicians and certainly not surgeons. 
Which audience are you addressing, because for surgeons, this paragraph is not appropriate.  
You need to work on verb tense, singular and plural words. You need the help of an English 
Editor.  
Page 4 line 48: include diverticulitis.  
Page 5 Line 4+5 begs the question of what are the complications - you should define them and 
move this sentence down to the next paragraph. Also, it would be better to add "colonies and 
small bowel obstruction" to the list.  
Page 7 Lines 4 -31: were there any patients who had a stoma done during a colectomy or other 
intra abdominal procedure that was part of a definitive  operation. All the stomas you describe 
sound like they were done as bypasses or for decompression!  
Page 7 Line  47: the mean value is not appropriate. Delete it or describe the median and 
interquartile range; the mean is not statistically accurate with this range.  
Page 8 Lines 19 -25: too many significant figures are shown in the months. Also, be certain to 
define that Lines 17 -25 relate only to children!  
Page 8 Line 51: please define junior doctors and if they were supervised. This is a potentially big 
problem! Be careful! You are going to need to discuss this in the discussion, especially with the 
incidence of com plications related to their formation and not the underlying diseases for which 
they were constructed. Also, most surgeons try to avoid transverse loop colostomies because of 
the known problems with them.  They have gone out of favor in the last 25 years a nd are 
constructed only very rarely in most practices.  
Page 10 Line 58: these practices are very different from yours and really cannot be compared 
unless you define the differences. Also, the sentence on Page 11 Lines 7 -8 is naive. Of course 
there are dif ferences in the patient populations - the situation is markedly different!  
Page 11 Lines 22 -25: of course the differences are obvious, as there are different patient 
populations.  Did refs 11 and 13 involve pediatric patients or only adults? Are those stud ies done 
in Africa? You need to be more definitive with your explanations of these differences. Moreover, 
why is this important to you in your goals of this study?  
Page 12 Lines 14 and 15: Then why were they allowed to do it without supervision?  
Page 12 Li nes 35 -50: did skin problems vary with colon vs ideal stomas? They should have!  
Page 13 Line 7: Then why were they done?  
Page 14 Lines 4 -40: What have you done to address this very obvious problem?  
 
 
ADDITIONAL REQUESTS/SUGGESTIONS:  
This manuscript really  is a quality improvement study for their hospital and cannot be used as a 
general manuscript representing this surgical practice across  Tanzania or for that matter across 
the different countries in sub -Saharan Africa.  Moreover, the study clearly defines  action items 
that need to be taken - most blatantly the lack of supervision of junior doctors in even doing 
these operations without direct supervision, or better education and training in how to do these 
colostomy formations, or even the use of a loop tr ansverse colostomy, which should almost 
never be done because of the very well known complication rate of this procedure!  
 
 
 
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:  
 
Needs some language corrections before being published  
 
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.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declar ed or apparent competing interests are not utilized for these reviews. This reviewer has 
agreed to publication of their comments online under a Creative Commons Attribution License 
attributed to Research Square and was paid a small honorarium for completin g the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open  peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the a uthors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which wi ll not be published.   
 
I agree to the open peer review policy of the journal  
Please review this paper.
user
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: 1 Date: 27 Jul 2018  
 
Reviewer: Reviewer 2  
 
Reviewer's report:  
 
PEER REVIEWER COMMENTS: To view the full report from the academic peer review er, 
please see the attached file.  
 
REVIEWER COMMENTS FROM REPORT: This study is really a quality improvement study 
for their hospital and cannot be taken as indicative of the practice of surgery throughout 
Tanzania or Africa as a whole. The group has done a complete, well carried out analysis of their 
results in their hospital, but what this report lacks is a good contrast of the practice at their 
hospital in their population versus what has been reported before in the literature. There is not an 
attempt to  contrast the population of differences in practice of previous reports from non -
Tanzanian or African groups who see a different patient population, especially the lack of 
children with such problems, who would be referred to a primary pediatric surgeon, n ot a general 
hospital that treats all comers like this one.  A major potential problem is the very blatant 
description of the markedly increased complication rate of these operations done by junior 
doctors, who they clearly state are not adequately trained , yet they are still the ones doing the 
majority of these cases without supervision. In fact, there is only one brief statement saying that 
these junior doctors "should" have more supervision, and they don't describe that in their hospital 
such increased s upervision has been established or how it was done. Indeed, there is no outcry to 
FIX THIS PROBLEM! This will need to be addressed before the submission can be considered 
for publication.  
 
REQUESTED REVISIONS:  
 
The first sentence of the introduction is dir ected at non -physicians and certainly not surgeons. 
Which audience are you addressing, because for surgeons, this paragraph is not appropriate.  
You need to work on verb tense, singular and plural words. You need the help of an English 
Editor.  
Page 4 line 48: include diverticulitis.  
Page 5 Line 4+5 begs the question of what are the complications - you should define them and 
move this sentence down to the next paragraph. Also, it would be better to add "colonies and 
small bowel obstruction" to the list.  
Page 7 Lines 4 -31: were there any patients who had a stoma done during a colectomy or other 
intra abdominal procedure that was part of a definitive  operation. All the stomas you describe 
sound like they were done as bypasses or for decompression!  
Page 7 Line  47: the mean value is not appropriate. Delete it or describe the median and 
interquartile range; the mean is not statistically accurate with this range.  
Page 8 Lines 19 -25: too many significant figures are shown in the months. Also, be certain to 
define that Lines 17 -25 relate only to children!  
Page 8 Line 51: please define junior doctors and if they were supervised. This is a potentially big 
problem! Be careful! You are going to need to discuss this in the discussion, especially with the 
incidence of com plications related to their formation and not the underlying diseases for which 
they were constructed. Also, most surgeons try to avoid transverse loop colostomies because of 
the known problems with them.  They have gone out of favor in the last 25 years a nd are 
constructed only very rarely in most practices.  
Page 10 Line 58: these practices are very different from yours and really cannot be compared 
unless you define the differences. Also, the sentence on Page 11 Lines 7 -8 is naive. Of course 
there are dif ferences in the patient populations - the situation is markedly different!  
Page 11 Lines 22 -25: of course the differences are obvious, as there are different patient 
populations.  Did refs 11 and 13 involve pediatric patients or only adults? Are those stud ies done 
in Africa? You need to be more definitive with your explanations of these differences. Moreover, 
why is this important to you in your goals of this study?  
Page 12 Lines 14 and 15: Then why were they allowed to do it without supervision?  
Page 12 Li nes 35 -50: did skin problems vary with colon vs ideal stomas? They should have!  
Page 13 Line 7: Then why were they done?  
Page 14 Lines 4 -40: What have you done to address this very obvious problem?  
 
 
ADDITIONAL REQUESTS/SUGGESTIONS:  
This manuscript really  is a quality improvement study for their hospital and cannot be used as a 
general manuscript representing this surgical practice across  Tanzania or for that matter across 
the different countries in sub -Saharan Africa.  Moreover, the study clearly defines  action items 
that need to be taken - most blatantly the lack of supervision of junior doctors in even doing 
these operations without direct supervision, or better education and training in how to do these 
colostomy formations, or even the use of a loop tr ansverse colostomy, which should almost 
never be done because of the very well known complication rate of this procedure!  
 
 
 
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:  
 
Needs some language corrections before being published  
 
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.  
 
This reviewer has been recruited by a partner organization, Research Square. Reviewers with 
declar ed or apparent competing interests are not utilized for these reviews. This reviewer has 
agreed to publication of their comments online under a Creative Commons Attribution License 
attributed to Research Square and was paid a small honorarium for completin g the review within 
a specified timeframe. Honoraria for reviews such as this are paid regardless of the reviewer 
recommendation.  
 
I agree to the open  peer review policy of the journal. I understan d that my name will be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with the a uthors' 
responses. I agree for my report to be made available under an Open Access Creative Commons 
CC-BY license ( http://creativecommons.org/licenses/by/4.0/ ). I understand that any comments 
which I do not wish to be included in my named report can be in cluded as confidential comments 
to the editor s, which wi ll not be published.   
 
I agree to the open peer review policy of the journal  
assistant