Title: Perioperative outcomes of the surgical management of achalasia in two tertiary
Cameroonian hospitals: a cohort study
Version: 3 Date: 17 Jan 2024
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?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
Yes - experiments and analyses were performed appropriately
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?
Yes - the author's interpretation is reasonable
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?
Probably - with minor revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: Because this was a re-review I also added the re-review headings.
HAVE THE AUTHORS RESPONDED ADEQUATELY TO EACH OF THE QUESTIONS
RAISED IN THE COMMENTS?
Yes
HAVE THEY MADE THE APPROPRIATE CHANGES IN THE MANUSCRIPT?
For the reviewers' comments, yes.
WHAT IS YOUR OVERALL IMPRESSION OF THE REVISED MANUSCRIPT?
Although this needs another edit this is a good paper that reports believable data and supports
the excellent care delivered at these two hospitals in Cameron. This is good for the hospitals,
good for the country, and quite frankly good for the continent.
WHAT HAVE  THE AURTHORS DONE WELL?
They did the best that can be expected in a finance-challenged country in Africa and they did an
excellent job. The topic is timely for their country and their continent.
IN WHAT WAYS DOES IT NOT MEET BEST PRACTICE?
Quite frankly, it DOES  meet best practice.
ADDITIONAL REQUESTS/SUGGESTIONS:
ARE THERE ANY ADDITIONAL REVISIONS THE AUTHORS SHOULD MAKE?
Authors please note that I did not review your first submission but have read your responses to
the previous reviews.  I will, however, approach this as if it was a primary review -please note
that my goal is to make this a better submission for you and your career/hospital. All suggestions
will be constructive and positive!
1. Line 42 and through the text. Statistically with less than 100 patients (in your case 29) all
percentages should be rounded off to the whole number as well as age, months of symptoms
( e.g. 51+|- 20 line 43), etc. and all the values that have a decimal point need to be reviewed as
to whether they should also be rounded off. Then when you report these values the number of
decimal points in the value as well as the variance (which you need to add to a statistics paragraph
need to be the same. For instance line 217 the Eckhardt score  should be 9+\-1 or 9.1+\-1.1
2. Be prepared I am going to make many suggestions-  all are constructive so please understand
that I do highly support your submission, but it needs some change to what I think must be
French to English  translation
3 Line 42 change cases to patients
4. Line 52 delete the term “There was an acceptable “ change to “The”. Acceptable could be
argued. Just describe your data without any editorial comment, let your data speak for itself and
it will!
5. Line 48 and line 246 the term hemivalve is not the usual term. I would suggest that you change
it to partial fundoplication
6. Lines 65-67 this is a mistake on your part, the incidences are 10-105 PER 100,00 of the
population not 10 to 105. Please rephrase as per 100,000 population. I suggest that after the
word “incidences' you put (per 100,000 population) that will clear this up and convert what look
like  %s in refs 4 and 5
7. Line 77 and line 249change to “open”
8. Line 83. Botox is a trade name, change to botulinum toxin
9. Line 86 start a new paragraph
10. Line 107. The word hyperprotestic is not a word. Yes there is a word hyperproteic but that
is not common, just change to “high protein diet”
11. Line 113  the phrase “on lakes” makes no sense to me-  delete the part of that sentence at
the end starting with “to put…”
12. Line 115 define where and how long the cardiomyotomy was made how far down into the
cardiac and how far up the distal esophagus
13. Line 117 change device to procedure
14. Line 152 add here how many patients were identified and how many patients were contacted,
this will give the reader an idea of what % of the operated patients were evaluated. This could
also be put on lines 146-149 but needs to be somewhere in the manuscript. I prefer in the methods
section
15.line 131 change assembly to procedure
16. Lines 152-153. An argument could be given to exclude the infants; it is a bit of a different
topic and some of your data will be skewed such as duration of symptoms. I would discuss the
infants as a separate category but not just Clyde them I. Your overall data analyses will leave
that up to you and the journal editor but really they are two different populations
17. Line 154. You are somewhere going to have to explain why you had a female predominance
- other studies do not show this
18. Line 162-163. Best to define what you mean by paradoxical dysplasia, some readers will
not know this
19. Line 174. The word stenosis is not appropriate, I would say non relaxation at the (e.g.)
junction
20. Line 190 add the ” and extended XXXcm onto the cardia” -this is crucially important to report
21. Line 202 change to removal not ablation
22. Lines 208-209 you need to define surgical site infections that required a laparotomy.  These
must have been deep space infections like a subphrenic abscess or a contained esophageal leak;
clearly defined these, because they required laparotomy. They were not just a wound infection!
23. Line 225 delete the phrase of ""an acceptable sample size"" and just say 29  lack African
patients in Cameroon. You have a respectable number you do not need to say this and those
who understand the system will be impressed that you got such good follow up! Let your study
speak for itself. Your results are great
24. Line 228 change to partial fundoplication was the most common anti-reflux  procedure”
25. Line 229 change to “occurred in 3 patients all requiring re-laparotomy but with excellent
postop recovery”
26. Line 234. Does the medical system in Cameroon also explain in part the long duration of
symptoms because of difficulty getting advanced medical diagnostic consultations? I suspect so
but do not know if that is true.  It certainly would be true for patients living in rural areas, right?
27 line 251 I think you forgot something here. I think you meant to say “suggest that this
approach can be supported over an open approach” and not “cannot be”
28. Line 256. I agree with what you said but you do have the total number of patients operated
in and you should report that number. See  #14 above
29. Line 262 again delete the word “acceptable"" and let your data speak for itself. It sounds
like you are trying to justify your report. You DO NOT NEED TO DO THIS. Every reader and
the editor should know how difficult this study was for you to do!  Well done!
30. Delete figure 3, it adds virtually nothing that is not in the text. Provide references for tables
1 and 2. Table 4 is unnecessary. Adding these data to the text will prevent another table for the
reader to have to look for
Now authors I know ow that no one likes to edit their work BUT you have done a really good
study and you want it to come across  in a positive way- all the suggestions above WILL
IMPROVE the study which is good for you, good for your hospitals, good for Cameroon, and
good for the continent.  You should be proud of this study!!!!!"
Title: Perioperative outcomes of the surgical management of achalasia in two tertiary
Cameroonian hospitals: a cohort study
Version: 3 Date: 17 Jan 2024
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?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
Yes - experiments and analyses were performed appropriately
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?
Yes - the author's interpretation is reasonable
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?
Probably - with minor revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: Because this was a re-review I also added the re-review headings.
HAVE THE AUTHORS RESPONDED ADEQUATELY TO EACH OF THE QUESTIONS
RAISED IN THE COMMENTS?
Yes
HAVE THEY MADE THE APPROPRIATE CHANGES IN THE MANUSCRIPT?
For the reviewers' comments, yes.
WHAT IS YOUR OVERALL IMPRESSION OF THE REVISED MANUSCRIPT?
Although this needs another edit this is a good paper that reports believable data and supports
the excellent care delivered at these two hospitals in Cameron. This is good for the hospitals,
good for the country, and quite frankly good for the continent.
WHAT HAVE  THE AURTHORS DONE WELL?
They did the best that can be expected in a finance-challenged country in Africa and they did an
excellent job. The topic is timely for their country and their continent.
IN WHAT WAYS DOES IT NOT MEET BEST PRACTICE?
Quite frankly, it DOES  meet best practice.
ADDITIONAL REQUESTS/SUGGESTIONS:
ARE THERE ANY ADDITIONAL REVISIONS THE AUTHORS SHOULD MAKE?
Authors please note that I did not review your first submission but have read your responses to
the previous reviews.  I will, however, approach this as if it was a primary review -please note
that my goal is to make this a better submission for you and your career/hospital. All suggestions
will be constructive and positive!
1. Line 42 and through the text. Statistically with less than 100 patients (in your case 29) all
percentages should be rounded off to the whole number as well as age, months of symptoms
( e.g. 51+|- 20 line 43), etc. and all the values that have a decimal point need to be reviewed as
to whether they should also be rounded off. Then when you report these values the number of
decimal points in the value as well as the variance (which you need to add to a statistics paragraph
need to be the same. For instance line 217 the Eckhardt score  should be 9+\-1 or 9.1+\-1.1
2. Be prepared I am going to make many suggestions-  all are constructive so please understand
that I do highly support your submission, but it needs some change to what I think must be
French to English  translation
3 Line 42 change cases to patients
4. Line 52 delete the term “There was an acceptable “ change to “The”. Acceptable could be
argued. Just describe your data without any editorial comment, let your data speak for itself and
it will!
5. Line 48 and line 246 the term hemivalve is not the usual term. I would suggest that you change
it to partial fundoplication
6. Lines 65-67 this is a mistake on your part, the incidences are 10-105 PER 100,00 of the
population not 10 to 105. Please rephrase as per 100,000 population. I suggest that after the
word “incidences' you put (per 100,000 population) that will clear this up and convert what look
like  %s in refs 4 and 5
7. Line 77 and line 249change to “open”
8. Line 83. Botox is a trade name, change to botulinum toxin
9. Line 86 start a new paragraph
10. Line 107. The word hyperprotestic is not a word. Yes there is a word hyperproteic but that
is not common, just change to “high protein diet”
11. Line 113  the phrase “on lakes” makes no sense to me-  delete the part of that sentence at
the end starting with “to put…”
12. Line 115 define where and how long the cardiomyotomy was made how far down into the
cardiac and how far up the distal esophagus
13. Line 117 change device to procedure
14. Line 152 add here how many patients were identified and how many patients were contacted,
this will give the reader an idea of what % of the operated patients were evaluated. This could
also be put on lines 146-149 but needs to be somewhere in the manuscript. I prefer in the methods
section
15.line 131 change assembly to procedure
16. Lines 152-153. An argument could be given to exclude the infants; it is a bit of a different
topic and some of your data will be skewed such as duration of symptoms. I would discuss the
infants as a separate category but not just Clyde them I. Your overall data analyses will leave
that up to you and the journal editor but really they are two different populations
17. Line 154. You are somewhere going to have to explain why you had a female predominance
- other studies do not show this
18. Line 162-163. Best to define what you mean by paradoxical dysplasia, some readers will
not know this
19. Line 174. The word stenosis is not appropriate, I would say non relaxation at the (e.g.)
junction
20. Line 190 add the ” and extended XXXcm onto the cardia” -this is crucially important to report
21. Line 202 change to removal not ablation
22. Lines 208-209 you need to define surgical site infections that required a laparotomy.  These
must have been deep space infections like a subphrenic abscess or a contained esophageal leak;
clearly defined these, because they required laparotomy. They were not just a wound infection!
23. Line 225 delete the phrase of ""an acceptable sample size"" and just say 29  lack African
patients in Cameroon. You have a respectable number you do not need to say this and those
who understand the system will be impressed that you got such good follow up! Let your study
speak for itself. Your results are great
24. Line 228 change to partial fundoplication was the most common anti-reflux  procedure”
25. Line 229 change to “occurred in 3 patients all requiring re-laparotomy but with excellent
postop recovery”
26. Line 234. Does the medical system in Cameroon also explain in part the long duration of
symptoms because of difficulty getting advanced medical diagnostic consultations? I suspect so
but do not know if that is true.  It certainly would be true for patients living in rural areas, right?
27 line 251 I think you forgot something here. I think you meant to say “suggest that this
approach can be supported over an open approach” and not “cannot be”
28. Line 256. I agree with what you said but you do have the total number of patients operated
in and you should report that number. See  #14 above
29. Line 262 again delete the word “acceptable"" and let your data speak for itself. It sounds
like you are trying to justify your report. You DO NOT NEED TO DO THIS. Every reader and
the editor should know how difficult this study was for you to do!  Well done!
30. Delete figure 3, it adds virtually nothing that is not in the text. Provide references for tables
1 and 2. Table 4 is unnecessary. Adding these data to the text will prevent another table for the
reader to have to look for
Now authors I know ow that no one likes to edit their work BUT you have done a really good
study and you want it to come across  in a positive way- all the suggestions above WILL
IMPROVE the study which is good for you, good for your hospitals, good for Cameroon, and
good for the continent.  You should be proud of this study!!!!!"
Please review this paper.
user
Title: Perioperative outcomes of the surgical management of achalasia in two tertiary
Cameroonian hospitals: a cohort study
Version: 3 Date: 17 Jan 2024
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?
Yes - the approach is appropriate
EXECUTION - Are the experiments and analyses performed with sufficient technical rigor to
allow confidence in the results?
Yes - experiments and analyses were performed appropriately
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?
Yes - the author's interpretation is reasonable
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?
Probably - with minor revisions
PEER REVIEWER COMMENTS:
GENERAL COMMENTS: Because this was a re-review I also added the re-review headings.
HAVE THE AUTHORS RESPONDED ADEQUATELY TO EACH OF THE QUESTIONS
RAISED IN THE COMMENTS?
Yes
HAVE THEY MADE THE APPROPRIATE CHANGES IN THE MANUSCRIPT?
For the reviewers' comments, yes.
WHAT IS YOUR OVERALL IMPRESSION OF THE REVISED MANUSCRIPT?
Although this needs another edit this is a good paper that reports believable data and supports
the excellent care delivered at these two hospitals in Cameron. This is good for the hospitals,
good for the country, and quite frankly good for the continent.
WHAT HAVE  THE AURTHORS DONE WELL?
They did the best that can be expected in a finance-challenged country in Africa and they did an
excellent job. The topic is timely for their country and their continent.
IN WHAT WAYS DOES IT NOT MEET BEST PRACTICE?
Quite frankly, it DOES  meet best practice.
ADDITIONAL REQUESTS/SUGGESTIONS:
ARE THERE ANY ADDITIONAL REVISIONS THE AUTHORS SHOULD MAKE?
Authors please note that I did not review your first submission but have read your responses to
the previous reviews.  I will, however, approach this as if it was a primary review -please note
that my goal is to make this a better submission for you and your career/hospital. All suggestions
will be constructive and positive!
1. Line 42 and through the text. Statistically with less than 100 patients (in your case 29) all
percentages should be rounded off to the whole number as well as age, months of symptoms
( e.g. 51+|- 20 line 43), etc. and all the values that have a decimal point need to be reviewed as
to whether they should also be rounded off. Then when you report these values the number of
decimal points in the value as well as the variance (which you need to add to a statistics paragraph
need to be the same. For instance line 217 the Eckhardt score  should be 9+\-1 or 9.1+\-1.1
2. Be prepared I am going to make many suggestions-  all are constructive so please understand
that I do highly support your submission, but it needs some change to what I think must be
French to English  translation
3 Line 42 change cases to patients
4. Line 52 delete the term “There was an acceptable “ change to “The”. Acceptable could be
argued. Just describe your data without any editorial comment, let your data speak for itself and
it will!
5. Line 48 and line 246 the term hemivalve is not the usual term. I would suggest that you change
it to partial fundoplication
6. Lines 65-67 this is a mistake on your part, the incidences are 10-105 PER 100,00 of the
population not 10 to 105. Please rephrase as per 100,000 population. I suggest that after the
word “incidences' you put (per 100,000 population) that will clear this up and convert what look
like  %s in refs 4 and 5
7. Line 77 and line 249change to “open”
8. Line 83. Botox is a trade name, change to botulinum toxin
9. Line 86 start a new paragraph
10. Line 107. The word hyperprotestic is not a word. Yes there is a word hyperproteic but that
is not common, just change to “high protein diet”
11. Line 113  the phrase “on lakes” makes no sense to me-  delete the part of that sentence at
the end starting with “to put…”
12. Line 115 define where and how long the cardiomyotomy was made how far down into the
cardiac and how far up the distal esophagus
13. Line 117 change device to procedure
14. Line 152 add here how many patients were identified and how many patients were contacted,
this will give the reader an idea of what % of the operated patients were evaluated. This could
also be put on lines 146-149 but needs to be somewhere in the manuscript. I prefer in the methods
section
15.line 131 change assembly to procedure
16. Lines 152-153. An argument could be given to exclude the infants; it is a bit of a different
topic and some of your data will be skewed such as duration of symptoms. I would discuss the
infants as a separate category but not just Clyde them I. Your overall data analyses will leave
that up to you and the journal editor but really they are two different populations
17. Line 154. You are somewhere going to have to explain why you had a female predominance
- other studies do not show this
18. Line 162-163. Best to define what you mean by paradoxical dysplasia, some readers will
not know this
19. Line 174. The word stenosis is not appropriate, I would say non relaxation at the (e.g.)
junction
20. Line 190 add the ” and extended XXXcm onto the cardia” -this is crucially important to report
21. Line 202 change to removal not ablation
22. Lines 208-209 you need to define surgical site infections that required a laparotomy.  These
must have been deep space infections like a subphrenic abscess or a contained esophageal leak;
clearly defined these, because they required laparotomy. They were not just a wound infection!
23. Line 225 delete the phrase of ""an acceptable sample size"" and just say 29  lack African
patients in Cameroon. You have a respectable number you do not need to say this and those
who understand the system will be impressed that you got such good follow up! Let your study
speak for itself. Your results are great
24. Line 228 change to partial fundoplication was the most common anti-reflux  procedure”
25. Line 229 change to “occurred in 3 patients all requiring re-laparotomy but with excellent
postop recovery”
26. Line 234. Does the medical system in Cameroon also explain in part the long duration of
symptoms because of difficulty getting advanced medical diagnostic consultations? I suspect so
but do not know if that is true.  It certainly would be true for patients living in rural areas, right?
27 line 251 I think you forgot something here. I think you meant to say “suggest that this
approach can be supported over an open approach” and not “cannot be”
28. Line 256. I agree with what you said but you do have the total number of patients operated
in and you should report that number. See  #14 above
29. Line 262 again delete the word “acceptable"" and let your data speak for itself. It sounds
like you are trying to justify your report. You DO NOT NEED TO DO THIS. Every reader and
the editor should know how difficult this study was for you to do!  Well done!
30. Delete figure 3, it adds virtually nothing that is not in the text. Provide references for tables
1 and 2. Table 4 is unnecessary. Adding these data to the text will prevent another table for the
reader to have to look for
Now authors I know ow that no one likes to edit their work BUT you have done a really good
study and you want it to come across  in a positive way- all the suggestions above WILL
IMPROVE the study which is good for you, good for your hospitals, good for Cameroon, and
good for the continent.  You should be proud of this study!!!!!"
assistant