Title: Frequency, outcomes, and need for intervention in stricturing gastrointestinal
tuberculosis: A systematic review and meta-analysis
Version: 1 Date: 08 Aug 2022
Reviewer's report:
The search strategy, by specifying “AND” stricture OR fibrosis OR stenosis, will be biased
towards articles where strictures have been found and so “frequency” should not be included in
the title nor recorded as a result in the abstract and manuscript.  So, the study might be better
titled as “The effect of anti-tuberculosis (TB) treatment on the need for surgical intervention in
gastro-intestinal tuberculosis with strictures…”.
Such a study would then have to exclude those in whom surgery was undertaken immediately
and include only those who had surgery after completing a course of effective TB treatment.
Furthermore, the decision for endoscopic or surgical intervention may be limited by availability
of the two different procedures.  Each included paper should investigate whether the criteria for
each procedure, where both were available, are consistent among the different publications.
If the authors wished to estimate the frequency of stricture formation, then studies of
gastrointestinal TB not requiring surgical intervention might be helpful in providing a lower
limit to the frequency of stricture formation.
Currently, the conclusions are unsafe due to the heterogeneity of the papers and the inclusion
bias.
The inclusion criteria should consider how gastro-intestinal TB was diagnosed, whether by
a positive culture or PCR of gastro-intestinal tissue, concurrent cultures from pulmonary
specimens or merely by histological diagnosis (where Crohn’s disease might remain a possible
diagnosis) with or without concurrent radiological criteria.
As structuring is not an all-or-none phenomenon, especially with regard to symptoms of
diarrhoea or intestinal obstruction, the authors might usefully request individual patient data
from the included papers.  For instance, a >90% stricture might always require surgery, whereas
lesser degrees of stricture formation might be more amenable to treatment.  The authors have
also noted the importance of the site of stricture formation and the number of lesions.
As the authors note in the discussion, the degree of resolution of structuring may well depend
on duration of the disease process and time to diagnosis.  The individual patient data may shed
light on whether this hypothesis is correct.
The search strategy (supplementary Table 1) has been included.  The studies which were
excluded in Supplementary Table 2 includes the 34 papers after eligibility criteria were satisfied.
However, the other three supplementary tables were not available in the download available to
me.
The supplementary figures have not been included in the download available to me.
In view of the high heterogeneity, a random effects model was correctly used.  The limitations
of such a model in this context should be discussed.
Title: Frequency, outcomes, and need for intervention in stricturing gastrointestinal
tuberculosis: A systematic review and meta-analysis
Version: 1 Date: 08 Aug 2022
Reviewer's report:
The search strategy, by specifying “AND” stricture OR fibrosis OR stenosis, will be biased
towards articles where strictures have been found and so “frequency” should not be included in
the title nor recorded as a result in the abstract and manuscript.  So, the study might be better
titled as “The effect of anti-tuberculosis (TB) treatment on the need for surgical intervention in
gastro-intestinal tuberculosis with strictures…”.
Such a study would then have to exclude those in whom surgery was undertaken immediately
and include only those who had surgery after completing a course of effective TB treatment.
Furthermore, the decision for endoscopic or surgical intervention may be limited by availability
of the two different procedures.  Each included paper should investigate whether the criteria for
each procedure, where both were available, are consistent among the different publications.
If the authors wished to estimate the frequency of stricture formation, then studies of
gastrointestinal TB not requiring surgical intervention might be helpful in providing a lower
limit to the frequency of stricture formation.
Currently, the conclusions are unsafe due to the heterogeneity of the papers and the inclusion
bias.
The inclusion criteria should consider how gastro-intestinal TB was diagnosed, whether by
a positive culture or PCR of gastro-intestinal tissue, concurrent cultures from pulmonary
specimens or merely by histological diagnosis (where Crohn’s disease might remain a possible
diagnosis) with or without concurrent radiological criteria.
As structuring is not an all-or-none phenomenon, especially with regard to symptoms of
diarrhoea or intestinal obstruction, the authors might usefully request individual patient data
from the included papers.  For instance, a >90% stricture might always require surgery, whereas
lesser degrees of stricture formation might be more amenable to treatment.  The authors have
also noted the importance of the site of stricture formation and the number of lesions.
As the authors note in the discussion, the degree of resolution of structuring may well depend
on duration of the disease process and time to diagnosis.  The individual patient data may shed
light on whether this hypothesis is correct.
The search strategy (supplementary Table 1) has been included.  The studies which were
excluded in Supplementary Table 2 includes the 34 papers after eligibility criteria were satisfied.
However, the other three supplementary tables were not available in the download available to
me.
The supplementary figures have not been included in the download available to me.
In view of the high heterogeneity, a random effects model was correctly used.  The limitations
of such a model in this context should be discussed.
Please review this paper.
user
Title: Frequency, outcomes, and need for intervention in stricturing gastrointestinal
tuberculosis: A systematic review and meta-analysis
Version: 1 Date: 08 Aug 2022
Reviewer's report:
The search strategy, by specifying “AND” stricture OR fibrosis OR stenosis, will be biased
towards articles where strictures have been found and so “frequency” should not be included in
the title nor recorded as a result in the abstract and manuscript.  So, the study might be better
titled as “The effect of anti-tuberculosis (TB) treatment on the need for surgical intervention in
gastro-intestinal tuberculosis with strictures…”.
Such a study would then have to exclude those in whom surgery was undertaken immediately
and include only those who had surgery after completing a course of effective TB treatment.
Furthermore, the decision for endoscopic or surgical intervention may be limited by availability
of the two different procedures.  Each included paper should investigate whether the criteria for
each procedure, where both were available, are consistent among the different publications.
If the authors wished to estimate the frequency of stricture formation, then studies of
gastrointestinal TB not requiring surgical intervention might be helpful in providing a lower
limit to the frequency of stricture formation.
Currently, the conclusions are unsafe due to the heterogeneity of the papers and the inclusion
bias.
The inclusion criteria should consider how gastro-intestinal TB was diagnosed, whether by
a positive culture or PCR of gastro-intestinal tissue, concurrent cultures from pulmonary
specimens or merely by histological diagnosis (where Crohn’s disease might remain a possible
diagnosis) with or without concurrent radiological criteria.
As structuring is not an all-or-none phenomenon, especially with regard to symptoms of
diarrhoea or intestinal obstruction, the authors might usefully request individual patient data
from the included papers.  For instance, a >90% stricture might always require surgery, whereas
lesser degrees of stricture formation might be more amenable to treatment.  The authors have
also noted the importance of the site of stricture formation and the number of lesions.
As the authors note in the discussion, the degree of resolution of structuring may well depend
on duration of the disease process and time to diagnosis.  The individual patient data may shed
light on whether this hypothesis is correct.
The search strategy (supplementary Table 1) has been included.  The studies which were
excluded in Supplementary Table 2 includes the 34 papers after eligibility criteria were satisfied.
However, the other three supplementary tables were not available in the download available to
me.
The supplementary figures have not been included in the download available to me.
In view of the high heterogeneity, a random effects model was correctly used.  The limitations
of such a model in this context should be discussed.
assistant