Reviewer’s report
Title: The challenging diagnosis and treatment of duodenal diverticulum perforation. A report of two
cases.
Version: 1 Date: 28 Oct 2019
Reviewer: Deeksha Kapoor
Reviewer's report:
The authors have made an effort in the correct direction to address the absence of consensus in the
management of duodenal diverticular perforation. 
However, i would like to make a few comments and raise a few questions 
Case 1 - 
- There is no mention of any oral contrast being given during CT abdomen, which helped in identifying
the site of perforation. 
- Is it a routine protocol at the author's institute to perform a oral contrast study after perforation repair
before initiating oral feeds? And if not, why was it done for this case? 
Case 2 - 
- What was the indication of performing a MR abdomen for this patient ?
- Patient was started on oral diet from day 10 on wards, so what was the indication of performing a CT
scan on day 18 and then a MR abdomen the next day ? 
Would like to respond to the authors reply, and am open to further interaction over this article.
On page 6, lines 30/31 - What does 'limited perforation' mean ? and how will it be identified/ defined ? 
Endoscopic management is just mentioned, without describing where it would be indicated and what
would be the success rate for the same 
Comments - 
A patient presenting with free intra abdominal duodenal leak is  expected to have peritonitis and
requires surgery. However, conservative management can be attempted in a patient with contained
retroperitoneal leak, no signs of generalized peritonitis and maybe a patient with known duodenal
diverticulum. 
It is by extension of logic that a properly performed CT abdomen with on table oral contrast is
important in treatment  planning and maybe considered  imperative for diagnosis  of a  diverticular
perforation. Surgical versus conservative measures can be described depending on peritoneal features,
patient's hemodynamic status, CT findings and availability of interventional radiology team. 
These parameters have not been adequately highlighted in the article and should be emphasized.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
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 manuscript or would you recommend an additional
statistical review?
If  an  additional  statistical  review  is  recommended,  please  specify  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 questions:
1. Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this
manuscript, either now or in the future?
2. Do you hold any stocks or shares in an organisation that 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 you 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 interests 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.
I declare that i have no competing interests
I agree to the open peer review policy of the journal. I understand that my name will be included on my
report to the authors and, if the manuscript is accepted for publication, my named report including any 
attachments I upload will be posted on the website along with the authors' 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 included as confidential comments to the editors, which will not
be published.
I agree to the open peer review policy of the journal
Reviewer’s report
Title: The challenging diagnosis and treatment of duodenal diverticulum perforation. A report of two
cases.
Version: 1 Date: 28 Oct 2019
Reviewer: Deeksha Kapoor
Reviewer's report:
The authors have made an effort in the correct direction to address the absence of consensus in the
management of duodenal diverticular perforation. 
However, i would like to make a few comments and raise a few questions 
Case 1 - 
- There is no mention of any oral contrast being given during CT abdomen, which helped in identifying
the site of perforation. 
- Is it a routine protocol at the author's institute to perform a oral contrast study after perforation repair
before initiating oral feeds? And if not, why was it done for this case? 
Case 2 - 
- What was the indication of performing a MR abdomen for this patient ?
- Patient was started on oral diet from day 10 on wards, so what was the indication of performing a CT
scan on day 18 and then a MR abdomen the next day ? 
Would like to respond to the authors reply, and am open to further interaction over this article.
On page 6, lines 30/31 - What does 'limited perforation' mean ? and how will it be identified/ defined ? 
Endoscopic management is just mentioned, without describing where it would be indicated and what
would be the success rate for the same 
Comments - 
A patient presenting with free intra abdominal duodenal leak is  expected to have peritonitis and
requires surgery. However, conservative management can be attempted in a patient with contained
retroperitoneal leak, no signs of generalized peritonitis and maybe a patient with known duodenal
diverticulum. 
It is by extension of logic that a properly performed CT abdomen with on table oral contrast is
important in treatment  planning and maybe considered  imperative for diagnosis  of a  diverticular
perforation. Surgical versus conservative measures can be described depending on peritoneal features,
patient's hemodynamic status, CT findings and availability of interventional radiology team. 
These parameters have not been adequately highlighted in the article and should be emphasized.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
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 manuscript or would you recommend an additional
statistical review?
If  an  additional  statistical  review  is  recommended,  please  specify  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 questions:
1. Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this
manuscript, either now or in the future?
2. Do you hold any stocks or shares in an organisation that 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 you 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 interests 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.
I declare that i have no competing interests
I agree to the open peer review policy of the journal. I understand that my name will be included on my
report to the authors and, if the manuscript is accepted for publication, my named report including any 
attachments I upload will be posted on the website along with the authors' 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 included as confidential comments to the editors, which will not
be published.
I agree to the open peer review policy of the journal
Please review this paper.
user
Reviewer’s report
Title: The challenging diagnosis and treatment of duodenal diverticulum perforation. A report of two
cases.
Version: 1 Date: 28 Oct 2019
Reviewer: Deeksha Kapoor
Reviewer's report:
The authors have made an effort in the correct direction to address the absence of consensus in the
management of duodenal diverticular perforation. 
However, i would like to make a few comments and raise a few questions 
Case 1 - 
- There is no mention of any oral contrast being given during CT abdomen, which helped in identifying
the site of perforation. 
- Is it a routine protocol at the author's institute to perform a oral contrast study after perforation repair
before initiating oral feeds? And if not, why was it done for this case? 
Case 2 - 
- What was the indication of performing a MR abdomen for this patient ?
- Patient was started on oral diet from day 10 on wards, so what was the indication of performing a CT
scan on day 18 and then a MR abdomen the next day ? 
Would like to respond to the authors reply, and am open to further interaction over this article.
On page 6, lines 30/31 - What does 'limited perforation' mean ? and how will it be identified/ defined ? 
Endoscopic management is just mentioned, without describing where it would be indicated and what
would be the success rate for the same 
Comments - 
A patient presenting with free intra abdominal duodenal leak is  expected to have peritonitis and
requires surgery. However, conservative management can be attempted in a patient with contained
retroperitoneal leak, no signs of generalized peritonitis and maybe a patient with known duodenal
diverticulum. 
It is by extension of logic that a properly performed CT abdomen with on table oral contrast is
important in treatment  planning and maybe considered  imperative for diagnosis  of a  diverticular
perforation. Surgical versus conservative measures can be described depending on peritoneal features,
patient's hemodynamic status, CT findings and availability of interventional radiology team. 
These parameters have not been adequately highlighted in the article and should be emphasized.
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
Yes
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 manuscript or would you recommend an additional
statistical review?
If  an  additional  statistical  review  is  recommended,  please  specify  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 questions:
1. Have you in the past five years received reimbursements, fees, funding, or salary from an
organisation that may in any way gain or lose financially from the publication of this
manuscript, either now or in the future?
2. Do you hold any stocks or shares in an organisation that 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 you 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 interests 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.
I declare that i have no competing interests
I agree to the open peer review policy of the journal. I understand that my name will be included on my
report to the authors and, if the manuscript is accepted for publication, my named report including any 
attachments I upload will be posted on the website along with the authors' 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 included as confidential comments to the editors, which will not
be published.
I agree to the open peer review policy of the journal
assistant