Reviewer’ s report
Title: Indications and complications of intestinal stomas at a tertiary care hospital in a resource-
limited setting: A Tanzanian experience
Version: 3Date: 31 Jan 2019
Reviewer: Reviewer 2
Reviewer's report:
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER: Has the author
addressed your concerns sufficiently for you to now recommend the work as a technically soundcontribution? NoReviewer comments: Additional suggestions1. I would change the title a bit atthe start to "Indications for and complications of ——"2. Background. Change to " An intestinal
aroma, though a lifesaving procedure on the care of many gastrointestinal conditions, carries—-"3.Page 2 line 22 change "and their management" to "and management of aromas" 4 page 2 line 51change to "the most frequent complication of a stoma" and line 54 to " "the most frequentcomplication after stoma closure" and alter delete the word "about" and wrote out the word 35.Line 36 and page 3 line 4 the word "rank" is not ideal use the phrase "level of training" would bebetter 5.page 3 line11 delete the phrase "this study shows that" 6. Page 3 line 19 change to "in theformation and complications of intestinal stomas are the following:"7 page 3 line 24 "specialistsusing change to "and specialists using proper meticulous techniques, and the need to determine—-"8 page 4 line 7 put "has long been one of the more commonly performed" after the word"stoma"9. Page 4 line 55 change "colonies" to "colonic" 10 page 5 line 11 add the word "patient"before the word "education" 11. Page 7 lines 4-6 change "cut circumferentially " to "completelytransected"12. Page 7 line 9 Change "Vircyl" to " polyglactin" use the non-generic name13. Page 7
line 9 the sentence starting with "in this study" delete it this sentence makes no sense14. Page 7
line 14 change to " under either direct or indirect ( by phone) supervision"15 page 7 line 38. Werethe antibiotics given IV or orally?16. Page 7 line 38 the sentence starting with " Whereas in themajority" makes no sense, a loop colostomy is not divided.17. Page 8 line 47 add the phrase (+\-standard deviation) after the word "mean"18. Page 9 line 11 too many significant figureschange 3.72 to 3.7 and 1.38 to 1.4 also line 14 add the word "children" after the word "those"19.Page 9 Line 50 delete the phrase "had double barreled colostomy" because it was in the start ofthat same sentence and on line 50 add the phrase "performing these colostomies" after the word"surgeons". With this the last 2 sentences in this paragraph are unnecessary.20. Page 10 line 7reword to complications related to stoma formation21. Page 10 line 11 drop the word "About"because you give an exact number22. Page 10 lines 15-23 wouldn't it be better to report the%complications in each type of stoma for instance 33 complications developed in the Xnumber ofpatients who had a sigmoid colostomy rather than the % of complications that occurred in thesigmoid colostomy of all the complications. More important is the % that occurs in each type ofcolostomy23. Page 10 line 23-30 add the actual percentages here because this OS THE PRIMARYFINDING OF YOUR PAPER!!!Page 10 lines 42-49 which type of stoma (% ) has the greatest rateof need for revision?24. Page 11 line 19 is 33% correct with only 2 patients that suggests that therewere only 6 total patients25. Page 11 line 40 I would add the phrase ( through the stoma site" after
the word "extraperitoneally) and the phrase " via a formal laparotomy" at the end of the
sentence.26. After reading the results section, nowhere do you describe the policy that at night, the
majority of operations were done by junior colors without direct supervision by specialists- I knowthat you are going to high light this in the discussion but somewhere you should mention this inmore depth.27. First paragraph of discussion the references 4 and 10 come from the developedworld I would add that into the sentence where appropriate and when you review those papersagain, be certain that they were not ONLY adults!!!! If so then say so and quite your mean age inadults as a comparison. The same holds true for references 3,11,and 12 in the next paragraph ofthese papers o let address adults the change your paragraph to only compare your adults and not IClaude the children of your study because the indications differ so radically between adults and
children. 28. Page 13 I really think that the discussion on page 13 lines 4-19 is not helpful-these
studies are most likely from practices that are radically different from yours and thus comparisonis not appropriate. Sorry but here is where your study will. be criticized!29. Page 13 line 32. Your% really is no different than that of Husain say they are similar.30. Page 13 line 39 I disagree. Howmany of these stomas created by junior doctors were at night when there was little of any directsupervision!!! This MUST be changed!31. Page 13 line 55 here you need to add a sentence like "in our study, another likely explanation for the morbidity and mortality of emergency operationswas that at night, the overwhelming majority of these operations were done by junior surgeonswithout any direct supervision by specialists. ISN'T THIS ONE OF YOUR PRIMARYFINDINGS????32. Page 14 line 26 add also extraperitoneal pathway of the existing stoma33.page15 line 4 Add the word "item" after the word "Laparotomy" 34. Page 15 line 31 maybe adding thephrase" who have not shown true objective proficiency in stoma construction " after the word"doctors" 35. Page 15 line 49 was the rate much higher when done by junior doctors? If so thensay so36. Page 16 line 45. If you really want to be strong and try to make a difference you can addthis sentence after the word "operations". " our study provides direct evidence that junior doctorswho have not demonstrated objectively documented competence in creation and closure of stomasshould never be allowed to do these operations without direct supervision by specialists, even inoperations after hours and at night." A strong statement but that is what your study shows!37.
Table 1 what was the etiology of. Peel perforation? Diverticulitis, bowel obstruction? Add as a
footnote Tables 2- 6 Round off all the percentages Table 4 you need to add the total numberof each type of stoma created in the 4th line of the table Finally as the authors you will need morehelp with the grammar and writing thisis well done but there are multiple places that the grammarand word usage needs to be polished the content I have addressed above but it still needs helpwith the writing that many/perhaps most journals may not offer
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
YesDoes the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
YesAre 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 furtherassessment 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 publishedDeclaration 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 thismanuscript, 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.
This reviewer has been recruited by a partner organization, Research Square. Reviewers with
declared or apparent competing interests are not utilized for these reviews. This reviewer hasagreed to publication of their comments online under a Creative Commons Attribution Licenseattributed to Research Square and was paid a small honorarium for completing the review within aspecified timeframe. Honoraria for reviews such as this are paid regardless of the reviewerrecommendation.
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 CommonsCC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any commentswhich I do not wish to be included in my named report can be included as confidential commentsto the editors, which will 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 Tanzanian experience
Version: 3Date: 31 Jan 2019
Reviewer: Reviewer 2
Reviewer's report:
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER: Has the author
addressed your concerns sufficiently for you to now recommend the work as a technically soundcontribution? NoReviewer comments: Additional suggestions1. I would change the title a bit atthe start to "Indications for and complications of ——"2. Background. Change to " An intestinal
aroma, though a lifesaving procedure on the care of many gastrointestinal conditions, carries—-"3.Page 2 line 22 change "and their management" to "and management of aromas" 4 page 2 line 51change to "the most frequent complication of a stoma" and line 54 to " "the most frequentcomplication after stoma closure" and alter delete the word "about" and wrote out the word 35.Line 36 and page 3 line 4 the word "rank" is not ideal use the phrase "level of training" would bebetter 5.page 3 line11 delete the phrase "this study shows that" 6. Page 3 line 19 change to "in theformation and complications of intestinal stomas are the following:"7 page 3 line 24 "specialistsusing change to "and specialists using proper meticulous techniques, and the need to determine—-"8 page 4 line 7 put "has long been one of the more commonly performed" after the word"stoma"9. Page 4 line 55 change "colonies" to "colonic" 10 page 5 line 11 add the word "patient"before the word "education" 11. Page 7 lines 4-6 change "cut circumferentially " to "completelytransected"12. Page 7 line 9 Change "Vircyl" to " polyglactin" use the non-generic name13. Page 7
line 9 the sentence starting with "in this study" delete it this sentence makes no sense14. Page 7
line 14 change to " under either direct or indirect ( by phone) supervision"15 page 7 line 38. Werethe antibiotics given IV or orally?16. Page 7 line 38 the sentence starting with " Whereas in themajority" makes no sense, a loop colostomy is not divided.17. Page 8 line 47 add the phrase (+\-standard deviation) after the word "mean"18. Page 9 line 11 too many significant figureschange 3.72 to 3.7 and 1.38 to 1.4 also line 14 add the word "children" after the word "those"19.Page 9 Line 50 delete the phrase "had double barreled colostomy" because it was in the start ofthat same sentence and on line 50 add the phrase "performing these colostomies" after the word"surgeons". With this the last 2 sentences in this paragraph are unnecessary.20. Page 10 line 7reword to complications related to stoma formation21. Page 10 line 11 drop the word "About"because you give an exact number22. Page 10 lines 15-23 wouldn't it be better to report the%complications in each type of stoma for instance 33 complications developed in the Xnumber ofpatients who had a sigmoid colostomy rather than the % of complications that occurred in thesigmoid colostomy of all the complications. More important is the % that occurs in each type ofcolostomy23. Page 10 line 23-30 add the actual percentages here because this OS THE PRIMARYFINDING OF YOUR PAPER!!!Page 10 lines 42-49 which type of stoma (% ) has the greatest rateof need for revision?24. Page 11 line 19 is 33% correct with only 2 patients that suggests that therewere only 6 total patients25. Page 11 line 40 I would add the phrase ( through the stoma site" after
the word "extraperitoneally) and the phrase " via a formal laparotomy" at the end of the
sentence.26. After reading the results section, nowhere do you describe the policy that at night, the
majority of operations were done by junior colors without direct supervision by specialists- I knowthat you are going to high light this in the discussion but somewhere you should mention this inmore depth.27. First paragraph of discussion the references 4 and 10 come from the developedworld I would add that into the sentence where appropriate and when you review those papersagain, be certain that they were not ONLY adults!!!! If so then say so and quite your mean age inadults as a comparison. The same holds true for references 3,11,and 12 in the next paragraph ofthese papers o let address adults the change your paragraph to only compare your adults and not IClaude the children of your study because the indications differ so radically between adults and
children. 28. Page 13 I really think that the discussion on page 13 lines 4-19 is not helpful-these
studies are most likely from practices that are radically different from yours and thus comparisonis not appropriate. Sorry but here is where your study will. be criticized!29. Page 13 line 32. Your% really is no different than that of Husain say they are similar.30. Page 13 line 39 I disagree. Howmany of these stomas created by junior doctors were at night when there was little of any directsupervision!!! This MUST be changed!31. Page 13 line 55 here you need to add a sentence like "in our study, another likely explanation for the morbidity and mortality of emergency operationswas that at night, the overwhelming majority of these operations were done by junior surgeonswithout any direct supervision by specialists. ISN'T THIS ONE OF YOUR PRIMARYFINDINGS????32. Page 14 line 26 add also extraperitoneal pathway of the existing stoma33.page15 line 4 Add the word "item" after the word "Laparotomy" 34. Page 15 line 31 maybe adding thephrase" who have not shown true objective proficiency in stoma construction " after the word"doctors" 35. Page 15 line 49 was the rate much higher when done by junior doctors? If so thensay so36. Page 16 line 45. If you really want to be strong and try to make a difference you can addthis sentence after the word "operations". " our study provides direct evidence that junior doctorswho have not demonstrated objectively documented competence in creation and closure of stomasshould never be allowed to do these operations without direct supervision by specialists, even inoperations after hours and at night." A strong statement but that is what your study shows!37.
Table 1 what was the etiology of. Peel perforation? Diverticulitis, bowel obstruction? Add as a
footnote Tables 2- 6 Round off all the percentages Table 4 you need to add the total numberof each type of stoma created in the 4th line of the table Finally as the authors you will need morehelp with the grammar and writing thisis well done but there are multiple places that the grammarand word usage needs to be polished the content I have addressed above but it still needs helpwith the writing that many/perhaps most journals may not offer
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
YesDoes the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
YesAre 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 furtherassessment 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 publishedDeclaration 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 thismanuscript, 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.
This reviewer has been recruited by a partner organization, Research Square. Reviewers with
declared or apparent competing interests are not utilized for these reviews. This reviewer hasagreed to publication of their comments online under a Creative Commons Attribution Licenseattributed to Research Square and was paid a small honorarium for completing the review within aspecified timeframe. Honoraria for reviews such as this are paid regardless of the reviewerrecommendation.
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 CommonsCC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any commentswhich I do not wish to be included in my named report can be included as confidential commentsto 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: Indications and complications of intestinal stomas at a tertiary care hospital in a resource-
limited setting: A Tanzanian experience
Version: 3Date: 31 Jan 2019
Reviewer: Reviewer 2
Reviewer's report:
REVISION ASSESSMENT FROM THE ACADEMIC PEER REVIEWER: Has the author
addressed your concerns sufficiently for you to now recommend the work as a technically soundcontribution? NoReviewer comments: Additional suggestions1. I would change the title a bit atthe start to "Indications for and complications of ——"2. Background. Change to " An intestinal
aroma, though a lifesaving procedure on the care of many gastrointestinal conditions, carries—-"3.Page 2 line 22 change "and their management" to "and management of aromas" 4 page 2 line 51change to "the most frequent complication of a stoma" and line 54 to " "the most frequentcomplication after stoma closure" and alter delete the word "about" and wrote out the word 35.Line 36 and page 3 line 4 the word "rank" is not ideal use the phrase "level of training" would bebetter 5.page 3 line11 delete the phrase "this study shows that" 6. Page 3 line 19 change to "in theformation and complications of intestinal stomas are the following:"7 page 3 line 24 "specialistsusing change to "and specialists using proper meticulous techniques, and the need to determine—-"8 page 4 line 7 put "has long been one of the more commonly performed" after the word"stoma"9. Page 4 line 55 change "colonies" to "colonic" 10 page 5 line 11 add the word "patient"before the word "education" 11. Page 7 lines 4-6 change "cut circumferentially " to "completelytransected"12. Page 7 line 9 Change "Vircyl" to " polyglactin" use the non-generic name13. Page 7
line 9 the sentence starting with "in this study" delete it this sentence makes no sense14. Page 7
line 14 change to " under either direct or indirect ( by phone) supervision"15 page 7 line 38. Werethe antibiotics given IV or orally?16. Page 7 line 38 the sentence starting with " Whereas in themajority" makes no sense, a loop colostomy is not divided.17. Page 8 line 47 add the phrase (+\-standard deviation) after the word "mean"18. Page 9 line 11 too many significant figureschange 3.72 to 3.7 and 1.38 to 1.4 also line 14 add the word "children" after the word "those"19.Page 9 Line 50 delete the phrase "had double barreled colostomy" because it was in the start ofthat same sentence and on line 50 add the phrase "performing these colostomies" after the word"surgeons". With this the last 2 sentences in this paragraph are unnecessary.20. Page 10 line 7reword to complications related to stoma formation21. Page 10 line 11 drop the word "About"because you give an exact number22. Page 10 lines 15-23 wouldn't it be better to report the%complications in each type of stoma for instance 33 complications developed in the Xnumber ofpatients who had a sigmoid colostomy rather than the % of complications that occurred in thesigmoid colostomy of all the complications. More important is the % that occurs in each type ofcolostomy23. Page 10 line 23-30 add the actual percentages here because this OS THE PRIMARYFINDING OF YOUR PAPER!!!Page 10 lines 42-49 which type of stoma (% ) has the greatest rateof need for revision?24. Page 11 line 19 is 33% correct with only 2 patients that suggests that therewere only 6 total patients25. Page 11 line 40 I would add the phrase ( through the stoma site" after
the word "extraperitoneally) and the phrase " via a formal laparotomy" at the end of the
sentence.26. After reading the results section, nowhere do you describe the policy that at night, the
majority of operations were done by junior colors without direct supervision by specialists- I knowthat you are going to high light this in the discussion but somewhere you should mention this inmore depth.27. First paragraph of discussion the references 4 and 10 come from the developedworld I would add that into the sentence where appropriate and when you review those papersagain, be certain that they were not ONLY adults!!!! If so then say so and quite your mean age inadults as a comparison. The same holds true for references 3,11,and 12 in the next paragraph ofthese papers o let address adults the change your paragraph to only compare your adults and not IClaude the children of your study because the indications differ so radically between adults and
children. 28. Page 13 I really think that the discussion on page 13 lines 4-19 is not helpful-these
studies are most likely from practices that are radically different from yours and thus comparisonis not appropriate. Sorry but here is where your study will. be criticized!29. Page 13 line 32. Your% really is no different than that of Husain say they are similar.30. Page 13 line 39 I disagree. Howmany of these stomas created by junior doctors were at night when there was little of any directsupervision!!! This MUST be changed!31. Page 13 line 55 here you need to add a sentence like "in our study, another likely explanation for the morbidity and mortality of emergency operationswas that at night, the overwhelming majority of these operations were done by junior surgeonswithout any direct supervision by specialists. ISN'T THIS ONE OF YOUR PRIMARYFINDINGS????32. Page 14 line 26 add also extraperitoneal pathway of the existing stoma33.page15 line 4 Add the word "item" after the word "Laparotomy" 34. Page 15 line 31 maybe adding thephrase" who have not shown true objective proficiency in stoma construction " after the word"doctors" 35. Page 15 line 49 was the rate much higher when done by junior doctors? If so thensay so36. Page 16 line 45. If you really want to be strong and try to make a difference you can addthis sentence after the word "operations". " our study provides direct evidence that junior doctorswho have not demonstrated objectively documented competence in creation and closure of stomasshould never be allowed to do these operations without direct supervision by specialists, even inoperations after hours and at night." A strong statement but that is what your study shows!37.
Table 1 what was the etiology of. Peel perforation? Diverticulitis, bowel obstruction? Add as a
footnote Tables 2- 6 Round off all the percentages Table 4 you need to add the total numberof each type of stoma created in the 4th line of the table Finally as the authors you will need morehelp with the grammar and writing thisis well done but there are multiple places that the grammarand word usage needs to be polished the content I have addressed above but it still needs helpwith the writing that many/perhaps most journals may not offer
Are the methods appropriate and well described?
If not, please specify what is required in your comments to the authors.
YesDoes the work include the necessary controls?
If not, please specify which controls are required in your comments to the authors.
YesAre 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 furtherassessment 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 publishedDeclaration 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 thismanuscript, 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.
This reviewer has been recruited by a partner organization, Research Square. Reviewers with
declared or apparent competing interests are not utilized for these reviews. This reviewer hasagreed to publication of their comments online under a Creative Commons Attribution Licenseattributed to Research Square and was paid a small honorarium for completing the review within aspecified timeframe. Honoraria for reviews such as this are paid regardless of the reviewerrecommendation.
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 CommonsCC-BY license (http://creativecommons.org/licenses/by/4.0/). I understand that any commentswhich I do not wish to be included in my named report can be included as confidential commentsto the editors, which will not be published.
I agree to the open peer review policy of the journal
assistant