Reviewer’s report
Title: 
Preoptimisation in patients with acute obstructive colon cancer
(PREOCC) – a prospective registration study protocol.
Version: 
2 
Date: 
27 Mar 2023
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?
Yes - current version is technically sound
PEER REVIEWER COMMENTS: 
GENERAL COMMENTS: HAVE THE AUTHORS RESPONDED
ADEQUATELY TO EACH OF THE QUESTIONS YOU RAISED IN YOUR
COMMENTS 
In large part yes thank you authors. See my comments below in the next section
HAVE THEY MADE THE APPROPRIATE CHANGES IN THE
MANUSCRIPT 
Yes in large part- thank you!
1. I still have some concerns cc my comment #14. 
For an obstructing colonic
lesion of the right colon or hepatic flexure, if the ileocecal valve is competent,
the proximal colon can as you say dilate and may even perforate. I really doubt ,
however, that reliance on the clinical findings ( vital parameters)of the patients
will tell you whether the proximal colon is decompressed with only an NG tube.
Shouldn't you check a simple X-ray after starting NG decompression in patients
with colonic obstruction who do not have a SEMS -I.e. those with a proximal
right sided colonic obstruction? I rather think so
2. In response to comment 15 your use of the phrase" ileo-/colostomy" really
should be worded as " ileostomy of colostomy proximal to the site of
obstruction, preferentially in the transverse colon". But please note. These are
not great permanent colostomies because they tend to prolapse yes they are good
temporary colostomies but not good permanent colostomies- have you
considered a cecostomy which is also able to be done laparoscopically but
obviously only for temporary decompression
3. Thank you for your detailed response to the lack of a DSMB. I now
understand your plan BUT will other readers know this if you do not address in
the manuscript why a DSMB is not required? I didn't and my guess is that
concerned others will also raise the question of why a DSMB is not being used. I
think a simple clarification in the manuscript will prevent this.
Again thank you for your detailed response !
WHAT IS YOUR OVERALL IMPRESSION OF THE REVISED
MANUSCRIPT 
Much clearer now and I am happy with the manuscript
ADDITIONAL REQUESTS/SUGGESTIONS: 
ARE THERE ANY ADDITIONAL REVISIONS THE AUTHORS SHOULD
MAKE 
I have re-read the entire track changes manuscript( thank you for including it!
Very helpful as you obviously understand) and have only a few minor
suggestions 
All line numbers refer to the track changes manuscript 
1. Line 38, 182, 279 change " ileo- or colostomy" to "ileostomy or colostomy
proximal to the site of obstruction"
2. Authors I learned that optimization is the correct spelling in Europe while in
the US it is with a "x" instead of an "s" hahahahah. 
I am always open to learn
3. Line 121 might you add at the end of the sentence that and because the use of
a SEMS has not been well studied; therefore in these patients we will rely on the
BG to decompress the more proximal colon"
4. Lines 124/5 this needs to be edited I think you mean "placement of a SEMS or
after decompression by an ileostomy or colostomy and is beneficial ***"
5 line 130 change "potent" to " competent"
6. Line 136 I still think a screening abdominal fils might be useful several hours
after the NG is placed because the patient's vital parameters may not reflect
whether the proximal colon is decompressed with a total right sided colonic
obstruction - though I must say I have no experience with this possibility
7. Line 233. I might suggest that you delete the word "no" and change to "
repeated regular supervision is not possible". Sounds better than "no"
8. Line 307. I think the protocol will be better understood by adding a paragraph
here on why no DSMB is included. But I will leave that up to you and the
journal editor.
9. Line 392 change " sufficient " to " competent"
10. I did not get a copy of the figure or tables so I cannot comment on them
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.
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 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 completing the review within a specified
timeframe. Honoraria for reviews such as this are paid regardless of the reviewer
recommendation.
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Web of Science Reviewer Recognition
. Springer Nature can send verification
of this review directly to a Web of Science researcher profile (a subsidiary of
Clarivate Analytics). If you would like to take advantage of this service, please
click on the “Yes” option below. Your name, email address, title of the reviewed
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“Review Data”) will then be transmitted to Web of Science after the final
decision on the manuscript has been made. If you have already registered with
Web of Science for a 
Web of Science researcher profile (this service was
previously known as “Publons”), they will notify you of the receipt of this
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not registered with Web of Science, you will receive an email from them asking
you to register in order for them to be able to recognize your review on your new
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metadata for the benefit of Web of Science and you as a reviewer, carefully
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No
Reviewer’s report
Title: 
Preoptimisation in patients with acute obstructive colon cancer
(PREOCC) – a prospective registration study protocol.
Version: 
2 
Date: 
27 Mar 2023
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?
Yes - current version is technically sound
PEER REVIEWER COMMENTS: 
GENERAL COMMENTS: HAVE THE AUTHORS RESPONDED
ADEQUATELY TO EACH OF THE QUESTIONS YOU RAISED IN YOUR
COMMENTS 
In large part yes thank you authors. See my comments below in the next section
HAVE THEY MADE THE APPROPRIATE CHANGES IN THE
MANUSCRIPT 
Yes in large part- thank you!
1. I still have some concerns cc my comment #14. 
For an obstructing colonic
lesion of the right colon or hepatic flexure, if the ileocecal valve is competent,
the proximal colon can as you say dilate and may even perforate. I really doubt ,
however, that reliance on the clinical findings ( vital parameters)of the patients
will tell you whether the proximal colon is decompressed with only an NG tube.
Shouldn't you check a simple X-ray after starting NG decompression in patients
with colonic obstruction who do not have a SEMS -I.e. those with a proximal
right sided colonic obstruction? I rather think so
2. In response to comment 15 your use of the phrase" ileo-/colostomy" really
should be worded as " ileostomy of colostomy proximal to the site of
obstruction, preferentially in the transverse colon". But please note. These are
not great permanent colostomies because they tend to prolapse yes they are good
temporary colostomies but not good permanent colostomies- have you
considered a cecostomy which is also able to be done laparoscopically but
obviously only for temporary decompression
3. Thank you for your detailed response to the lack of a DSMB. I now
understand your plan BUT will other readers know this if you do not address in
the manuscript why a DSMB is not required? I didn't and my guess is that
concerned others will also raise the question of why a DSMB is not being used. I
think a simple clarification in the manuscript will prevent this.
Again thank you for your detailed response !
WHAT IS YOUR OVERALL IMPRESSION OF THE REVISED
MANUSCRIPT 
Much clearer now and I am happy with the manuscript
ADDITIONAL REQUESTS/SUGGESTIONS: 
ARE THERE ANY ADDITIONAL REVISIONS THE AUTHORS SHOULD
MAKE 
I have re-read the entire track changes manuscript( thank you for including it!
Very helpful as you obviously understand) and have only a few minor
suggestions 
All line numbers refer to the track changes manuscript 
1. Line 38, 182, 279 change " ileo- or colostomy" to "ileostomy or colostomy
proximal to the site of obstruction"
2. Authors I learned that optimization is the correct spelling in Europe while in
the US it is with a "x" instead of an "s" hahahahah. 
I am always open to learn
3. Line 121 might you add at the end of the sentence that and because the use of
a SEMS has not been well studied; therefore in these patients we will rely on the
BG to decompress the more proximal colon"
4. Lines 124/5 this needs to be edited I think you mean "placement of a SEMS or
after decompression by an ileostomy or colostomy and is beneficial ***"
5 line 130 change "potent" to " competent"
6. Line 136 I still think a screening abdominal fils might be useful several hours
after the NG is placed because the patient's vital parameters may not reflect
whether the proximal colon is decompressed with a total right sided colonic
obstruction - though I must say I have no experience with this possibility
7. Line 233. I might suggest that you delete the word "no" and change to "
repeated regular supervision is not possible". Sounds better than "no"
8. Line 307. I think the protocol will be better understood by adding a paragraph
here on why no DSMB is included. But I will leave that up to you and the
journal editor.
9. Line 392 change " sufficient " to " competent"
10. I did not get a copy of the figure or tables so I cannot comment on them
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.
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 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 completing the review within a specified
timeframe. Honoraria for reviews such as this are paid regardless of the reviewer
recommendation.
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Web of Science Reviewer Recognition
. Springer Nature can send verification
of this review directly to a Web of Science researcher profile (a subsidiary of
Clarivate Analytics). If you would like to take advantage of this service, please
click on the “Yes” option below. Your name, email address, title of the reviewed
manuscript, name of the journal, and date of your review submission (the
“Review Data”) will then be transmitted to Web of Science after the final
decision on the manuscript has been made. If you have already registered with
Web of Science for a 
Web of Science researcher profile (this service was
previously known as “Publons”), they will notify you of the receipt of this
review and update your profile as per your settings and their policy. If you are
not registered with Web of Science, you will receive an email from them asking
you to register in order for them to be able to recognize your review on your new
profile page. Web of Science may use the Review Data to generate derivative
metadata for the benefit of Web of Science and you as a reviewer, carefully
considering the sensitivity of such information. For example, Web of Science
may verify your record as a reviewer by updating your profile published on its
webservice if you have registered for such service or help editors to identify
candidate reviewers. Please find the details of processing in Web of Science’s
privacy policy 
https://clarivate.com/privacy-center/notices-policies/privacy-
policy/
No
Please review this paper.
user
Reviewer’s report
Title: 
Preoptimisation in patients with acute obstructive colon cancer
(PREOCC) – a prospective registration study protocol.
Version: 
2 
Date: 
27 Mar 2023
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?
Yes - current version is technically sound
PEER REVIEWER COMMENTS: 
GENERAL COMMENTS: HAVE THE AUTHORS RESPONDED
ADEQUATELY TO EACH OF THE QUESTIONS YOU RAISED IN YOUR
COMMENTS 
In large part yes thank you authors. See my comments below in the next section
HAVE THEY MADE THE APPROPRIATE CHANGES IN THE
MANUSCRIPT 
Yes in large part- thank you!
1. I still have some concerns cc my comment #14. 
For an obstructing colonic
lesion of the right colon or hepatic flexure, if the ileocecal valve is competent,
the proximal colon can as you say dilate and may even perforate. I really doubt ,
however, that reliance on the clinical findings ( vital parameters)of the patients
will tell you whether the proximal colon is decompressed with only an NG tube.
Shouldn't you check a simple X-ray after starting NG decompression in patients
with colonic obstruction who do not have a SEMS -I.e. those with a proximal
right sided colonic obstruction? I rather think so
2. In response to comment 15 your use of the phrase" ileo-/colostomy" really
should be worded as " ileostomy of colostomy proximal to the site of
obstruction, preferentially in the transverse colon". But please note. These are
not great permanent colostomies because they tend to prolapse yes they are good
temporary colostomies but not good permanent colostomies- have you
considered a cecostomy which is also able to be done laparoscopically but
obviously only for temporary decompression
3. Thank you for your detailed response to the lack of a DSMB. I now
understand your plan BUT will other readers know this if you do not address in
the manuscript why a DSMB is not required? I didn't and my guess is that
concerned others will also raise the question of why a DSMB is not being used. I
think a simple clarification in the manuscript will prevent this.
Again thank you for your detailed response !
WHAT IS YOUR OVERALL IMPRESSION OF THE REVISED
MANUSCRIPT 
Much clearer now and I am happy with the manuscript
ADDITIONAL REQUESTS/SUGGESTIONS: 
ARE THERE ANY ADDITIONAL REVISIONS THE AUTHORS SHOULD
MAKE 
I have re-read the entire track changes manuscript( thank you for including it!
Very helpful as you obviously understand) and have only a few minor
suggestions 
All line numbers refer to the track changes manuscript 
1. Line 38, 182, 279 change " ileo- or colostomy" to "ileostomy or colostomy
proximal to the site of obstruction"
2. Authors I learned that optimization is the correct spelling in Europe while in
the US it is with a "x" instead of an "s" hahahahah. 
I am always open to learn
3. Line 121 might you add at the end of the sentence that and because the use of
a SEMS has not been well studied; therefore in these patients we will rely on the
BG to decompress the more proximal colon"
4. Lines 124/5 this needs to be edited I think you mean "placement of a SEMS or
after decompression by an ileostomy or colostomy and is beneficial ***"
5 line 130 change "potent" to " competent"
6. Line 136 I still think a screening abdominal fils might be useful several hours
after the NG is placed because the patient's vital parameters may not reflect
whether the proximal colon is decompressed with a total right sided colonic
obstruction - though I must say I have no experience with this possibility
7. Line 233. I might suggest that you delete the word "no" and change to "
repeated regular supervision is not possible". Sounds better than "no"
8. Line 307. I think the protocol will be better understood by adding a paragraph
here on why no DSMB is included. But I will leave that up to you and the
journal editor.
9. Line 392 change " sufficient " to " competent"
10. I did not get a copy of the figure or tables so I cannot comment on them
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.
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 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 completing the review within a specified
timeframe. Honoraria for reviews such as this are paid regardless of the reviewer
recommendation.
Reviewer Publication Consent.
 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
) if this manuscript is accepted for
publication. Any comments that I do not wish to be included in the published
report have been included as confidential comments to the editor, which will not
be published.
If you are not happy for us to publish this report, please contact the
editorial office before completing the review.
If you wish, you can include your
name in your published report. Please note you must decide whether to include
your name at the start of the process and confirm this decision whenever
prompted. If you change your decision later, we will not be able to publish your
name.
I agree to the terms of the CC-BY 4.0 license; please 
do not
 publish my name
with my report. (default)
Is the study design appropriate to answer the research question (including the use
of appropriate controls), and are the conclusions supported by the evidence
presented?
Yes
Are the methods sufficiently described to allow the study to be repeated?
Yes
Is the use of statistics and treatment of uncertainties appropriate?
Yes
Is the presentation of the work clear?
No
Are the images in this manuscript (including electrophoretic gels and blots) free
from apparent manipulation?
Yes
Web of Science Reviewer Recognition
. Springer Nature can send verification
of this review directly to a Web of Science researcher profile (a subsidiary of
Clarivate Analytics). If you would like to take advantage of this service, please
click on the “Yes” option below. Your name, email address, title of the reviewed
manuscript, name of the journal, and date of your review submission (the
“Review Data”) will then be transmitted to Web of Science after the final
decision on the manuscript has been made. If you have already registered with
Web of Science for a 
Web of Science researcher profile (this service was
previously known as “Publons”), they will notify you of the receipt of this
review and update your profile as per your settings and their policy. If you are
not registered with Web of Science, you will receive an email from them asking
you to register in order for them to be able to recognize your review on your new
profile page. Web of Science may use the Review Data to generate derivative
metadata for the benefit of Web of Science and you as a reviewer, carefully
considering the sensitivity of such information. For example, Web of Science
may verify your record as a reviewer by updating your profile published on its
webservice if you have registered for such service or help editors to identify
candidate reviewers. Please find the details of processing in Web of Science’s
privacy policy 
https://clarivate.com/privacy-center/notices-policies/privacy-
policy/
No
assistant