Reviewer ’s report  
 
Title: Long -term Outcomes and Quality of Life of Patien ts with Hirschsprung Disease: A 
Systematic Review and Meta -analysis  
 
Version: 0 Date: 23 May 2019  
 
Reviewer: Zaheer Nabi  
 
Reviewer's report:  
 
In this systematic review entitled as "Prevalence of Long -term Outcome and quality of life of 
Patients with Hirschsprung's Disease: A Systematic Review and Meta -analysis", the authors have 
analyzed the long term outcomes and quality of life in patients with Hirschsprung's disease. This 
review included twelve studies (n=625). The authors concluded that children &gt; 10 years of 
age have higher prevalence of bowel dysfunction than controls.  
 
 
I have the following comments on this manuscript:  
 
1. What is the new information provided by this meta -analysis? In a previous meta -analysis 
including 6 studies with 316 patients (Zimmer et al. Pediatr Surg Int. 2016), similar 
conclusions have been drawn. The  current systematic review has larger sample size and a 
longer follow -up duration, but essentially draws similar conclusions.  
 
2. How did the authors define long term follow -up? Did they include children &gt; 10 years 
of age or patients who completed at le ast 10 years of follow -up? The authors have used 
these terms interchangeably. Kindly clarify the same in the manuscript as not all patients 
undergo surgery in infancy and duration of follow up may differ from age of the patients.  
 
3. Type of surgery (Lapar oscopy assisted pull through vs completely transanal pull through) 
and length of aganglionic colonic segment may impact the outcomes in patients with HD. 
However, the influence of these factors could not be determined due to limited number of 
studies repor ting the same. Therefore, the review essentially replicates the current 
knowledge from individual studies reporting the long -term outcomes in patients with HD.  
 
4. Age of surgery and syndromic patients (e.g. Down's syndrome ) may affect the long term 
outcom es of surgery. It would be useful to evaluate and mention the impact of these  
factors.  
 
5. Was there any difference between children vs adults with respect to functional outcomes 
and quality of life? In a large study (346 patients, &gt;7 years), the outco mes were better 
in adult patients(Meinds RJ. Br J Surg. 2019)  
 
6. The entire manuscript needs to be screened and rectified for grammatical and syntax 
errors by a native English speaker.  
Are the methods appropriate and well described?  
If not, ple ase 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.  
 
Yes 
 
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 manus cript or would you recommend an 
additional statistical review?  
If an additional s tatistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not su itable for publication unless extensively edited  
 
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 sal ary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publica tion 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 t he 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 wi ll be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with th e authors' 
responses. I agree for my report to be made available un der 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 in cluded 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: Long -term Outcomes and Quality of Life of Patien ts with Hirschsprung Disease: A 
Systematic Review and Meta -analysis  
 
Version: 0 Date: 23 May 2019  
 
Reviewer: Zaheer Nabi  
 
Reviewer's report:  
 
In this systematic review entitled as "Prevalence of Long -term Outcome and quality of life of 
Patients with Hirschsprung's Disease: A Systematic Review and Meta -analysis", the authors have 
analyzed the long term outcomes and quality of life in patients with Hirschsprung's disease. This 
review included twelve studies (n=625). The authors concluded that children &gt; 10 years of 
age have higher prevalence of bowel dysfunction than controls.  
 
 
I have the following comments on this manuscript:  
 
1. What is the new information provided by this meta -analysis? In a previous meta -analysis 
including 6 studies with 316 patients (Zimmer et al. Pediatr Surg Int. 2016), similar 
conclusions have been drawn. The  current systematic review has larger sample size and a 
longer follow -up duration, but essentially draws similar conclusions.  
 
2. How did the authors define long term follow -up? Did they include children &gt; 10 years 
of age or patients who completed at le ast 10 years of follow -up? The authors have used 
these terms interchangeably. Kindly clarify the same in the manuscript as not all patients 
undergo surgery in infancy and duration of follow up may differ from age of the patients.  
 
3. Type of surgery (Lapar oscopy assisted pull through vs completely transanal pull through) 
and length of aganglionic colonic segment may impact the outcomes in patients with HD. 
However, the influence of these factors could not be determined due to limited number of 
studies repor ting the same. Therefore, the review essentially replicates the current 
knowledge from individual studies reporting the long -term outcomes in patients with HD.  
 
4. Age of surgery and syndromic patients (e.g. Down's syndrome ) may affect the long term 
outcom es of surgery. It would be useful to evaluate and mention the impact of these  
factors.  
 
5. Was there any difference between children vs adults with respect to functional outcomes 
and quality of life? In a large study (346 patients, &gt;7 years), the outco mes were better 
in adult patients(Meinds RJ. Br J Surg. 2019)  
 
6. The entire manuscript needs to be screened and rectified for grammatical and syntax 
errors by a native English speaker.  
Are the methods appropriate and well described?  
If not, ple ase 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.  
 
Yes 
 
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 manus cript or would you recommend an 
additional statistical review?  
If an additional s tatistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not su itable for publication unless extensively edited  
 
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 sal ary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publica tion 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 t he 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 wi ll be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with th e authors' 
responses. I agree for my report to be made available un der 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 in cluded 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: Long -term Outcomes and Quality of Life of Patien ts with Hirschsprung Disease: A 
Systematic Review and Meta -analysis  
 
Version: 0 Date: 23 May 2019  
 
Reviewer: Zaheer Nabi  
 
Reviewer's report:  
 
In this systematic review entitled as "Prevalence of Long -term Outcome and quality of life of 
Patients with Hirschsprung's Disease: A Systematic Review and Meta -analysis", the authors have 
analyzed the long term outcomes and quality of life in patients with Hirschsprung's disease. This 
review included twelve studies (n=625). The authors concluded that children &gt; 10 years of 
age have higher prevalence of bowel dysfunction than controls.  
 
 
I have the following comments on this manuscript:  
 
1. What is the new information provided by this meta -analysis? In a previous meta -analysis 
including 6 studies with 316 patients (Zimmer et al. Pediatr Surg Int. 2016), similar 
conclusions have been drawn. The  current systematic review has larger sample size and a 
longer follow -up duration, but essentially draws similar conclusions.  
 
2. How did the authors define long term follow -up? Did they include children &gt; 10 years 
of age or patients who completed at le ast 10 years of follow -up? The authors have used 
these terms interchangeably. Kindly clarify the same in the manuscript as not all patients 
undergo surgery in infancy and duration of follow up may differ from age of the patients.  
 
3. Type of surgery (Lapar oscopy assisted pull through vs completely transanal pull through) 
and length of aganglionic colonic segment may impact the outcomes in patients with HD. 
However, the influence of these factors could not be determined due to limited number of 
studies repor ting the same. Therefore, the review essentially replicates the current 
knowledge from individual studies reporting the long -term outcomes in patients with HD.  
 
4. Age of surgery and syndromic patients (e.g. Down's syndrome ) may affect the long term 
outcom es of surgery. It would be useful to evaluate and mention the impact of these  
factors.  
 
5. Was there any difference between children vs adults with respect to functional outcomes 
and quality of life? In a large study (346 patients, &gt;7 years), the outco mes were better 
in adult patients(Meinds RJ. Br J Surg. 2019)  
 
6. The entire manuscript needs to be screened and rectified for grammatical and syntax 
errors by a native English speaker.  
Are the methods appropriate and well described?  
If not, ple ase 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.  
 
Yes 
 
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 manus cript or would you recommend an 
additional statistical review?  
If an additional s tatistical review is recommended, please speci fy what aspects require further 
assessment in your comments to the editors.  
 
I recommend additional statistical review  
 
Quality of written English  
Please indicate the quality of language in the manuscript:  
 
Not su itable for publication unless extensively edited  
 
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 sal ary 
from an organisation that may in any way gain or lose financial ly from the 
publication of this manuscript, either now or in the future?  
 
2.  Do you hold any stocks or shares in an organisation t hat may in any way gain or 
lose financially from the publica tion 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 t he 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 wi ll be included 
on my report to the authors and, if the manuscript is accepted f or publication, my named report 
including any attachments I upload will be posted on the website along with th e authors' 
responses. I agree for my report to be made available un der 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 in cluded as confidential comments 
to the editors, which will not be  published.  
 
I agree to the open peer review policy of the journal  
assistant