Management Strategies and Outcomes for Small Intestinal Neuroendocrine Tumours with Involvement of the Superior Mesenteric Vessels: A Systematic Review

Round 1

Reviewer 1 Report

Background is very thorough but lengthy. I would consider eliminating the information on distinct clinical phenotypes of duodenal NETs and distal NETs except include the incidence of mesenteric metastases specifically the incidence of disease involving the mesenteric root. I think this followed by the symptoms and complications that arise from this presentation should be addressed concluding with why this review was needed to review invasive radical and cytoreductive strategies.

The portion on classification systems may be better presented in a table format comparing the differences and referenced in section 3.1.

In each section the authors provide synopses of each retrospective analysis included. Given the limited number this is reasonable but no conclusion is drawn regarding quality of the published studies. This may be helpful to help the reader understand what prior work/merits supported the approach, and if translatable to care received at other centers.

The discussion needs to be edited. It’s a bit disjointed. Starts with description and utility of the classification systems but not all the studies utilized them and that was not addressed. It then moves on to critique current guidelines. Not sure this requires a paragraph. It providing an opinion on the various interventions it would probably help to keep it in the order as reviewed in the results section.

Do the authors have any opinion about criteria that should be used for stent, autotransplant or EVOTE? It was not clear.

Author Response

Many thanks for your detailed review. Please see our point by point responses below:

Background is very thorough but lengthy. I would consider eliminating the information on distinct clinical phenotypes of duodenal NETs and distal NETs except include the incidence of mesenteric metastases specifically the incidence of disease involving the mesenteric root. I think this followed by the symptoms and complications that arise from this presentation should be addressed concluding with why this review was needed to review invasive radical and cytoreductive strategies.

This has been edited as suggested.

The portion on classification systems may be better presented in a table format comparing the differences and referenced in section 3.1.

This has been added now.

In each section the authors provide synopses of each retrospective analysis included. Given the limited number this is reasonable but no conclusion is drawn regarding quality of the published studies. This may be helpful to help the reader understand what prior work/merits supported the approach, and if translatable to care received at other centers.

All included studies are of similar quality and are predominantly case series.

The discussion needs to be edited. It’s a bit disjointed. Starts with description and utility of the classification systems but not all the studies utilized them and that was not addressed. It then moves on to critique current guidelines. Not sure this requires a paragraph. It providing an opinion on the various interventions it would probably help to keep it in the order as reviewed in the results section.

This has been moved around as suggested.

Do the authors have any opinion about criteria that should be used for stent, autotransplant or EVOTE? It was not clear.

We cannot prescribe specific criteria based on the evidence available. Autotransplantation is only appropriate for tumours affecting the mesenteric root (stage IV Ohrvall or LDG classifications). Given the radicality of the approach, patient's should be extremely fit and extensively screened for the appropriateness of the surgery.

EVOTE and stenting have not been compared directly and it is therefore difficult to comment on which is superior. Hybrid approaches in general, may be useful in management of disease affecting the mesenteric vessels and I have added a sentence to this effect in the discussion.

Reviewer 2 Report

Dear Authors, 

this is a systematic review on the surgical management of ileal NET with a Superior MEsenteric vessels involvement. In this paper, there are some issues that I suggest to review, to make mor confortable and cohomprensive the reading and to improve the work. 

Minor issue:

line 25 “Global…globally” please reformulate.

Line 144: it is not the first systematic review. Please reformulate the sentence  (Capurso et al).

Major issue:

Line 53-56: This sentence is questionable: the topic is still debated and in literature are published papers for and against. I suggest the authors to reformulate this sentence with an adequate literature (over the European and International guidelines).

I suggest the author to report the results of the 11 selected paper in a more homogeneous way, trying to focus on the same data for each paper: Moreover I suggest to remove the introduction in the head of the EVOTE and stenting paragraph. These are results, not discussion. I suggest to move these parts in the introduction, to make more simple for the readers to understand the different parts which will follow in the results.

Tabel of the results: The table is difficult to read. There are too much sentences in the “outcome” and no information on the stage at diagnosis or urgency of the surgical approach. I suggest to add the “stage at diagnosis” and “urgency of the surgical approach”, remove the systemic treatment (that is not the topic of the review) and to remodulate the layout of the table.

I suggest to do the same in the text of the results.

I suggest a minor editing of the english language. 

Author Response

Many thanks for you review, please see below a point by point response:

Minor issue:

line 25 “Global…globally” please reformulate.

This has now been amended.

Line 144: it is not the first systematic review. Please reformulate the sentence  (Capurso et al).

We are not sure this needs re-formulating, Capurso et al.'s paper refers to management of liver metastases whilst this paper (and sentence) focuses on management of mesenteric metastases.

Major issue:

Line 53-56: This sentence is questionable: the topic is still debated and in literature are published papers for and against. I suggest the authors to reformulate this sentence with an adequate literature (over the European and International guidelines).

I suggest the author to report the results of the 11 selected paper in a more homogeneous way, trying to focus on the same data for each paper:

Moreover I suggest to remove the introduction in the head of the EVOTE and stenting paragraph. These are results, not discussion. I suggest to move these parts in the introduction, to make more simple for the readers to understand the different parts which will follow in the results.

This has been moved to the introduction as suggested.

Tabel of the results: The table is difficult to read. There are too much sentences in the “outcome” and no information on the stage at diagnosis or urgency of the surgical approach. I suggest to add the “stage at diagnosis” and “urgency of the surgical approach”, remove the systemic treatment (that is not the topic of the review) and to remodulate the layout of the table.

I suggest to do the same in the text of the results.

The table has been edited as suggested. It is not possible to report on all the same outcomes in each paper as they are not all presented in the same way and/or have different outcomes and each paper has a slightly different focus.

Round 2

Reviewer 2 Report

I appreciated the edited version.