Factors for Predicting Morbidity and Mortality of Gastric Cancer Patients After Laparoscopic Surgery: A Retrospective Study

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Comments on factors predicting laparoscopic surgery for gastric cancer.
This is a retrospective study dealing with predictive factors of gastric cancer underwent laparoscopic surgery. This topic is not so attractive, and the results showed no particular findings having profound scientific contribution. However, this article still has some value of reference since the study region is far away from Asia where gastric cancer is quite common.
Some description should be re-addressed as the following question mentioned before this manuscript could be considered for acceptance for publication.
1.    Please state clearly the definition of anemia. What are the criteria of hemoglobin level that can be recognized as suitable for receiving operation?
2.    As all patients should be evaluated thoroughly and recognized as having a high possibility of resectability before surgical intervention, please describe the reason why some patients undergo exploratory laparoscopy?  
3.    The lymph nodes around the stomach can be divided into different groups according to the distance away from the organ, the term ‘lymphadenopathy’ seemed to be too rough to be a single predictive factor.
4.    If stage 4 of gastric cancer means that there is distant metastasis, why were these patients prepared for operation?
5.    It is a peculiar phenomenon that the mortality rate is higher in subtotal gastrectomy group than that of total gastrectomy group(5.8% versus 0.8%), how about the authors’ explanation?

Author Response

"Please see the attachment."

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors

The authors describe their experience with regard to the factors affecting post-operative morbidity and mortality in gastric cancer patients treated by laparoscopic surgery. The data are highly valuable and deserve to be considered in clinical practice.

The Introduction needs to better articulate the importance of the study. It is desirable to provide a brief comparison of risk factors for morbidity and the pattern of complications for laparoscopic versus open surgery applied for gastric cancer.  The existing controversies in the literature and gaps in the current knowledge deserve to be discussed.

The Results currently focus on the risk factors for morbidity, but the patterns of post-surgical complications need to be provided as well. It is essential to describe with more emphasis the instances of hospital mortality.

The Discussion has to provide clear-cut comparison of the obtained data with the results of similar studies. Which risk factors are reproducible across studies and which are not?

Were there some avoidable deficiencies in the treatment plans? Please provide roadmap for future research and give some advices to the doctors how to improves risk/benefit ratio. If the coagulopathy or anemia are somehow compensated before surgery, would it indeed improve outcomes or these features merely serve as risk factors? The controversies related to the extent of lymphadenectomy may deserve a discussion.

To my opinion, the Conclusions section currently sounds somewhat vague and fails to deliver a meaningful message.   

Author Response

"Please see the attachment

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

The paper under review begins with a very clear abstract that well describes the aim of the study. In fact, "it aims to identify factors associated with postoperative morbidity and mortality in patients undergoing laparoscopic gastrectomy for gastric adenocarcinoma". In the introduction, it is recommended to report that there are three cornerstones on which the treatment of gastric cancer revolves: neoadjuvant therapy, where necessary, surgical treatment and finally adjuvant therapy, whenever necessary. Diagnostics are fundamental, which with endoscopy and biopsy allow us to study the microbiology and know if we have stable microsatellites or not and this opens the doors to immunotherapy. Then it gives us information on HER 2 that can guide us on the possibility of proposing trastuzumab. The imaging study will allow us to know the stage of the disease, the peritoneal carcinomatosis, the PCI and as we had written for a neoadjuvant treatment that can be the known FLOT only or in particularly advanced diseases we can avail ourselves of a direct vision with an exploratory laparoscopy with calculation of the surgical PCI and the bidirectional therapy with PIPAC. Only at this point is the patient entrusted to surgical care, now in high volume centers the patient is treated with a D2 lymphadenectomy but there are cases in which it must be extended to the removal of the para-aortic lymph nodes both in the East and in the West, (doi.org/10.3390/cancers16071376 to read and cite). The result then of the pathologist and the multidisciplinary commission, which had examined the patient concluded the diagnostics, will now be able to express themselves on the last stage of treatment with the adjuvant therapy. In the materials and methods section, colleagues write about the observation period, which was a bit long, and then confirm that they examined the data statistically, and the data were reported correctly in the iconography. The results make much use of tables but are very clear. It is advisable to review the discussion because the observations made are correct, it is right to consider the complications according to the Clavien-Dindo scale, we agree that minimally invasive surgery, whether laparoscopic or robotic, improves the patient's outcome. However, we must keep in mind that morbidity and mortality are linked not only to the comorbidities present at the time of diagnosis and the age of the patient to be treated, but also to how he is assisted from a nutritional point of view. We have numerous pre- and post-surgical aids available, including ERAS, which greatly improve nutritional conditions. Finally, if we need it, we infuse leucocyte-depleted blood which does not further weaken the patient. Good English, the bibliography supports the entire paper

Author Response

Please see the attachment."

Author Response File: Author Response.docx

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Most of my questions have been answered by the authors. However, two points still remained not resolved. 

1. The authors stated that anemia is a risk factor of prediction of morbidity, and suggested that rehabilitation (probably means correction) will be important before operation so as to reduce incidence of complication. However, definition of anemia in this manuscript is too rough to be a clinical indicator since we usually will not give transfusion for patients with hemoglobin level around 12 gm%.

2. The author did not explain why mortality is higher in subtotal gastrectomy group than that in total gastrectomy group.  

Author Response

Reviewer 1:

Most of my questions have been answered by the authors. However, two points still remained not resolved. 

1. The authors stated that anemia is a risk factor of prediction of morbidity, and suggested that rehabilitation (probably means correction) will be important before operation so as to reduce incidence of complication. However, definition of anemia in this manuscript is too rough to be a clinical indicator since we usually will not give transfusion for patients with hemoglobin level around 12 gm%.

The study references iron-deficiency anemia and iron deficiency. Corrections have been made to the text to emphasize this.

 

2. The author did not explain why mortality is higher in subtotal gastrectomy group than that in total gastrectomy group. 

We have reviewed our mortality data and found an error in the calculation. A 30-day operative mortality of 6.2% was recorded in the subtotal gastrectomy group (4 patients) and 11.1% in the total gastrectomy group (2 patients). Corrections have been made to the document.

 

 

Author Response File: Author Response.docx

Reviewer 2 Report

Comments and Suggestions for Authors Some of the raised comments have been addressed in the modified version of the text, while some have not. The authors are invited to go through my earlier remarks and provide point-by-point responses how they modified the text or provide arguments why they decided not to consider some of the suggestions. For example, “If the coagulopathy or anemia are somehow compensated before surgery, would it indeed improve outcomes, or these features merely serve as risk factors?”. What is “neajuvance”?  (line 257)

Author Response

 

Reviewer 2:

Some of the raised comments have been addressed in the modified version of the text, while some have not. The authors are invited to go through my earlier remarks and provide point-by-point responses how they modified the text or provide arguments why they decided not to consider some of the suggestions. For example, “If the coagulopathy or anemia are somehow compensated before surgery, would it indeed improve outcomes, or these features merely serve as risk factors?”. What is “neajuvance”?  (line 257).

Below are the responses to the questions raised and highlighted, as they appear in the document.

1. The Introduction needs to better articulate the importance of the study. It is desirable to provide a brief comparison of risk factors for morbidity and the pattern of complications for laparoscopic versus open surgery applied for gastric cancer.  The existing controversies in the literature and gaps in the current knowledge deserve to be discussed.

 

However, significant differences exist in surgical approaches, with open and laparoscopic techniques being prominent options. Laparoscopicgastrectomy has gained popularity for its potential to reduce postoperative pain, shorten recovery time, and minimize hospital stays compared to open surgery. Nonetheless, these benefits must be weighed against technical challenges and potential risks, especially in complex cases such astotal gastrectomy [6,7].

By examining the evolving landscape of surgical practices and identifying risk factors, this research seeks to contribute to optimizing outcomes andimproving the global management of gastric cancer.

2. The Results currently focus on the risk factors for morbidity, but the patterns of post-surgical complications need to be provided as well. It is essential to describe with more emphasis the instances of hospital mortality.

Morbidity and mortality were mainly related to reconstruction problems: four anastomosis leakage, and two duodenal stump dehiscence.

3. The Discussion has to provide clear-cut comparison of the obtained data with the results of similar studies. Which risk factors are reproducible across studies and which are not?

Our study highlights the critical role of prehabilitation, particularly in elderly patients, by addressing modifiable factors such as anemia and hypoalbuminemia. It underscores the importance of tailoring surgical strategies to individual risk profiles to enhance outcomes. Consistent with findings from other studies, our results reaffirm the significance of preoperative prehabilitation in optimizing the

surgical treatment of gastric adenocarcinoma.

4. Were there some avoidable deficiencies in the treatment plans? Please provide roadmap for future research and give some advices to the doctors how to improves risk/benefit ratio. If the coagulopathy or anemia are somehow compensated before surgery, would it indeed improve outcomes or these features merely serve as risk factors?

Our study identifies pre-existing iron deficiency anemia and coagulopathy as key factors associated with morbidity and mortality. Systematic implementation of preoperative correction for these deficits, as well as others such as hypoalbuminemia and sarcopenia, should be prioritized to optimize patient outcomes

In our study, pre-existing iron deficiency anemia and coagulopathy were identified as factors associated with morbidity and mortality. The conclusion emphasizes the need to address these deficits to optimize outcomes.

 

 

5. The controversies related to the extent of lymphadenectomy may deserve a discussion.

The extent of surgery is another factor influencing morbidity [7]. We found that extended lymphadenectomy was associated with an increased riskof complications, which may explain why advanced-stage disease consistently correlates with higher morbidity rates, as reflected in our results.However, good results have recently been reported, with low morbidity and mortality rates, with a more aggressive therapeutic approach, superextended D2 lymphadenectomy after neajuvance with chemoterapy[26].

6. To my opinion, the Conclusions section currently sounds somewhat vague and fails to deliver a meaningful message.   

Laparoscopic gastrectomy for gastric cancer is a complex procedure requiring meticulous

planning and execution. This study highlights the significant impact of preoperative

factors, such as anemia and coagulopathy, on postoperative morbidity and mortality.

These findings emphasize the potential value of targeted prehabilitation strategies to mit-

igate these risks. Comprehensive risk stratification and patient selection remain para-

mount to optimizing surgical outcomes. Future efforts should focus on integrating preha-

bilitation protocols into standard care for high-risk patients to improve perioperative

safety and long-term prognosis.

 

 

 

 

 

 

Author Response File: Author Response.docx

Reviewer 3 Report

Comments and Suggestions for Authors

Our fellow researchers have made some changes to their paper that make it absolutely important to present to a group of surgeons who will benefit from their observations about gastric cancer. Another brick is added to the construction of the temple that leads to improving the care of these patients. Endorse for publication

Author Response

  Thanks for your kind comments.

Round 3

Reviewer 2 Report

Comments and Suggestions for Authors

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