Is Chronic Pelvic Sepsis Complicating Low Anterior Resection of Rectal Cancer Preventable?

Round 1

Reviewer 1 Report (Previous Reviewer 2)

Comments and Suggestions for Authors

All queries answered. No further comments.

Author Response

Thank you for accepting the corrections

Reviewer 2 Report (Previous Reviewer 3)

Comments and Suggestions for Authors

The authors have addressed my major conceptual comments and substantially improved the manuscript. I now recommend minor revisions focused on softening a few over-strong statements, e.g., “chronic pelvic sepsis is preventable,” “generally futile,” “more cost-effective”. Subject to these changes, the article is suitable for publication as an Opinion piece.

Suggested amendments:

1) "Chronic pelvic sepsis is preventable if anastomotic integrity is maintained at one year." --> [chronic pelvic sepsis] “can be substantially reduced” or “may be largely prevented in many cases".

2) “It is generally futile to attempt to drain an anastomosis or the general peritoneal cavity as an enterocutaneous fistula may ensue” --> [to drain an anastomosis] “is often of limited benefit…” or “may be counterproductive in selected cases…”.

3) “The active management is a shorter pathway and more cost-effective.” --> “likely more cost-effective, although formal economic analyses are limited”.

These are minor issues, and no further round of review is necessary. Congratulations to the author on a solid and much-improved opinion article.

Author Response

Chronic pelvic sepsis is preventable if anastomotic integrity is maintained at one year

Response: Chronic pelvic sepsis can be substantially reduced if anastomotic integrity is maintained at one year. line 219

Response to comment 2: It may be counterproductive to attempt to drain an anastomosis or the general peritoneal cavity. line 137

Response to comment 3:  The active management is a shorter pathway and likely more cost- effective, although formal economic analyses are limited. line 189.

Author Response File: Author Response.docx

This manuscript is a resubmission of an earlier submission. The following is a list of the peer review reports and author responses from that submission.

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

Dear Author, I was please to read your valuable opinion on this important issue.

Reviewer 2 Report

Comments and Suggestions for Authors

Dear Authors, nothing new or novel in the manuscript. Also, the review is in narrative form with low scientific value.

Reviewer 3 Report

Comments and Suggestions for Authors

Thank you for giving me the opportunity to evaluate this interesting Opinion article. It addresses the important issue of chronic pelvic sepsis after low anterior resection (LAR). While clinically relevant, it reads more like a narrative summary than an opinion article. The central claim that chronic pelvic sepsis is preventable is a bit overstated and not sufficiently supported. Significant conceptual, structural, and evidentiary revisions are required. Here follow my specific comments:

1. The manuscript repeatedly asserts that chronic pelvic sepsis is preventable, yet the evidence presented does not justify this. Leak occurrence is multifactorial (tissue perfusion, radiotherapy, patient frailty, technical factors), and even optimal postoperative management cannot fully eliminate chronic sinuses or delayed reactivation leaks. The main thesis needs to be tempered.

2. A critical conceptual gap is the failure to differentiate between primary & secondary prevention, which is generally a common misunderstanding in clinical routine. In this specific case of anastomotic leaks, primary prevention would refer to preventing the index leak (e.g., tension-free anastomosis, ensuring perfusion, technical precision, appropriate diversion, patient optimization, etc.), while secondary prevention would indicate mitigating the consequences once a leak occurs (early detection, early endoscopy, early diversion, EVAC/EVASC, active drainage). These processes are separate, with distinct objectives and limitations. Conflating them leads to inaccurate conclusions about preventability. Importantly, the title of the article suggests actions to reinforce primary prevention, yet the discussion focuses almost exclusively on postoperative detection and management (secondary prevention). Primary preventive measures and their limitations should be explicitly acknowledged.

3. In the text, there is a rough classification of fistulae (intraperitoneal vs. extraperitoneal; early vs. late), but other clinical features that may influence their formation or prognosis have not been taken into consideration. These include (but are not limited to):

• simple vs. complex sinus tracts;
• high-output vs. low-output cavities;
• fistulous vs. non-fistulous leaks;
• irradiated vs. non-irradiated tissue.

4. Several statements look like oversimplifications of what literature actually supports. Some examples:

• Drain harms are overstated; the Cochrane review from 2004 (doi: 10.1002/14651858.CD002100.pub2) shows lack of benefit, not definitive harm, whereas one of the most recent series of almost 1,000 patients (10.1007/s11605-020-04781-6) failed to demonstrate association of drains with infectious complications (although there was a marginal association of the use of drains with leaks - 14 vs 8%, p = 0.041).
• Routine postoperative endoscopy on POD 4/5 is presented as essential despite limited adoption and modest evidence.
• Cost-effectiveness of active management is asserted without supporting analysis.

The article needs a more balanced appraisal of available data.

5. Writing and structure issues

• The current text is repetitive and sometimes unclear.
• Definitions of “chronic leak” vary within the manuscript.
• References are inconsistently formatted.
• As an opinion piece, it lacks a clearly articulated, novel argument.

Recommendation --> Major Revision

The topic is important and the references are relevant, but the manuscript requires substantial conceptual reframing (particularly regarding primary vs. secondary prevention), clearer definitions, strengthened evidence appraisal, and improved structure before it can be considered for publication. I would be happy to discuss any thoughts the author may have regarding my comments.

Comments on the Quality of English Language

The text needs polishing.