Abdominal Surgery Performed in Awake Patients Under Neuraxial Anesthesia: A Systematic Review Across Surgical Specialties

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

The authors performed a systematic review of neuraxial anesthesia versus general anesthesia for abdominal surgery.  The review included case reports and case series.  The inclusion of these articles creates a bias favoring neuraxial anesthesia as a case report of failed neuraxial anesthesia is less likely to be published.  The authors discuss the benefits of neuraxial anesthesia in the frail patient.  It would be helpful to discuss the largest trial comparing spinal to general anesthesia for hip surgery which demonstrated no difference in outcome.  While this article is not abdominal surgery, the size of the trial and the findings merit inclusion in the discussion.  There is also concern about the advocacy for unsafe practices.  The table includes reference to thoracic spinal anesthesia which has risks of injury to spinal cord

Author Response

Reviewer 1

The authors performed a systematic review of neuraxial anesthesia versus general anesthesia for abdominal surgery.  The review included case reports and case series. 

R1 Comment#1:The inclusion of these articles creates a bias favoring neuraxial anesthesia as a case report of failed neuraxial anesthesia is less likely to be published.

 

R1 Reponse#1: We thank the reviewer for the valuable comment, which remains undoubtedly true despite the supporting evidence presented in this investigation. Unfortunately, negative results often remain unpublished, and this is a well known issue in the medical literature. For this reason, we maintained a cautious tone throughout our manuscript, particularly in the conclusion, where we emphasize the need for stronger evidence to support the validity of NA. Nevertheless, we have included this valuable remark in the limitations paragraph.

 

R1C#2: The authors discuss the benefits of neuraxial anesthesia in the frail patient.  It would be helpful to discuss the largest trial comparing spinal to general anesthesia for hip surgery which demonstrated no difference in outcome. While this article is not abdominal surgery, the size of the trial and the findings merit inclusion in the discussion.

 

R1R#2: We thank the reviewer for this valuable comment, which provided an opportunity to include additional evidence on neuraxial anesthesia (NA). The decision to include studies from other specialties beyond abdominal surgery was indeed a matter of discussion among the authors. Consequently, we added two randomized controlled trials on hip surgery and regional anesthesia and incorporated a corresponding comment in the discussion section.
- Neuman MD et al. REGAIN Investigators. N Engl J Med. 2021;385(22):2025–2035. doi: 10.1056/NEJMoa2113514

- Li T et al. RAGA Study Investigators. JAMA. 2022;327(1):50–58. doi: 10.1001/jama.2021.22647

 

R1C#3: There is also concern about the advocacy for unsafe practices.  The table includes reference to thoracic spinal anesthesia which has risks of injury to spinal cord.

R1R#3: We fully agree with the reviewer’s concern regarding spinal anesthesia and the associated risk of spinal cord injury. For this reason, we added a paragraph in the discussion addressing the potential risks according to the main evidence available.

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript “Abdominal Surgery in the Awake Patient: A Systematic Review Across Surgical Specialties” explores the role of neuraxial anesthesia (NA) as an alternative to general anesthesia (GA) across different surgical specialties, with particular emphasis on abdominal procedures. The authors position NA within the evolving field of perioperative medicine. The topic is timely and relevant. Although this is presented as a narrative review, the authors report adherence to PRISMA guidelines, which enhances the transparency and credibility of the literature selection process.

The major concern is the inconsistency between the title, abstract, and the main body of the manuscript. While the manuscript primarily emphasizes the role of NA, the title and abstract do not fully reflect this focus. It would therefore be advisable to revise the title and rewrite the abstract accordingly.

In addition, the discussion section contains numerous facts presented without clear logical connections. A more structured and coherent discussion is recommended, with stronger emphasis on the role of NA in abdominal surgery.

Finally, there are multiple typographical errors throughout the text that should be corrected.

Please correct literature according to the instructions. 

Author Response

Reviewer 2

The manuscript “Abdominal Surgery in the Awake Patient: A Systematic Review Across Surgical Specialties” explores the role of neuraxial anesthesia (NA) as an alternative to general anesthesia (GA) across different surgical specialties, with particular emphasis on abdominal procedures. The authors position NA within the evolving field of perioperative medicine. The topic is timely and relevant. Although this is presented as a narrative review, the authors report adherence to PRISMA guidelines, which enhances the transparency and credibility of the literature selection process.

 

R2C#1:The major concern is the inconsistency between the title, abstract, and the main body of the manuscript. While the manuscript primarily emphasizes the role of NA, the title and abstract do not fully reflect this focus. It would therefore be advisable to revise the title and rewrite the abstract accordingly.

 

R2R#1: We thank the reviewer for the careful attention to the consistency between the title, abstract, and main text. Both the abstract and the title have been revised in accordance with the reviewer’s suggestions.

 

R2C#2: In addition, the discussion section contains numerous facts presented without clear logical connections. A more structured and coherent discussion is recommended, with stronger emphasis on the role of NA in abdominal surgery.

R2R#2: We agree with the reviewer regarding the lack of structure and consistency and have revised the manuscript accordingly. The discussion section has been reorganized to follow a clearer and more logical structure, as outlined below:

• A concise synthesis of the systematic review findings
• The rationale and possible advantages of neuraxial anesthesia (NA), with particular focus on its application in frail patients and in the context of postoperative cognitive dysfunction (POCD)
• Surgical specialty-specific paragraphs addressing different types of procedures or diseases and the corresponding evidence on the use of NA
• Negative findings from large randomized trials (as suggested by another reviewer)
• Future perspectives
• Study limitations

 

R2C#3: Finally, there are multiple typographical errors throughout the text that should be corrected.

R2R#3: The entire text has been carefully reviewed for typographical and formatting errors, and all necessary corrections have been made.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

The authors have addressed my concerns

Author Response

REVIEWER 1: The authors have addressed my concerns

Comment#1: We truly appreciate your help in improving our manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

The authors have revised the manuscript, but it still needs some minor changes. Please rewrite the references according to the instructions. Add short descriptions for all figures, and label the y-axes for Figures 3 and 4.

Author Response

REVIEWER 2: The authors have revised the manuscript, but it still needs some minor changes.

 

Comment #1: Please rewrite the references according to the instructions.
Response#1: References were modified according to the journal’s instructions.

 

Comment#2: Add short descriptions for all figures, and label the y-axes for Figures 3 and 4.
Reply#2: the figures were all provided with a caption and a brief description in the results. Y axes labels were added to Figure 3 and 4.

 

Figure 1
Caption: Study flow chart
Decription in the text: The diagram of the selection process is shown in Figure 1

 

Figure 2
Caption: Publications number per nation worldwide
Description in the text: Abdominal surgery performed with NA has been reported worldwide. A total of 31 countries has contributed to the literature, with 3 publications being multinational. The top 3 contributors were Italy (n=25), India (n=20), and the U.S.A. (n=16). Figure 2 graphically represents the number of contributing manuscripts per country.

 

Figure 3
Caption: Publications trend over the years
Description in the text: The oldest contribution to the literature is the manuscript by Stanley L.L. et al.[10], published in 1919. However, there has been a clear increase in publications in recent years, particularly over the last decade. The peak year for publications on abdominal surgery performed with NA was 2023, with 11 publications. Figure 3 visually illustrates the rising trend in publications over time.

 

Figure 4
Caption: Study type and frequency
Description in the text: Despite the increasing number of published manuscripts, the majority remain low-evidence studies, predominantly case reports and case series, which account for 62% of total publications. The second most common study type is randomized controlled trials (RCTs), representing 22% of the publications. Figure 4 presents the distribution of study types and their frequency.