Navigating the Spectrum of Pancreatic Surgery Complications: A Review

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This is a narrative review of complications following pancreatic surgery. Thank you for the opportunity to review it and provide my insights. Pancreatic surgery remains a field of considerable academic and clinical interest, and postoperative complications are highly relevant to both specialist HPB surgeons and general surgeons alike. My assessment was conducted using the SANRA (Scale for the Assessment of Narrative Review Articles) tool for narrative reviews (doi: 10.1186/s41073-019-0064-8).

Item 1 - Justification of importance: The importance of the scope of the article is explicitly stated in the Introduction (score 2/2).

Item 2 - Concrete aim: Although this item is suggested in the Introduction, there is no dedicated section outlining it, nor an explicit statement explaining why the common complications (POPF, DGE, PPH) were examined in depth, whereas less common ones (i.e. portal vein thrombosis, complications related to vascular and biliary anatomical variations) were only supperficially addressed, if at all (score 0/2).

Item 3 - Literature search: This section is also missing entirely.  Although a narrative review is less stringent than a systematic review or meta-analysis, a structured approach to the available literature is still required.  The authors are expected to provide a basic description of their search strategy (e.g., time frame considered, language restrictions, publication status, study design, databases searched, etc.), ideally accompanied by a relevant flowchart (score 0/2).

Item 4 - Referencing: This aspect has been adequately addressed (appropriate number of citations, up-to-date literature, reliable sources).  However, the quality of referencing should be interpreted in the context of the missing literature search strategy described in Item 3 (score 2-/2).

Item 5 - Scientific reasoning: This item is partially addressed (i.e., POPF --> inflammed POPF --> hemorrhage --> morbidity & mortality). However, the reasoning is not fully developed across all sections. One area for improvement is the analysis of prevention strategies: while the discussion is more comprehensive for POPF, it becomes redundant or superficial in other areas (e.g., limited discussion on the embedment of the gastroduodenal artery stump to prevent PPH). An additional suggestion would be to briefly mention the potential of newer technologies (such as machine learning) for predicting post-pancreatectomy complications. A comprehensive analysis is not necessary (and obviously beyond the scope of your article), but a concise reference to this emerging field would strengthen the manuscript by highlighting future directions. Overall, the manuscript often reads as a compilation of primary studies rather than a constructive synthesis, which is the expected approach in a narrative review, particularly on a topic that has been extensively studied. There is clear room for improvement in this section (score 1/2).

Item 6 - Appropriate presentation of data: Incedence rates, risk factors, and outcomes are sufficiently covered in the text, but... the addition of visual elements, such as a flowchart with the search strategy, or a table (or one per category of major complication) summarizing the evidence would significantly enhance the clarity and impact of the review. A visual summary of complications, associated risk factors, and predictive strategies would further improve readability and make the manuscript more engaging for the reader (score 1/2).

Overall assessment: 6-/12.

The data is definitely there; you just need to present it in a more appealing way to the reader and include a few additional details.  I look forward to receiving your response and building a constructive dialogue.

Author Response

Item 2 - Concrete aim: Although this item is suggested in the Introduction, there is no dedicated section outlining it, nor an explicit statement explaining why the common complications (POPF, DGE, PPH) were examined in depth, whereas less common ones (i.e. portal vein thrombosis, complications related to vascular and biliary anatomical variations) were only supperficially addressed, if at all (score 0/2).

Response 1- Thank you for pointing this out. We agree to this comment and have made the changes in the methods section. 

Item 3 - Literature search: This section is also missing entirely.  Although a narrative review is less stringent than a systematic review or meta-analysis, a structured approach to the available literature is still required.  The authors are expected to provide a basic description of their search strategy (e.g., time frame considered, language restrictions, publication status, study design, databases searched, etc.), ideally accompanied by a relevant flowchart (score 0/2).

Response 2- Thank you for pointing this out. Although a narrative review does not require a formal structure like a systematic review, however we appreciate and respect your comment and would like to mention briefly regarding our methodology in performing a literature search.

Item 5 - Scientific reasoning: This item is partially addressed (i.e., POPF --> inflammed POPF --> hemorrhage --> morbidity & mortality). However, the reasoning is not fully developed across all sections. One area for improvement is the analysis of prevention strategies: while the discussion is more comprehensive for POPF, it becomes redundant or superficial in other areas (e.g., limited discussion on the embedment of the gastroduodenal artery stump to prevent PPH). An additional suggestion would be to briefly mention the potential of newer technologies (such as machine learning) for predicting post-pancreatectomy complications. A comprehensive analysis is not necessary (and obviously beyond the scope of your article), but a concise reference to this emerging field would strengthen the manuscript by highlighting future directions. Overall, the manuscript often reads as a compilation of primary studies rather than a constructive synthesis, which is the expected approach in a narrative review, particularly on a topic that has been extensively studied. There is clear room for improvement in this section (score 1/2).

 

Response 3- Thank you for pointing this out. We agree to this comment and have made the necessary changes under the other parts of the manuscript - Under DGE and PPH.

Item 6 - Appropriate presentation of data: Incedence rates, risk factors, and outcomes are sufficiently covered in the text, but... the addition of visual elements, such as a flowchart with the search strategy, or a table (or one per category of major complication) summarizing the evidence would significantly enhance the clarity and impact of the review. A visual summary of complications, associated risk factors, and predictive strategies would further improve readability and make the manuscript more engaging for the reader (score 1/2).

 

Response 4- Thank you for pointing this out. We have taken into consideration and have attached/ inserted a table along with the updated manuscript. 

 

 

 

Reviewer 2 Report

Comments and Suggestions for Authors

The article "Navigating the spectrum of pancreatic surgery complications: A review" provides a comprehensive overview of complications associated with pancreatic surgery, particularly focusing on postoperative pancreatic fistula (POPF), delayed gastric emptying (DGE), and post-pancreatectomy hemorrhage (PPH). ​ These complications significantly impact patient outcomes, healthcare costs, and quality of life. ​ The review highlights the importance of preoperative risk assessment and postoperative management to mitigate these complications.

There are some weaknesses in this review that I find critical.

Critical Points:

1. The Authors stated: “In the United States, the 4th leading cause of death in men and 5th in women is pancreatic cancer which is also the 36 case in Europe [1].” This does not reflect the most current mortality rankings from authoritative sources like the CDC or the American Cancer Society. According to recent data. Pancreatic cancer is typically the 3rd or 4th leading cause of cancer-related deaths in both men and women in the U.S. However, it is not the 4th or 5th leading cause of death overall, which includes all causes (heart disease, stroke, accidents, etc.). According to the CDC (2022 data) the leading causes of death overall are: heart disease, cancer (all types), unintentional injuries, chronic lower respiratory diseases, and stroke. Pancreatic cancer, while serious, does not rank that high among all-cause mortality. In this regard the Reference n. 1“Ho, C.; Kleeff, J.; Friess, H.; Büchler, M.W. Complications of Pancreatic Surgery. HPB 2005…” for the statement about cause of mortality is inappropriate since this reference is from 2005 (outdated) for a statement about current mortality statistics and the reference is focused on surgical complications, not epidemiology or mortality rankings; for this reason it cannot support a 2020s claim about cause-of-death rankings.

Weaknesses

1. Lack of a Clear Review Type: The authors do not specify whether this is a narrative review, systematic review, scoping review or other form of review. This omission affects the scientific rigor of the methodology.

­2. There is no description of the search strategy, the academic research engines utilized (Pub Med, EMBASE, Google Scholar, Science Direct, Scopus and many other research engines). There are no mentions of the inclusion and exclusion criteria of the references chosen, nor about the overall number of sources reviewed, making it difficult to assess the comprehensiveness or the potential biases of article selection.

3. Structural issues: The structure of the text is not well organized and lacks a thematic and systematic structure. For instance, some complications are described with adequate context (e.g., hemorrhage), while others are treated briefly. The manuscript does not follow a strict logical progression, with headings and subheadings

4. Insufficient use of tables and figures:

The absence of summary tables is a major shortcoming. Tables would improve clarity and allow readers to easily compare the incidence, risk factors, classification systems (e.g., ISGPS for pancreatic fistula), and management strategies of the main complications. For a review, visual aids such as flowcharts, algorithms, or classification diagrams (e.g., Clavien-Dindo, ISGPS definitions) would greatly enhance educational

5. Poor Referencing and Evidence Support::

Some statements are often made without appropriate references or based on single studies and some cited references do not always support the stated claims. It should be beneficial to cite for each complication the references which are supported by RCT if any, and the most important guidelines in a special dedicated Table where prospective and RC Trials, when available, are reported subdivided for each compication reported.

6. Language and style: The manuscript contains some typos (“pankreatic leaks”). Abbreviations are sometimes used before being defined (e.g., POPF, PPH), which may confuse the reader.

Author Response

1. The Authors stated: “In the United States, the 4th leading cause of death in men and 5th in women is pancreatic cancer which is also the 36 case in Europe [1].” This does not reflect the most current mortality rankings from authoritative sources like the CDC or the American Cancer Society. According to recent data. Pancreatic cancer is typically the 3rd or 4th leading cause of cancer-related deaths in both men and women in the U.S. However, it is not the 4th or 5th leading cause of death overall, which includes all causes (heart disease, stroke, accidents, etc.). According to the CDC (2022 data) the leading causes of death overall are: heart disease, cancer (all types), unintentional injuries, chronic lower respiratory diseases, and stroke. Pancreatic cancer, while serious, does not rank that high among all-cause mortality. In this regard the Reference n. 1“Ho, C.; Kleeff, J.; Friess, H.; Büchler, M.W. Complications of Pancreatic Surgery. HPB 2005…” for the statement about cause of mortality is inappropriate since this reference is from 2005 (outdated) for a statement about current mortality statistics and the reference is focused on surgical complications, not epidemiology or mortality rankings; for this reason it cannot support a 2020s claim about cause-of-death rankings.

Response 1- Thank you for pointing this out. We agree to this comment and have made the necessary changes. We have removed the necessary line from the manuscript.

1. Lack of a Clear Review Type: The authors do not specify whether this is a narrative review, systematic review, scoping review or other form of review. This omission affects the scientific rigor of the methodology.

Response 2- Thank you for pointing this out. We agree to this comment and have included the same in the introduction.

­2. There is no description of the search strategy, the academic research engines utilized (Pub Med, EMBASE, Google Scholar, Science Direct, Scopus and many other research engines). There are no mentions of the inclusion and exclusion criteria of the references chosen, nor about the overall number of sources reviewed, making it difficult to assess the comprehensiveness or the potential biases of article selection.

 

Response 3- Thank you for bringing this up. Although a narrative review is not like a systematic review with a strict literature search criteria we agree and respect your comment considering the betterment of scientific practices, we have included the same.

 

3. Structural issues: The structure of the text is not well organized and lacks a thematic and systematic structure. For instance, some complications are described with adequate context (e.g., hemorrhage), while others are treated briefly. The manuscript does not follow a strict logical progression, with headings and subheadings

Response 4- Thank you for brining this up. We accept this comment and have segmented the manuscript in a logical sequence accordingly with adequate headings and subheadings.

 

4. Insufficient use of tables and figures:

The absence of summary tables is a major shortcoming. Tables would improve clarity and allow readers to easily compare the incidence, risk factors, classification systems (e.g., ISGPS for pancreatic fistula), and management strategies of the main complications. For a review, visual aids such as flowcharts, algorithms, or classification diagrams (e.g., Clavien-Dindo, ISGPS definitions) would greatly enhance educational

 

Response 5- Thank you for bringing this point up. We accept your comment and have included a table for visual enhancement in a summarized format. 

5. Poor Referencing and Evidence Support::

Some statements are often made without appropriate references or based on single studies and some cited references do not always support the stated claims. It should be beneficial to cite for each complication the references which are supported by RCT if any, and the most important guidelines in a special dedicated Table where prospective and RC Trials, when available, are reported subdivided for each compication reported.

 

Response 6- Thank you for bringing this up. We will have to very respectfully disagree to this as we have referenced adequately and were conscious in citing the literature. 

 

6. Language and style: The manuscript contains some typos (“pankreatic leaks”). Abbreviations are sometimes used before being defined (e.g., POPF, PPH), which may confuse the reader.

 

Response 7- Thank you for brining this up. We will have to respectfully disagree that we could not find any spelling error with regards to your example in the old file. However we do agree that only PPH was not introduced earlier, so thank you for that. We agree to it and have made the necessary changes in the introduction.

 

 

 

Reviewer 3 Report

Comments and Suggestions for Authors

The problem described in this article is well known, as demonstrated by the abundant literature currently available. With respect to the various complications that have been very correctly described, however, a concrete comment and a precise proposal on the behavior to be adopted by the authors based on their experience are missing. Furthermore, the numerous experiences currently reported in the literature with robotic and laparoscopic surgery deserve to be cited, especially if they have an impact on the reduction of complications. Finally, I would like to cite two articles that could be included.

Chirletti P: . J. Gastrointest Surg 2009

Author Response

The problem described in this article is well known, as demonstrated by the abundant literature currently available. With respect to the various complications that have been very correctly described, however, a concrete comment and a precise proposal on the behavior to be adopted by the authors based on their experience are missing. Furthermore, the numerous experiences currently reported in the literature with robotic and laparoscopic surgery deserve to be cited, especially if they have an impact on the reduction of complications. Finally, I would like to cite two articles that could be included. 

 

Response 1- Thank you for bringing this up. We agree that adding the data for lap vs robotic data to be added. We accept this comment and have made the necessary changes and have added it to the end of the document. 

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

This is a clinically relevant and timely review on post-pancreatectomy complications, but its overall contribution remains limited. In general, my previous comments have been addressed, although somewhat superficially. The structure is improved, and a brief literature search has been added, which helps methodologically, though it lacks key details such as timeframe, selection criteria, or use of MeSH terms. The discussion still feels more descriptive than analytical, and the rationale for focusing on POPF, DGE, and PPH remains underdeveloped. Less common complications are mentioned only in passing. I still believe the manuscript would benefit from (and enhance its didactic value through) the addition of visual elements (diagrams, figures, mind maps, etc.) beyond the simple aggregating table that has been included (Figure 1 should be renamed as Table 1 and presented in table format). Overall, this is an informative review with educational value, but without novel insights or synthesis.

Author Response

Thank you for this insightful comment. We agree with this astute assessment and have added the key details as requested which includes the timeframe, selection criteria and the use of MeSH terms which was already included previously. We believe the rationale behind the complications have been touched base in the introduction and believe that with complex surgeries there is a predisposition to a risk of developing complications which is also the case with pancreatectomy. We acknowledge your feedback and have made the necessary changes in the manuscript.

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for your thoughtful revisions and for addressing the majority of the points raised in my previous review. The manuscript is now more clearly structured and better emphasizes the clinical significance of the main complications following pancreatic surgery.

However, I must express some continued concern regarding the methodology section. While I appreciate the addition of a paragraph outlining the general approach to your literature search, the current description remains too vague to be considered methodologically sound—even for a narrative review.

Given the extremely large volume of literature available on this topic (e.g., more than 6,000 articles for "pancreatic fistula surgery complications" and over 160,000 for "pancreatic surgery" on PubMed alone), it is crucial to provide more detailed information about your selection process. Specifically, I encourage you to clarify the following aspects:

• Whether you used Boolean operators or any combination of terms to refine your search;

• If a time frame was applied to include only recent or particularly relevant publications;

• How you narrowed your selection to the 55 articles cited—e.g., based on study type, level of evidence, number of patients, relevance to clinical practice, or any other predefined criteria.

Even within the context of a narrative review, it is important to distinguish the article from a general textbook chapter. A minimum level of methodological transparency is expected in scientific publications, and your review would greatly benefit from such clarification. This would strengthen the credibility and reproducibility of your findings, and better guide the readers in understanding the basis of your synthesis.

Author Response

Thank you for this insightful comment. We agree with this astute assessment and have added the boolean operators and the time frame and why the articles were selected and stratified to be included with regards to the relevance of the topic at hand. We agree unlike a systematic review that requires a rigorous methodology, we have still provided the methodology for a narrative review with a minimal level of methodological transparency acknowledging the reviewer’s comment with the need for improving scientific quality of manuscripts.